A: The program involves training modules, each with on-demand video or PowerPoint, a deprescribing algorithm and a podcast demonstrating how to have discussions with patients and others. So far, we have completed modules on deprescribing anticholinergic bladder agents, proton pump inhibitors, dementia medications and oral antihyperglycemics.

Q:Were you surprised to cut use of some meds by 40% or more? 

A: Most deprescribing campaigns report 25% success rates. We expected some hesitancy from primary care physicians and consultants about deprescribing in general, but it was most noticeable with the dementia medications. … We attribute our success to relationships with patients and families and efforts to educate them. Like advance care planning conversations, deprescribing conversations are rarely “one and done.” It takes time to explain risks vs. benefits.

Q:As AMDA’s 2021 Choosing Wisely Champion, what advice do you have for others in the business? 

A: There is certainly room for improvement to periodically reevaluate a patient’s medications and taper and discontinue when no longer benefiting the patient, or if the risk outweighs the benefit. I look forward to a culture change.

A: These two positions do totally different jobs for you and your facility.

The pharmacy consultant will assist with your chart audits, destruction of medications and your antibiotic stewardship committee. She also will serve on your pharmacy and therapeutics committee as part of the medical committee. She can assist you with gradual dose reductions and make recommendations to the physicians and nurse practitioners regarding overuse, changing times to assist with drug compatibility, and other suggestions that could improve med pass efficiency. 

Pharmacy consultants also can do mock surveys and observe and provide in-service training on topics including, but not limited to, drug diversion, antipsychotics, antibiotics and administering eye drops.

The nurse consultant can assist with many supportive duties. She also can assist with mock surveys, especially in preparation of the facility’s annual survey, and with hiring new nurses, especially those with little-to- no long-term care experience. 

The nurse consultant also is a great resource for providing additional in-service training. Typically, they visit a few facilities and are able to share what the surveyors have looked at during one or more prior surveys. That can be very beneficial, as you can make corrections before your “visitors” arrive. 

The two consultants can work together, possibly relaying information between the facility and pharmacy.

Perhaps you continually have a delivery problem, or labels over the lid of a bottle prevent you from opening the bottle without damaging the label. A consultant nurse can convey this information to the pharmacy to ensure any issues get corrected

These two positions will make your life easier if used correctly and thoroughly.

A: Pressure injuries are a universally recognized quality indicator, meaning that the presence of such a wound implies that something went wrong. The care of pressure injuries is a multidisciplinary endeavor that involves doctors, nurses, CNAs, nutritionists, speech therapists, pharmacists and materials management personnel. It is a process that needs to be incorporated into the facility’s day-to-day activities.  

This concept is actually embedded within the federal regulations that govern nursing homes, which say facilities “should have a system/procedure to assure: assessments are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, and addressed.”

The commitment to pressure injury care  must come from the top level of administration, with representatives from each discipline gathering information and provide interventions that maximize the efficiency of prevention and treatment. 

Start by gathering wound statistics for a period of time, targeting specific cases where care might have been improved and asking specific questions.

Were the wounds present on admission? Were proper prevention interventions in place and care planned? Were treatment modalities appropriate and timely? Was nutrition properly assessed? Was the family properly informed? Were consultants utilized? All these questions must be honestly addressed for improvement. 

The maintenance of skin integrity for frail residents is a unique challenge for facilities across America. The best way to prevent and heal wounds is to tweak the system to proactively create and maintain a system that delivers maximum quality of care.

A: In late March, RaDonda Vaught was convicted of gross neglect of an impaired adult and negligent homicide for administering incorrect medication, causing patient death. She was acquitted of reckless homicide. There is much to learn from the multiple factors that contributed to this tragedy. 

To mitigate medication errors, re-educate about the basics of medication administration. Nurses should use the “five rights” — the right patient, right drug, right dose, right route and right time — every time. Examine the process nurses use and audit to ensure compliance. For example, assess how staff identify the “right resident.” Do residents wear name bands? If not, how do staff ensure they have the right resident? 

Vaught overrode warnings within an electronic medication cabinet and indicated that overriding was a common practice. Research has shown nurses may experience alarm fatigue and become desensitized, leading to missed alarms or delayed responses. Remind staff to take every warning seriously and ask about ones they don’t understand. Audit on it.

Vaught also was training a nurse. Review your orientation process. Ensure that staff leading trainings have a lighter load to allow time for teaching.Verify those doing the training do so correctly. 

Vaught attributed the error to systemic failures in her hospital’s processes.

