The biomedical engineers used a process called label-free multiphoton microscopy to view tissue and generate 3D maps of wound metabolism. 

Kyle P. Quinn, Ph.D., assistant professor of biomedical engineering, and Jake Jones, a doctoral student, used autofluorescence imaging of two molecules to monitor cell metabolism. They employed a method called redox ratio to measure concentrations in diabetic and non-diabetic mice over a period of 10 days.

Changes in the optical redox ratio and NADH fluorescence among the diabetic mice indicated that cells remained at the wound edge, growing and dividing, rather than migrating over the wound to restore the skin’s protective barrier.

“The ability of multiphoton microscopy to non-invasively collect structural and metabolic data suggests that it might have broader applications for wound care and dermatology,” Quinn said. 

The full study was published in Communications Biology.

In rodent tests, the bandages developed by engineers at the University of Wisconsin-Madison reduced healing times from nearly two weeks to three days.

“We suspected that the devices would produce some effect, but the magnitude was much more than we expected,” said Xudong Wang, a professor of materials science and engineering who reported the new method in the November issue of ACS Nano.

The new dressings eschew bulky external equipment for small electrodes at the injury site. They are linked to a band holding nanogenerators, which are looped around the torso. The expansion and contraction of the wearer’s ribs during breathing compels the nanogenerators to deliver low-intensity electric pulses.

The researchers determined the low-power pulses boosted viability for a type of skin cell called fibroblasts. Exposure to the nanogenerator’s pulses encouraged fibroblasts to line up and produce more biochemical substances that promote tissue growth.

The team is attempting to streamline its structure, allowing it to run off of small, imperceptible twitches or a heartbeat. The cost, Wang said, would not be “much more” than a regular bandage because it uses common materials. 

“The device in itself is very simple and convenient to fabricate,” she said. 

Tackling everything at once is overwhelming. It is best to break the program down into categories, then prioritize. I recommend you divide the program into these nine categories: 

(1) Wound care team: Identify the team leader and members. Ensure the team meetings focus on prevention.

(2) Sufficient supplies: Ensure there are sufficient support surfaces (bed and wheelchair), heel-lift devices, incontinence management and topical treatment products, and nutritional supplements.

(3) Communication systems: When a wound is found, stress communication between shifts and between the hospital and nursing facility. When a wound declines, ensure proper notification.

(4) Pre-admission process: What is needed prior to admission?

(5) Admission process: Risk assessment and care plan development, head-to-toe skin assessment to capture admitted wounds.

(6) Prevention program: Risk assessment and care plan updates, turning and repositioning program, toileting program, placement of support surfaces for the bed and wheelchair, heel elevation if needed, and monitoring of weights and intake.

(7) Treatment program: Weekly monitoring of wounds, and access to wound care clinicians and vascular physicians.

(8) Monitoring program: Treatment sheet review for completion, turning and repositioning, implementation of interventions, care plans kept up to date, and wound dressing technique.

(9) Education upon orientation and yearly, on topics such as skin breakdown and care plan development.

Taking on a single category at a time makes the program more manageable.

Please send your wound treatment-related questions to “Ask the Expert” at ltcnews@mcknights.com.

“The days of a great relationship with a discharge nurse are way behind us,” said Rich McKeon, vice president of McKesson Alternate Site Pharmacy Solutions.

At the same time, the dizzying amount of data available means long-term care providers have to pick when presenting to referral partners, said Mark Eastham, R.Ph., senior vice president, McKesson RxO.

“There is a ton of data out there, so it’s about coordinating that data and pulling out the pieces that make it actionable,” he said.

In addition to managing a referral stream, Eastham told McKnight’s that major challenges remain with providers being reimbursed correctly.

“We see the problems with how they are coding, and in a lot of cases it leads to underpayment,” he said. “There are a lot of new products coming into the market: If they don’t get it right now, it perpetuates  miscoding and missing out on significant revenue opportunities.”

Plus, as valuable as nurses are in long-term care, pharmacists shouldn’t be taken for granted, the executives agreed.

“The pharmacists play a vital role in the healthcare chain,” Eastham said. “They are getting six years of training. In particular, in a nursing home, it’s just critical that pharmacists are playing a key role.”

Other 2019 trends include the 340B Drug Pricing Program. The Health Resources and Services Administration continues to focus on covered entity compliance, the company noted. 

Additionally, there’s a need to address regulatory roadblocks that do not allow parties to openly discuss supply chain disruptions, Eastham said.

“Pharmacy leadership needs actionable insights to help maintain a healthy bottom line and achieve meaningful impact for their patients, their pharmacy and their health system,” he said.

The company will now work with nearly 100 facilities in 14 states. Terms of the deal were not disclosed.

