Making It Harder To Keep Nursing Homes Honest

The Bush administration shut off a source of information last fall about abuse and neglect in long-term care facilities. The rule designates state inspectors and Medicare and Medicaid contractors as federal employees. The new rule, which was issued in September, generally prohibits state health departments and contractors from participating in private lawsuits involving facilities that are in the federal assistance program without approval by the head of the Department of Health and Human Services. So essentially you have state vs. federal rights clashing heads. The practical effect is to force litigants to go to greater lengths to obtain inspection reports or depositions for cases they are pursuing or defending. The effect of the directives has started to play out in the nation's courtrooms. Requests for information, once fairly routine, now are stalled between state and federal officials.

Make the Call for Nursing Home Reform

On March 4, 2009, the Senate Aging Committee will hold a hearing addressing the financing of long-term services and supports. This is a unique platform to tell our legislators that long-term services and supports must be included in health care reform legislation. I have joined a coalition that is working to jam the Capitol phone lines on Tuesday, March 3, 2009, to tell our legislators that people must be supported in their needs regardless of whether their needs are acute or long-term. Activate your networks and on March 3 call toll-free, (800) 958-5374, and be connected directly to your member of Congress.

Voice Activated Resident Charting Saves Lives, Captures Revenue

The Villa St. Joseph, a nursing home near Pittsburgh, PA has introduced a voice activated computer system called AccuNurse that documents in real time all of the care being provided. Gone are charting specific patient interactions sometimes hours after they occurred. That only increases the likelihood of errors and omissions. And it has the added benefit of allowing staff to spend more time with residents. Now to be sure when you do all of this you also capture revenue that might have otherwise been lost but I can live with that given the alternative – care that could result in serious injury, illness or death because of improper and inaccurate data collection. Probably cuts down on lawsuits too. So kudos for facilities that incorporate technology for the benefit of residents and their bottom line. Just one more thing to ask about when checking out a home for your loved one.

Alzheimer's Inherited?

Boston University School of Medicine has conducted a study that might suggest a parental link for Alzheimer's. While the study has not been fully vetted, it is worth reading. It probably makes a case for mapping your genome though it is unclear what you could do about it if you uncover the gene largely responsible for the disease.

Medication Abuse in a Nursing Home

Three employees of a California nursing home are in police custody accused of forcibly administrating psychotropic drugs to patients to make them easier for staff to control. One, a former director of nursing, ordered that dementia patients be given high doses of the mood-altering drugs not as part of their therapy, but to make them more tranquil. In all, officials say 22 patients were affected. Police say three patients may have died from complications caused by the drugs and another may have been injured.

It’s tough enough keeping up with your own medications let alone worrying about someone you love in a nursing facility.

Here are few tips from my book Who Moved My Dentures?

1. Take a nurse with you when you go to visit a place you are considering or have chosen a facility. He/She will know what to look for and can spot medication mis-management. They might ask questions like-

2. Is there a multidisciplinary approach to care, that is, is there a team approach?

3. Is care individualized for each patient?

4. What kind of quality assurance program do they have in place?

5. How is their data handled?

6. Are medical records computerized?

7. Is there full documentation of what is taking place?

8. What are the checks and balances in place to assure that everything is being done above board?

9. What emergency procedures are in place?

10. What hospital will a resident be taken to if care is needed?

11. How is a resident’s own physician brought into the care team?

Answers to these questions may give some peace of mind that the overall clinical quality of care, including medication management, is sound. Or it may reveal the opposite. Act accordingly.

Be Aware the Legal Structure of Nursing Homes

We know we live in a litigious society and that one of the costs gobbling up healthcare dollars is liability and malpractice insurance. Some long term care operators simply can not afford it. So they improvise making it much harder for you to sue if something happens to a loved one. So you could have what appears to be one nursing home, one entity actually being many more.

For example the facility can first set up a parent company. Then it can set up multiple companies under that. It may set up an LLC to hold the land and collect rents. Any profits are passed up the chain to the parent. The land LLC has enough to operate but no more. The actual nursing home hires employees, obtains a license to operate and contracts with the parent organization for management services. Again it is a separate LLC. Bottom line, at the end of the month, it has little money in the bank.

So who do you first sue in a typical situation? The nursing home. But they have no money. You can try to go after the parent company but it will be hard to prove they did anything to jeopardize resident care.

The lesson – awareness – when scoping out a nursing home for a loved one, inquire and search to find out how it is legally organized. If the situation I describe is what you find, that should send a message to you – a bad one. Choose wisely and do your homework.

Guest Post Advance for Long Term Care Management

Here is a link to a guest blog post I wrote for Advance in Long Term Care Management on the resident experience.