As nurse leaders, we must ensure our facilities’ systems promote safe care delivery. As nursing professionals, we also must work within those systems to provide appropriate care for the residents who depend on us.

Responses from about 20 physicians offer insight into the dramatic shifts in care delivery that occurred during this time period. For example, use of the technology was heaviest during COVID-19 peaks from March through May of 2020, the doctors reported. Most telehealth appointments were initiated for follow-up care, history and physicals, and regulatory exams.

About half of the physicians performed more than 20 telehealth visits, but almost 13% conducted more than 100 visits during the year. 

The choice to provide remote care was most frequently necessitated by facility COVID-19 outbreaks and the need to provide care in more than one building, said lead author Ana Gomes, DO, regional medical director of Genesis Physician Services. Access to a smartphone or laptop and nurse assistance were vital to a successful visit, the authors added.

Nearly half of doctors felt telehealth patient interactions were successful, but 20% reported feeling frustrated and 20% called telehealth an “option of last resort.”

The biggest challenges doctors found were issues with Wi-Fi access and technical support at the facility level. Staffing shortages contributed to communication challenges as well, respondents said.

Overall, however, these geriatricians felt telehealth gave needed access in constrained circumstances. In addition, 64% of the physicians agreed that telehealth could contribute positively to their practice moving forward.

“Physicians found telehealth instrumental in their ability to communicate directly with patients and their families, to discuss advance care planning, and support nursing staff in addition to complementing their medical practice,” they wrote.

A: Call me the bearer of bad news, but the answer is “not much.” The more time the MDS nurse spends completing “other duties as assigned,” the less time he or she has to focus on oversight of care quality and reimbursement. I completely understand and firmly agree that patient care should come first, but when the facility’s reimbursement experts are busy elsewhere, it should be no surprise that case mix index (CMI) may wane, and assessments, including those required for Medicare billing, might be late or missed. 

As you continue to address the root cause of the issue — staffing — you may consider bringing in some outside assistance. Many facilities have been able to maintain a focus on reimbursement accuracy by employing short-term, remote MDS help to assist in keeping the MDS coordinator’s workload manageable. Not only can this keep the MDS schedule on track, but it can also save you from unintentionally pushing your MDS nurse out the door from sheer exhaustion. Filling an empty position is the last thing you need. 

If staffing is not in crisis, another welcomed practice is cross-training others to complete MDS duties. One of the biggest pet peeves for an MDS coordinator is the feeling that they can help on the floor, but no one can help them in return. Others trained in the role can offer reciprocation when direct care is assigned. 

If you haven’t already, consider a data analytics platform. As an ongoing tool in your belt, such software can identify common coding errors and other areas of data inaccuracy to maximize MDS accuracy.

A: Despite the Centers for Medicare & Medicaid Services directing state agencies in November 2021 to resume standard survey activity, 34% of skilled nursing facilities nationwide have been waiting more than two years for a standard survey. This is potentially an extremely dangerous situation for nursing homes nationwide.

First, surveys are intended to not only ensure compliance with safety and quality of care regulations, but also to help facilities with important and timely self-correction. Going more than two years without a standard survey can lead to existing issues getting much worse. 

The last two years have presented new and compounding issues like worsening staffing shortages and COVID-19 infection control issues, for example, amid increased expenses and revenue shortages. Given delays, and surveyors’ need to catch up, facilities can expect surveyors to take deeper dives than usual when they do show up. The likely result will be more citations and higher financial penalties — two outcomes that would be enormously unhelpful to this struggling industry. 

Moreover, providers will continue to be impacted by the F-884 tag for COVID requirements. Facilities can expect that surveyors will continue to nitpick infection control and vaccination requirements, policies and procedures as well. 

It is interesting that CMS points to staffing shortages among survey agencies as a partial reason for the survey delays. We can only hope that survey agencies nationwide and CMS will be empathetic to facilities suffering nursing shortages since they now find themselves in a comparable situation.

We can hope, but we should not count on it.

Yowler has served as PharMerica’s chief financial officer since 2019, playing a lead role in the development and execution of the financial and operational strategy of the company. She takes over for Robert Dries, who is retiring. Dries was to remain onboard temporarily as an executive advisor to assist with a smooth transition, Louisville-based PharMerica told Louisville Business First. The company quietly moved Yowler to the top of its leadership website and shared news of her promotion on LinkedIn in March.

Yowler joined PharMerica after 20 years as a senior healthcare executive. She has experience in finance and operations at multiple companies in the long-term care and healthcare industry, including Omnicare, Partners Pharmacy and PricewaterhouseCoopers.