Both companies have telemedicine platforms that allow residents in post-acute facilities to have access to physicians on weekends, overnight and on holidays.

“We feel very like-minded,” Curavi President and CEO Alissa A. Meade told McKnight’s. “This acquisition is a natural fit for Curavi and our strategic growth.” Curavi, founded in 2016 by University of Pittsburgh Medical Center geriatricians, had worked with 40 facilities in three states with general and specialty care, after-hours coverage, geriatric psychiatry consultations and “bring your own provider” solutions.

The acquisition will further Curavi’s goals of achieving scale efficiencies through an extensive physician network service, and allowing local providers to give telemedicine consults and deliver specialty consultations such as geri-psych services.

Meade will be the CEO of the combined company and TripleCare’s interim CEO Mary Jo Gorman, M.D., will take a new seat on Curavi’s board. 

Both Meade and Gorman agreed that nursing facilities have reframed their thoughts around telemedicine, moving from a “nice to have” to an “absolute have.”

“The other thing that is favorable in overall trends is that Medicare is increasingly recognizing how important it is,” Gorman said. 

Ziegler, with a team led by Grant Chamberlain, acted as TripleCare’s sole advisor during the deal.

Not this time. Within long-term care, 2019 is already shaping up as one of the most potentially disruptive ever. Uncertainty is aplenty, and along with the usual workforce and regulatory demons, we can feel the PDPM (also known as the Patient-Driven Panic Model) shaking the ground like a horde of approaching Orcs.   

Given the urgency of the situation, it seems prudent to move beyond well-intentioned Resolutions and embrace a new perspective: the New Year’s Revelation. Because though we have little idea what to expect in 2019, one thing is certain: Whatever happens will be eye-opening and educational.  

If you’ve ever had a conflict with a difficult person and turn to friends for counsel, someone will inevitably blurt out, “Well, just remember … everyone is your teacher.” You’ll want to slap them, because you know they’re right. The unwelcome challenges, transitions and people we find most distasteful and frightening, the ones that threaten everything we hold dear, invariably turn out to be transformative in the long run. 

Oh, we’re resistant at the time — pumping our tiny fists at the universe in anger and victimhood. But the hard-to admit truth is we’ll learn something and be better because of them, and experiencing invaluable epiphanies. 

So what will we face in this new year? Who knows? I certainly don’t, and neither do you. But literary icon Samuel Beckett has a suggestion, which I seem to quote every year at this time.

“Try again. Fail again. Fail better,” he said. And maybe that’s the only foolproof Resolution we can make for dealing with whatever Revelations 2019 brings.

Things I Think is written by Gary Tetz, a national Silver Medalist and regional Gold Medal winner in Humor Writing in the 2014 American Society of Business Publication Editors (ASBPE) awards program. 

The analysis examined trends of telemedicine uptake in a large commercially insured population between 2005 and 2017. Findings showed that annual telemedicine visits increased from 206 in 2005 to more than 202,000 visits in 2017. Much of the increase happened in the last two years, with an average annual growth rate of 261% between 2015 and 2017, compared to an average 52% growth rate between 2005 and 2014.

This substantial recent increase could indicate that the future of telehealth in all specialty care areas, including long-term care, will continue to grow, says lead author Michael Barnett, M.D., of the Harvard T.H. Chan School of Public and Brigham and Women’s Hospital in Boston.

“If the growth rates we are observing continue, in a decade telemedicine will be seen as quite common,” he said.

Yet while industry leaders have often touted telemedicine as a solution for reaching patients in rural locations or areas with a shortage of trained professionals, this study showed that 83% of the most recent telehealth users were urban residents. Data did show that telemedicine uptake increased where there was a lack of psychiatrists.

Around 90 volunteers spent four days in August at the former Rockford Nursing & Rehabilitation Center in Rockford, IL. Their effort was part of a city initiative to improve dilapidated properties.

The Dec. 15 fire, which remains under investigation, left it a burned shell.

“It tugs at my heart because of all the work that was done,” Vickie Fogel, president of the North End Square neighborhood association, told the Rockford Register Star.

The city plans to demolish the building, but it will ask the owner to pay for the costs, the newspaper reported. The damage was estimated at $120,000.

After being labeled a “special focus facility” in 2010, the facility lost its Centers for Medicare & Medicaid Services certification and closed. In 2017, a judge ordered the owner, North Main Properties, to pay $300,000 due to safety issues. The fine has not been paid, and the city said it will pursue legal action, the newspaper reported.

SOUTHWEST

Medicaid costs to skyrocket

NEW MEXICO — The state’s Medicaid costs will hit $1 billion in 2019, boosted by paying an additional $63 million, according to local reports.