Disruptive Innovation - Are We Capable?

The New York Times ran an article on February 1, 2009 entitled Disruptive Innovation, Applied to Health Care. The author contends that we have to innovate our way towards a new health care business model — one that reduces costs yet improves both quality and accessibility. And she blames hospitals’ old business models for our stagnation.

She cites systems like Kaiser Permanente and others who have integrated systems, geared toward wellness, where care is given in the most appropriate setting. They purport to have fixed fee systems that accept monthly payments from members in exchange for cradle to grave care.

Since I am a healthcare marketer, I approach this from that mindset. If indeed there is such a thing as cradle to grave healthcare, won’t this heat up competition even more fiercely as healthcare systems compete for your lifetime care? Or if every body chooses sides, will there be a need for marketing at all? You first have to contend that health care is local and I contend it is not or at least that it is changing.

So let’s move beyond that. Another premise of the article is that these integrated systems have the patient at the center of care. I contend that when you are marketing a service no one wants then providing a great experience is the best way to assure word of mouth marketing, the best marketing available. So addressing the patient experience becomes the heart of the matter. The article further goes on to address the IT infrastructure, EMR, etc. and cites one physician who contends that IT investment doesn’t impersonalize care, it does the opposite.

And I agree. Information is a gold mine. The more information you have about someone the better you can address their specific needs and in the case of marketing, you can direct your efforts in a targeted and less costly manner. So while I see hospitals invest more and more in advertising and battling it out on the airwaves, smart hospitals are collecting information and using it without violating standards to make care better and their marketing efforts better.

So:

Where do you think this is heading?
Can hospitals innovate?
Will a national health plan help or hinder this?
What role does marketing play in this and in the patient experience?
Are you using information to form a more intimate bond with patients and prospects?

And for consumers I would ask do you want and would you pay for the idea of one hospital or system taking care of you for life? And would you contend that providing more information about yourself (confidentially protected) would actually contribute to better care and a better health care experience?

Resident Experience Part Two

I have contended that not every nursing facility can become a Green House, small homes that cater to residents where the home is primary and nursing facility secondary in the equation. I believe that traditional individual facilities can enhance the experience themselves. The new Gables Care Center at the Boutwells Landing senior housing complex in Minnesota is an example.

The 108-bed care center is believed to be the first in the nation designed around the "Liberty" concept, which enables residents to do what they want to do when they want to do it.

Residents have autonomy over how they lead their lives — when they wake up and go to bed, when and what they eat, and when and how often they receive personal care. Every aspect — from design to services to technology — has been designed around the experience.

Nursing homes can learn a lesson and consumers can hold up this model as something that should be expected.

Asian Perspectives on Aging

I came across an interesting article on an Asian viewpoint of nursing homes. We often think of the Asian culture as one who takes care of their elders. Some of that is shifting as two family incomes come more into play and their societal life gets as hectic as those of us in the U.S. Values are changing...sadly. Take a read.

Crabby Old Man

No sage advice today but came across a poem sent from an activity professionals forum. It came on the heels of a great article in the Charlotte Observer about a young Girl Scout who "adopted" a woman at an assisted living facility. Both the story and poem speak about connecting and learning from one generation to the next.

Here is the story:

When an old man died in the geriatric ward of a small hospital near Tampa, Florida, it was believed that he had nothing left of any value.

Later, when the nurses were going through his meager possessions, they found this poem. Its quality and content so impressed the staff that copies were made and distributed to every nurse in the hospital.


Crabby Old Man

What do you see nurses? ...What do you see?
What are you thinking.....when you're looking at me?
A crabby old man, ..not very wise,
Uncertain of habit ......with faraway eyes?

Who dribbles his food.......and makes no reply.
When you say in a loud voice.....'I do wish you'd try!'
Who seems not to notice ..the things that you do.
And forever is losing .......... A sock or a shoe?

Who, resisting or not...........lets you do as you will,
With bathing and feeding ... the long day to fill?
Is that what you're thinking? Is that what you see?
Then open your eyes, nurse......you're not looking at me.

I'll tell you who I am ......... As I sit here so still,
As I do what you're bidding, ....as I eat at your will.
I'm a small child of ten ......with a father and mother,
Brothers and sisters ........who love one another.

A young g boy of sixteen ..with wings on his feet
Dreaming that soon now. .......a lover he'll meet.
A groom soon at twenty .....my heart gives a leap.
Remembering, the vows......that I promised to keep .

At twenty-five, now .......... I have young of my own.
Who need me to guide .... and a secure happy home.
A man of thirty ........ my young now grown fast,
Bound to each other .......... with ties that should last.

