Dr. Eleanor Barbera

Last week I was speaking about the needs of younger residents at the North Carolina Health Care Facilities Association convention and had the opportunity to hear a presentation by David Gifford, MD, MPH, Senior Vice President of Quality and Regulatory Affairs of the American Health Care Association (AHCA). He was discussing what providers could expect from upcoming AHCA quality initiatives. I was listening with a clinician’s ears and, aside from feeling grateful that I’m a clinician and not an administrator, several points stood out for me.

• Turnover is going to be added to the 5-Star Rating System. Better-rated facilities will be expected to have a turnover rate of 40% or less. He didn’t specify how to accomplish this, but my article, “Keys to reducing turnover in LTC,” offers many suggestions to address the problem. As I noted in the column, a 2007 Donoghue and Castle study found that “increasing the number of aides per resident from 33 per 100 to 41 per 100 reduced CNA turnover from 65% to 41% and also lowered LPN and RN turnover.” Taking that action alone could bring your facility to the sought-after turnover rate.

• Analyze problems with the right attitude. When doing a root-cause analysis of challenges such as falls, infections, pressure ulcers, etc., Gifford recommends operating from the assumption that “everything is preventable” rather than a defeatist whaddayagonnado stance. (OK, I’m paraphrasing that last part.) In his experience, this attitude makes a big difference in finding areas of potential change.

He also points out that difficulties frequently stem from a systems problem or lack of skill rather than a knowledge deficit on the part of staff. Rather than providing knowledge-focused in-service trainings in an attempt to rectify situations, ask staff members what “frustrates” them about a particular problem and whether they have suggestions about how to remedy it.

• Use pilot studies. When making needed modifications, start with a very small sample rather than immediately making a facility-wide adjustment of systems. Follow the model of “one staff member, one resident, one day.” This trial run provides the opportunity to see how the new system works and creates staff buy-in before committing the entire facility to the changes. Staff buy-in is enhanced if the selected staff member is someone respected by peers.

• Partner with hospitals. Note that 25% of the hospital’s satisfaction score is based on post-hospital satisfaction, so your satisfaction rating affects theirs.

• Post-discharge follow up has a huge impact on satisfaction. In a study of residents discharged after joint replacement surgery, researchers found that one-third of the discharged residents didn’t have primary care physicians and therefore couldn’t properly follow up with care. They also found that one-third of the people had something wrong with their discharge information, such as forgetting to mention that the only bathroom was up a flight of stairs. The facility started calling individuals the day after discharge to make sure they had everything they needed, calling again three to five days later and again three weeks after discharge. Their satisfaction ratings went “through the roof.”

As a clinician, this doesn’t surprise me at all. Transitions are notoriously difficult, emotionally and practically speaking. Important details fall through the cracks. Elders generally don’t have the supports at home they have in our facilities.

In addition, because people tend to better remember the last piece of information presented to them, it makes sense that satisfaction with a short-term stay would increase when the last contact with a facility is a warm and concerned call to see how the discharged resident is faring and assistance in rectifying any troubles.

• Prevent rehospitalizations. Gifford recommends the following to accomplish this:

o   Use of the INTERACT program (Interventions to Reduce Acute Care Transfers), which focuses on identifying problems early before they require hospitalization and offers free tools for quality improvement, enhanced communication, assessing the need for hospitalization and for advance care planning.

o   In-house treatment, if possible, to avoid negative outcomes associated with hospitalization such as increased rate of infection, pressure ulcers, confusion, etc. Certain illnesses such as pneumonia are found to be amenable to in-house care. Following the INTERACT guidelines will help facilities determine which residents can be assisted without hospitalization.

o   Advance care planning. Gifford mentioned a study that found a 20% reduction in rehospitalizations from having end-of-life conversations. He recommended asking, upon admission, five questions put forth by Atul Gawande, MD in his book “Being Mortal.” They are:

1.    What is your understanding of where you are and of your illness?

2.    What are your fears and worries for the future?

3.    What are your goals and priorities?

4.    What outcomes are unacceptable to you? What are you willing to sacrifice and not?

5.    What would a good day look like?

Addressing these quality initiatives is a huge, but not insurmountable, assignment. Using strategies such as the INTERACT program, making changes based on research in the field, and identifying problems within your facility and using staff input to correct them can make the undertaking more manageable.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident’s Guide, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the 2014 American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.