The cause is the federal government reducing reimbursements for beneficiaries, rather than an increased number of people receiving services. While the state’s Medicaid enrollment has declined, the federal government is dropping its contribution to 90% in the next fiscal year, down 3%, the Santa Fe New Mexican reported. 

Enrollment is expected to stay reasonably flat, with 848,000 citizens set to be on the rolls by June 2020.

Gov. Susana Martinez (R) is proposing new premiums and co-pays for some New Mexicans enrolled in Medicaid to help offset the costs.

PLAINS/MOUNTAINS

Pot on ballot in 2020?

NEBRASKA — Some lawmakers are seeking to put a medical marijuana proposal on the state ballot in 2020, the New York Times reported in December.

The District of Columbia and 32 states have legalized it in some form, including three states touching Nebraska. That includes Colorado, where the business has created an estimated 40,000 jobs.

Gov. Pete Ricketts (R) was opposed to marijuana legalization efforts in 2016 and 2017.

EAST

Peds facility under fire

NEW JERSEY — Inspectors found 15 occupied rooms at a pediatric long-term care facility that had cleanliness problems, according to a new report. 

Inspectors had visited Wanaque Center for Nursing and Rehabilitation on Oct. 30 and Nov. 14 during an adenovirus outbreak that eventually killed 11 children. The report was released by the state’s health department on Dec. 17.

Among the findings: A disabled child was wearing two urine-soaked diapers and reported he’d been denied a request to be changed, the North Jersey Record reported. In 15 of 27 occupied rooms, inspectors said bed frames, ventilator carts and heating units had accumulated rust.

The center’s administrator said in a statement that nothing in the report listed systemic deficiencies in policies or procedures. The center’s owners have not commented.

SOUTHEAST

Favorable treatment alleged

ARKANSAS — The Arkansas Health Care Association and its consultants were asked to craft the details for limiting in-home Medicaid assistance, according to newly released documents. 

Proposed amendments to federal waivers were attached to a March 16 email from the director of the association to the state’s Department of Human Services. Agencies that provide the in-home care, along with elder advocates and other members of the public, did not see the rules on the state’s Medicaid website until Oct. 8. The Northwest Arkansas Democrat Gazette published its investigation Dec. 17.

Other elder groups objected to the AHCA affiliate being put ahead of others.

“I think the nursing home association has as much right to be involved in proposed changes to DHS rules as anyone,” Herb Sanderson, AARP’s Arkansas director, told the newspaper. “What I take exception with is, apparently they were involved and nobody else was.”

Proposed changes would reduce the rates to assisted living facilities by around 22%.

Rachel Bunch, executive director of the Arkansas Health Care Association, said it is a misconception the group wants to take business away from others.

“We want to have programs that are sustainable, so that the whole long-term care continuum can work together,” she told the newspaper.

The rules were slated to go to subcommittee for further review and debate in December.

Staffing issues affect practically every facet of a facility’s culture and daily workings. But as successful operators can attest, there are ways to find balance, even in uneven times.

Top long-term care executives and professionals shared both their most vexing challenges and greatest successes during a special McKnight’s roundtable discussion in October, sponsored by Essity, manufacturer of TENA continence care products. Probing discussions covered workforce, caregiving and other top issues. 

Tipping Points

Rising resident acuity is a leading stressor, and it couldn’t come at a worse time for providers already struggling with unprecedented staffing challenges. A great deal of on-the-fly modifications are needed, experts said.

“We need to be prepared to give care everywhere,” said Blake Gillman, vice president/director of post-acute care services for Life Care Services. “It’s as much a challenge as it is an opportunity.”

Staff vacancies are at disturbing levels in many locales. As recently as early 2017, there were at least 22,000 unfilled new jobs in senior care, including skilled nursing, the Bureau of Labor Statistics says.

The first task is to find the workers; the second, to keep them.

That’s why providers that include Des Moines-based Lifespace Communities are using strategies like tying staff retention to executive incentive compensation, said Sara Elizabeth Hamm, DNP, RN, the company’s senior vice president of successful aging & health services. 

“So many large companies have incentive programs based entirely on occupancy, and that needs to change,” she told fellow roundtable participants. 

Chronic wage pressures are impeding efforts to recruit and retain staff.

Courtney Bishnoi, senior director of quality for the American Health Care Association, said one key to combating sluggish wages is providing meaningful work.

“If you’re a CNA and your job is about providing care and your career path is about moving up to being a nurse, you’re not going to leave your job to work in fast food,” she explained. 

Workplace violence and bullying, compounded by caring for growing numbers of mentally ill residents, are other powerful factors straining staffs.

 “If we do not support our staff and hold patients accountable [for violence], then we have failed them,” said Tambria Turco, vice president of clinical operations for Covenant Care.  