Her background includes work in corporate finance, operations, mergers and acquisitions, and strategic planning.

She holds a bachelor of science degree in business administration in accounting from Ohio University.

Yowler told the news organization that one of her key goals will be to work with employees to fill their needs, supporting the work environment and communicating with them about opportunities within the company. 

With more than 140 pharmacies and 6,000-plus employees, PharMerica is one of the nation’s largest providers of pharmacy solutions for long-term care, senior living, hospice, behavioral health and specialty settings.

If there’s one thing nursing home providers, consumer advocates and regulators can agree on when it comes to developing a minimum staffing rule, it might be just how difficult the job will be.

The Centers for Medicare & Medicaid Services has vowed to study the issue of staffing — the types and levels needed — and propose a  rule mandating coverage in one year, an effort the agency said is “at the heart” of a sweeping federal initiative to reform nursing home care.

The agency has been grappling with the relationship between staffing and patient outcomes for more than 20 years, commissioning prior studies but failing to update standards as part of other, broader healthcare initiatives. A proposed skilled nursing pay rule issued in April, however, underscores its commitment to formalizing a requirement next year. CMS said it intends to adopt a value-based incentive for nurse staffing hours and officially requested comment on 17 issues that could shape a direct care staffing minimum.

“This new evidence-based requirement will permanently strengthen staffing and quality of care by ensuring facilities have enough well-trained staff on duty to provide the services needed by the residents who rely on them,” a CMS spokeswoman told McKnight’s Long-Term Care News April 14. “Setting minimum staffing standards will further encourage facilities to pay a living wage, with competitive benefits, and provide opportunities for advancement. Quantitative standards will also enable closer oversight.”

Areas of focus unveiled by CMS in the 2023  proposed pay rule range from which positions to include to how to account for labor challenges to how potential costs — and whether better outcomes, such as fewer hospitalizations, might offset them. But the ongoing labor shortage itself seems unlikely to slow CMS’ effort.

“It seems like now is the moment,” said Steven Littlehale, a gerontological nurse specialist and data analyst with Zimmet Health Care Services Group. “We may actually see real, authentic minimum staffing requirements that go beyond the hard-to-define terms such as ‘sufficient’ staffing.”

History at work

The basis for today’s staffing rules dates back to the 1987 Nursing Home Reform Act, which called for 24-hour LPN coverage and eight hours of RN coverage each day. The law also triggered the need for “sufficient” staff to meet resident needs.

A 2001 study established an oft-cited but never mandated benchmark of 4.1 hours of per day, per resident care.

“For 20 years, we have been arguing that CMS needs to set minimum staffing standards,” Charlene Harrington, RN, Ph.D., professor emeritus at the University of California San Francisco School of Nursing, told McKnight’s. “Facilities, if they’re trying to make money, they just have too much of an incentive not to meet what we know the standard should be.”

Harrington wants CMS to adopt 24-hour RN coverage and take the overall minimum above 4.1 — though 60% of nursing homes operate below that threshold now, according to one March study. Washington, D.C, is the only area with a 4.1 requirement, and just 20 other states require per-day, per-patient care totaling 2.5 hours or more.

CMS said in April that a more stringent RN rule could be “an alternative or supplementary approach.

“Greater RN presence has been associated in research literature with higher quality of care and fewer deficiencies,” the agency wrote, adding that it also could reduce the likelihood of LPNs working outside of their scope of practice. 

Who counts?

Today’s nursing homes are much different from what they were in 1987, with residents often requiring care from a broader range of workers than the once-typical, long-stay resident. CMS acknowledged as much, noting increases in residents with dementia, psychiatric diagnoses and admissions from hospitals.

CMS also called attention to Arkansas’ rule including therapists and other non-nurses in staffing calculations. In April, Florida Gov. Ron DeSantis (R) signed a bill adding nursing, dietary, therapeutic and mental health workers into an overall staffing measure. The state still requires a 3.6-hour minimum weekly average of per-resident, per-day care provided by CNAs and licensed nurses and at least one CNA on shift per 20 residents.

Lori Porter, CEO of the National Association of Health Care Assistants, said her members support a minimum, and she’d like to see CNA coverage expressed in a ratio of staff to patients, ideally at 1:10. No matter how CMS approaches the metric, she wants the emphasis to remain on CNAs.

“People who truly know nursing homes realize that 90% of the care a resident requires is from a CNA,” she said. “In that setting, there are very few skilled needs of a resident that require a nurse.”