At forty, my young sons .....have grown and are gone,
But my woman's beside me.......to see I don't mourn.
At fifty, once more, ........ babies play 'round my knee,
Again, we know children ...... my loved one and me.

Dark days are upon me ............. my wife is now dead.
I look at the future ..............I shudder with dread.
For my young are all rearing......young of their own.
And I think of the years... and the love that I've known.

I'm now an old man.........and nature is cruel.
'Tis jest to make old age ....look like a fool.
The body, it crumbles..........grace and vigor, depart.
There is now a stone........where I once had a heart.

But inside this old carcass ...... a young guy still dwells,
And now and again ......my battered heart swells
I remember the joys........... I remember the pain.
And I'm loving and living.............life over again.

I think of the years .all too few......gone too fast.
And accept the stark fact........that nothing can last.
So open your eyes, people ..........open and see..
Not a crabby old man. Look closer....see........ME!!


Reminds me of the Alan Jackson Song, Remember When. Here is a sample of my version of that great song.

The Patient and Resident Experience

As a quick update, I wanted to guide you to an article I wrote for Health Leaders recounting my day spent at the Cleveland Clinic meeting with their patient experience team. It might help you understand how health care is evolving and what you should start looking for when evaluating health care providers as well as any senior services you are contemplating for a loved one.

Doctor Doctor Give Me the News I Have A Bad Case of Remembering You

A new study by the University of Chicago published in the Archives of Internal Medicine of nearly 3,000 adults admitted to their affiliated hospital reveals that patients are rarely able to identify their doctors by name or to describe their roles in their care. Patients were asked about the roles of the various physicians attending to them and to name the doctors on those teams. 75 percent were unable to name a single doctor assigned to their care. Of the 25 percent who did, 60 percent got it wrong. And get this; patients able to name one of their physicians also were more likely to be unsatisfied with their care. So if you know someone, it’s easier to blame by name?!

I went in for an endoscopy recently and my local hospital quizzed me on why I was there and who was my physician. For a moment I had to think of the guy’s name. Recently my mother fell and fractured her neck (she’s fine and stubborn at 87). And really it was not up to her to monitor the flow of physicians and others into her room. That was my job and I didn’t perform it well. And I could not be there all the time.

Dr. Ernest Moy, medical officer at the federal Agency for Healthcare Research and Quality, had this to say in the article: “In some ways ignorance is bliss. We assume when you walk into a hospital you are going to be taken care of, but maybe we put a little too much faith in hospitals.”

Until you experience the health care system first hand you really have no idea how complicated it is. In this day of consumerism and paying out of pocket, of health care advocates ready to come to your aid, of complicated medical bills and sorting it out, maybe it does make sense to know who is visiting you and why. And that doesn’t even begin to speak to what happens after you are discharged. My mother went back to Florida (she fell and was hospitalized in PA) and I tried in vain to hook her orthopedic surgeon in Florida with the orthopedic surgeons at the hospital so that her care could be somewhat coordinated.

So I might suggest for both consumers and hospitals that you put together a standard form that you insist any caregiver coming into the room fill out (well at least the physicians to start). Ask for their name, specialty, date, time and a short reason why they were there. You could even have some items listed that they could check – here to give patient update; examination; etc. I would even be so bold as to ask for their cell number.

It’s your health and you need to stay on top of it when you are well and when you are sick.

Some Caveats to the Nursing Home Compare 5 Star Rating System

We have said in the past that the Nursing Home Compare site even before the 5 Star rating was introduced was just a start in evaluating nursing facilities. I will continue to share a myriad of tips I have accumulated for evaluating care homes. That said when looking at the 5 Star system keep a few things in mind.

Rating are based on three sources of data: health inspections, staffing and quality measures.

The good thing about inspections is that they are done by real people going into the facility. However, since states administer the Medicaid program and many if not most nursing home residents are on Medicaid, state licensing requirements and records of inspections vary greatly from state to state.

Staffing is reported so that you can understand the nurse to resident ratio, in other words there are so many nurses to take care of so many residents. And the numbers reflect the acuity or sickness level of the resident. That is good. However, this number is self-reported by facilities and represents just a two week snapshot in time so a home may just report its best two week period.

There are ten quality measures reported in the data. Of course this does not cover all aspects of care and for many consumers quality data is hard to understand to begin with so consult with your doctor or a nurse to have them tell you more about what it means for example to have a certain score for the number of pressure sores reported in a home.

The system only compares homes to peers statewide not across the country so that is truly not representative of how a home stacks up. And then the top 10 percent of homes in that state automatically are assigned five stars.

If you are in one of the worst of the worst states and you have a facility that has a five star rating, nationwide compared against all 15,000+ facilities you may actually have a home that is two stars.

But again this is a starting point. We'll share more in future blogs.