University of Pittsburgh Medical Center
And
University of Pittsburgh Institute on Aging
Chairman Eachus and Members of the House Democratic Policy Committee:
I am Shikha Iyengar, VP Geriatric Services, Community Provider Services of UPMC and Administrative Director of the University of Pittsburgh Institute on Aging. I would like to thank you and the committee members for giving me this opportunity to share with you our thoughts on providing quality long-term care in Pennsylvania. Today I am speaking on behalf of the geriatricians from the University of Pittsburgh Medical Center and the Institute on Aging who are committed to improving long-term care for all Pennsylvanians. Dr. David Nace, Director of Long-Term Care at the Institute on Aging and UPMC Senior Communities could not be here personally to testify as he is at the annual meeting of the American Medical Directors Association.
While most people are aware that UPMC is one of the largest integrated delivery systems in the Country, they may not realize that UPMC also has a very comprehensive long-term care system besides the nineteen hospitals and more than 4,500 physicians within its system. The long-term care system of UPMC includes:
Eight hospital-based transitional care units, four free standing nursing facilities, five free standing assisted and six independent living facilities, and one CCRC campus – representing about 2,500 residential long-term care bed/units within the system.
UPMC also has a full spectrum of in-home services that provides approximately 400,000 in-home visits/year through its home health agency, in addition to providing home care, home infusion, respiratory services and medical equipment and care management to over 12,000 individuals on any given day.
UPMC hospitals discharge about 16,000 patients each year to long-term care facilities in South Western PA and we receive about the same number of transfers to our acute care hospitals from the area long-term care facilities.
Our physicians serve as medical directors as well as attending physicians in many long-term care facilities. Approximately 36,000 annual visits are made by more than 130 internists, family practitioners and geriatricians employed by UPMC
We agree with the proposals made by Governor Rendell in the Prescription for PA and the provisions in Pennsylvania’s Health Care Reform Act, House Bill 700 as it relates to accessibility, affordability and quality of care in long-term care; however, we are concerned with the proposed implementation process. We do not believe that collecting and submitting additional data on medication errors and on infections would translate to improved quality of care. Data collection by itself does not enhance services to residents at these facilities. Quality of care can only be improved by supporting care providers and the residents they serve through enhancing their access to resources which make provision of clinical care more efficient, effective, and less bureaucratic. Therefore, we are proposing that nursing facilities take a different approach to improving quality of care.
We all agree that the current health care delivery system for older adults is broken. Designing an optimal system is expensive and will take a long time to achieve. Band-aid approach to addressing the care issues are ineffective. Therefore, we propose to re-engineer the long-term care system by "raising the floor", each time as we achieve our goals until we reach the optimal level. The key components to raising the floor at the basic level includes:
Providing enhanced care coordination across settings, especially at transitions from one level of care to another
Making key clinical data available at the point of care
Educating the health care team in managing common geriatric syndromes with practical decision support tools
Supporting optimal prescribing to maximize benefits and minimize harms and burdens of medication
Eliciting, documenting, and designing care around, resident’s care goals
I would like to share with you a few examples of how we have we have implemented the components required to raising the floor in long-term care.
Providing enhanced care coordination across settings, especially at transitions
The main problem with our health care system is that it operates in "silos" from acute care to long-term care to home care. This includes everything from care delivery to regulations to reimbursement. These silos have resulted in duplication, inefficiencies and poor quality care costing our health care system millions of dollars.
Raising the floor would force us to review our systems and processes across the health care continuum to achieve a smooth transition from one level of care to another.
We have proposed to the Long-Term Living Council, an evidenced based enhanced care coordination program for high risk patients called "staying-at-Home". We believe that if effective care coordination were available which included monitoring adherence to medication regimen, coordinating care with the primary care physician and the specialists and assuring that supportive services are available when needed, many of the high risk patients could be safely taken care of in their own home instead of being permanently placed in a nursing home. We applaud recent efforts in support of community based alternatives to care, and encourage the Legislature to evaluate ways to identify financing mechanisms that will allow such alternatives to grow and succeed.