But Littlehale said care provided by non-nursing staff also should get serious consideration by CMS, given the increasing complexity of nursing home patients and specialties providers are implementing to care for them.

“We really need to encourage flexibility and creativity,” he said. “What about the facility that sees the value and has access to, for example, therapy aides or more social workers or rec therapy? These are really important players on the interdisciplinary team. Maybe based on your particular unique case mix, you want to really have more of them at the bedside for completely valid reasons.”

How to account for acuity?

Harrington noted the current rule requires more nursing care when patient needs increase, a provision she said has been largely ignored by regulators. She said CMS should move beyond past time-study methods and build on existing research using simulation models. That approach would provide a better understanding of how long certain care, such as assistance with activities of daily living, takes, and how those numbers might change based on a building’s patient population.

“There’s every evidence that the case-mix has increased over time since 2001, so as the acuity increases, the minimum standard probably needs to be higher than the 4.1,” she said.

The agency could base acuity on previous months’ MDS submissions to get a read on a facility’s average patient acuity level. In 2020, Harrington and Mary Ellen Dellefield of the San Diego VA outlined acuity categories based on the Patient Driven Payment Model, creating a guide for determining if nursing home staffing is adequate.

How to measure success?

Providers likely will have time to work up to new standards, and some observers suspect CMS may create tiered goals rather than a single hours perpatient, per day target.

One incentive would be funding made available through the SNF VBP program, which will likely add a staffing hours element in 2026. In proposing that measure, CMS said it would “provide a more comprehensive assessment of and accountability for the quality of care provided to residents and … drive improvements in staffing that are likely to translate into better resident care.”

There is little doubt that CMS will encourage compliance by making providers’ ability to meet  new staffing standards public. Against that backdrop, providers are concerned that a lack of workers could lead to penalties and reputational harm.

“Anyone who wants to can recommend that there be more staff, better staffing, more RN coverage, and we’re all for it — excepting there are no people,” Ruth Katz, senior vice president of public policy and advocacy for LeadingAge, said in early April. “There is sort of a fear that new requirements could be put out … and then nursing homes punished for not meeting the requirements when there’s just nobody out there to even apply.”

A March Innovation in Aging study found the cost of meeting acuity-based benchmarks would average more than $530,000 per facility. CMS has said it will consider adequate funding as part of its rule-making process, though it can’t increase its overall spending without Congressional approval.

UCLA health economist Ashvin Gandhi, Ph.D., said CMS should try to discern how legitimate financial concerns are. If CMS sets its metrics too high, he cautioned, it could lead some providers to reject more Medicaid patients or cut costs in other ways that “adversely affect” resident care.

“It’s obviously very important that we have standards of care and that facilities should be meeting those standards,” Gandhi said. “CMS does have to think really carefully about whether and to what degree facilities are going to be able to financially meet staffing requirements. You could have unintentional consequences.”

Truth be told, the past two years have been an incredibly challenging time for way too many long-term care operators. And by all accounts, a full recovery appears far from imminent, much less guaranteed. Bleak might not be the best way to describe the current reality, but it’s certainly in the team picture.

At times like these, I’m reminded of a question Peter Drucker often asked clients after hearing their tales of woe:

“So what are you going to do about it?” 

If the most famous management thinker of all time were still alive, he’d probably ask any LTC professional grasping for more residents the same question.

One possible response would be to assume the fetal position and try to think about a happy place. Trust me, the relief from this tactic is temporary at best. Nor does it do much to address the underlying issue.

Some far better approaches were recommended recently at the National Investment Center for Seniors Housing & Care’s Spring conference. Panelists backed a multipronged approach that emphasizes better care and outreach.

One such tactic might be to help referral sources like hospitals look better, said Joe Kiernan, chief strategy officer and senior vice president at Lakewood, NJ-based Ocean Healthcare.

“[Hospitals] want to minimize exposure and costs,” he said. “Our goal … is to re-engage our clinical program, and that will add to our market share.”

Ramping up clinical capabilities doesn’t mean a provider has to have post-surgery suites or ventilators, Kiernan added. Ocean provides IV medications for cardiopulmonary, sepsis and stroke patients.

Providers were also encouraged to provide better value to all customers; play to strengths; manage online reviews and create a brand that attracts employees. In the end, the best approach to restoring occupancy will need to be based on your organization’s unique circumstances, motivations and leadership. But act you must.

Which reminds me of something else Drucker often said: “The best way to predict the future is to create it.”