We are proposing that we streamline the assessment process for LTC services by requiring the Area Agency on Aging, DPW and health care providers across the continuum to collaborate and leverage the existing systems to complete the assessments effectively. We can reduce duplication of effort and safely transition the patient to the most appropriate setting with the most appropriate care providers.
Making key clinical data available and consistent across the care continuum
This is the most critical element in raising the floor of geriatric care and providing high quality care to older adults. UPMC has been working collaboratively with the nursing facilities and home-care providers to develop a variety of automation and other technology-based tools that would make key demographic and clinical data available and more readily communicated through the transition of care. None of these initiatives would be cost prohibitive to the nursing facilities, and would significantly improve the quality of care provided to its residents. For example:
We have made efforts to simplify the nursing home placement and home-care discharge processes by utilizing technologies that support the secure transfer of clinical information needed to make referral decisions, and to facilitate timely discharge from acute facilities. Some of these are web-based solutions that can be accessed by anyone, anywhere. The systems also have the capability to auto fax the information to the nursing facilities and other providers, if they decide not to invest in acquiring the system. This process has significantly reduced the amount of time social workers spend on referral management on both the acute and long-term care side. We have not completed the implementation process, but when it is fully done, we believe the social workers would have time to do the social service activities for which they are trained instead of spending most of their time on unnecessary paperwork.
In working with the area nursing facilities, we have also developed a standard physician order set form to be completed by the physician and a nursing summary to be completed by the nurses when the patient is discharged from the hospital. This standard order set will provide discharge orders including medications, assistive devices, isolation precautions, functional and rehab requirements, etc. It is our plan to send the information electronically to those facilities that have the capability to receive such information, or auto fax it to the facilities before the patient arrives at the facility as well as send a copy with the patient.
We have identified easy to access technologies and tools that enhance nurse-to-nurse communication across levels of care. These tools allow communication of patient needs from one direct-care-giver to another, enhancing continuity of care and improving the patient experience.
Our goal is to work with the nursing facilities to develop similar processes that can be standardized for when the patient is transferred from the nursing home to the hospital.
We believe that these initiatives will help in reducing medical errors at the time of transition and improve quality of care effectively.
Supporting optimal prescribing to maximize benefits and minimize harms and burdens of medication
We believe effective medication management and addressing polypharmacy issues is critical to improving quality of care and quality of life for older adults. Dr. Handler, one of our geriatricians is actively pursuing the development of a long-term care data repository in UPMC Medical Archival System (MARS), which has laboratory and pharmacy data for the nursing home residents. Using this data, he is developing algorithms to predict adverse events and send alerts to the nursing facilities with recommendations on how to avert the adverse event. Since our researchers are also clinicians in nursing facilities, we are able to translate the research findings very quickly into clinical practice. At present we have the data repository completed with the pharmacy and lab data. The development of data repository required us to evaluate the quality of lab and pharmacy data, which was incomplete and of poor quality. This initiative required the nursing facilities, the lab and the pharmacy providers to improve their processes so that clean data can be sent to the repository. While Dr. Handler is continuing with his research, the clinicians already have access to the data repository to review data and make appropriate clinical decisions.
We are in full support of the provisions in PA Bill 700 that quality of health care is enhanced when all health care professionals are able to practice to the fullest extent of their education, training and skills. There is evidenced-based data to support the effectiveness of mid-level practitioners in nursing facilities. Our geriatricians are able to provide access to daily onsite medical care to the residents, families and staff because of the physician/nurse practitioner model applied in nursing facilities. However, the regulations imposed by DOH restricting the NP’s to give verbal orders has impaired the utilization of mid-level practitioners significantly. We urge the committee to change the current regulation to allow mid-level practitioners to function to the fullest extent possible.
Educating the health care team in managing common geriatric syndromes with practical decision support tools
The health care providers in general are not educated in geriatrics and gerontology. We agree that we need to educate the leadership which includes not only the administrator and director of nursing but the medical director in geriatrics and long-term care. We also need to educate the direct care workers in effectively managing the care of older adults. We believe that the traditional educational methods are not effective and do not translate to improved practices. So, we have developed an innovative program called "Three Peas heretofore Not in a Pod", a educational program that requires the attendance and active participation of the Administrator, Medical Director and the Director of Nursing. We are in our third year, so do not know the long-term impact on learning. The program includes an annual conference where a current topic related to quality of care is discussed followed by a six month long collaborative where the nursing facilities go through the implementation of the initiative. Examples include, implementation of POLST which is physicians orders for life sustaining treatment, medication reconciliation at the time of transition, etc.
We have also developed a gerontology certificate program for direct care workers, which includes many experiential and hands-on learning exercises. The curriculum includes a session on sensitivity training, another session on management of delirium, dementia, depression, incontinence, balance and mobility, a session on how to have a discussion with the patient and family on their goals, values and wishes related to their care. The certificate program also includes training the direct care workers in the soft skills of effective communication with the resident, family and other team members, negotiation, conflict management, team work, etc. We are currently piloting the program within UPMC, but have also offered individual modules to the facilities in the area.
We encourage recognition that enhancing the knowledge and skill sets of care-givers in these settings is critical to the quality of care provided, in addition to supporting the needs of facilities to foster retention of that staff. Staffing costs constitute a high percentage of total cost of long-term care. While investment in educational programs enhances quality of care, it is also costly in the short-term. Good public policy would provide incentives, or funding to support such educational activities, which may not otherwise be pursued because of the choices the facilities have to make to operate within the limited resources and the low operating margins many experience. Certainly this would be consistent with the State’s goals of increasing well trained direct care staff available for healthcare.
Eliciting, documenting, and designing care around, resident’s care goals
We have collaborated with CQEL and helped many nursing facilities implement POLST as a tool to document resident’s care goals and have developed a "how to implement POLST manual for the nursing facilities. We are now working with the hospitals, EMS , home health agencies to recognize POLST as a tool where patient’s wishes for life sustaining treatment are documented. To this date, more than 20 nursing facilities have adopted POLST and many hospitals are in the process of developing policies around POLST.
Emphasizing proactive and preventive care
We have a very successful "influenza management program" that has achieved immunization rates among the employees of nursing facilities above 75%, more than double the national average, while maintaining higher than 90% rate for the residents. Additionally, we have implemented protocols in nursing facilities along with the pharmacy such that residents are rarely transferred to acute care for influenza. Furthermore, the nursing facilities have protocols in place to contain outbreaks from spreading across the entire facility. We have similar protocols for management of pneumonia and other infectious diseases commonly seen in nursing facilities.
We are now focusing our attention on implementing screening and management of osteoporosis in nursing facilities.
Conclusion:
Dr. Handler is presenting the findings of his study at the national meeting of the American Medical Director’s Association on "Patient Safety Culture in Nursing facilities". This is the first study of such type conducted in nursing facilities. He surveyed 151 care providers in four nursing facilities and found that nursing homes ranked lower in almost all key characteristics when compared to hospitals in having a supportive patient safety culture. Furthermore, the nursing facilities had lowest scores on non-punitive responses when errors were made and on team work among direct care providers. These results are not surprising because based on highly regulated nature of LTC, we know that regulations is the predominant form of oversight in nursing homes which invokes a punitive culture and suppresses creativity and innovativeness in LTC. Furthermore, the hierarchical nature so predominant in nursing facilities creates a very difficult environment for implementing any quality improvement initiatives.
In conclusion, we urge the Committee to avoid healthcare reforms involving more costly regulations that serve to detract from quality of care instead of improving it. Rather, we recommend that you focus on developing a LTC delivery system that fosters a culture conducive to embracing innovativeness, creativity and fosters learning so that we can re-engineer the system and raise the floor of geriatric care provided in LTC.
Thank you.
Respectfully submitted,
Shikha Iyengar