Participants were quick to point to leadership failures as a major cause of many staffing problems.

“In this industry, we often see middle or unit management not being well equipped to become managers,” said Bishnoi.

Deep dig for solutions

Participants eagerly shared innovative strategies that have helped them overcome staffing problems.

Hamm, for example, said Lifespace Communities recently recruited an undergraduate fine arts major to provide activities services to residents in exchange for room and board. Gillman added that Life Care Services routinely partners with universities and high schools “to catch potential workers in advance of moving through their career.”

Retention often is sabotaged from the start because hiring managers are looking too much at resumes rather than the people behind them, the panelists agreed.

Nexion Health Management battles this by employing an “unbox me” approach, according to Tara Roberts, vice president of rehabilitation and wound care services.

“We try not to get hung up on people’s certifications or letters behind their names and focus on their talents and interests as human beings,” she said. 

Covenant Care takes it one step further by viewing candidates’ lives beyond work hours.

“Our belief is to integrate people into our organization without looking at particular roles or titles,” Turco said. “While we all may come into a facility or organization with a specific title, it’s really more about who we are. We are community leaders. We are PTA members, boosters, church members. Capitalizing on this instead of pigeonholing people has created a great deal of success for us.”

Successful providers are beginning to find a wealth of talent right under their noses.

“Recruitment isn’t successful if you are constantly turning people over. The best place to look is inside first because it’s as important to retain as it is recruit,” said Bishnoi. “The message we need to convey is that long-term care is a place you can enter with very little training and grow your career path and socioeconomic status. This is not something every industry offers.”

Another benefit from recruiting within: Your employees should be immersed in the organization’s culture.

“Many DONs started out here as nursing assistants or unit managers. We now have these young vibrant people as CNAs wanting more and more,” said Stacey Merritt Hord, senior vice president of clinical operations for SavaSeniorCare. “You have to be constantly thinking about career progression.”

Julie Anderson-Black, vice president of business development and managed care relations for Windsor SNF Management Company, agreed: “The more we can value our staff and mentor and take people we see as leaders from a CNA on up, that’s where the culture shifts and changes and the satisfaction for the patients really is taken up to a different level.”

The same philosophy applies to recruiting managers and directors. Hamm said Lifespace Communities has been very successful with its internal staff development efforts, adding, “We have so many incredible individuals who started out in housekeeping or maintenance who now are leaders.”

Prioritizing engagement

It’s one thing to find the right employee. Keeping her or him is another. That’s why retention and engagement are so vital to staffing success. Making routine and regular engagement should be a high priority, panelists agreed.

One way is to engage staff on levels beyond their jobs, said Roberts, who has seen job satisfaction soar with a technique called purpose-driven mentoring. 

“We try to ensure any supervisor spends time with their employees to find out more about them beyond just being a CNA or a nurse or housekeeper,” she said. “When we do find individuals and are able to move them along their desired path, we then have to utilize them in their new roles, or they will move on.”

Successful providers never dismiss employee surveys.

“We are very passionate about knowing where our workforce sits as far as job satisfaction,” said Gillman, who noted a recent survey indicated less than half of Life Care Services’ staff said they felt they could call any co-workers friends. The company is now working with employees to build and identify more meaningful co-worker relationships. 

Hamm said Lifespace Communities routinely surveys staff to identify whether they’d recommend the organization to their friends. The results can be revealing and compel changes.

Successful companies have found empowerment effective.

Consider Windsor SNF Management, which created grand rounds for lower level clinicians at its facilities. Much like conventional grand rounds with DONs and physicians, interdisciplinary grand rounds give frontline caregivers such as aides and nursing assistants the ability to engage with residents on a higher level, and provide meaningful feedback on important, sometimes, critical, resident care issues.

Anderson-Black said the program imbues staff confidence, and contributes to the organization’s success in reducing rehospitalization rates. 

“When soliciting feedback during these rounds, we’ve taken it a step further and this creates a lot of satisfaction and most importantly identifies value and respect.”

Anderson-Black’s co-worker, Heidi Capela, vice president of clinical services, has had similar success with a program called the “DON Council,” a panel of 13 nursing directors across the company’s campuses that empowers participants to weigh in on a variety of issues, including assessing supplies and equipment. The company also has certified more than 200 nurses as wound care specialists.

Empowering caregiving staff in product selection, in fact, has reaped many benefits, roundtable participants pointed out. Nowhere is that more evident than incontinence care, a field that often finds science clashing with practice.

“It’s so important you have your nurses engaged in decisions about incontinence care,” said Hamm, who worked with staff to develop a clinical advisory committee that selected all of the products, from basic skin care to incontinence care, while working with vendor wound care experts to develop standardized formularies. 

One reason for the program’s success was flexibility in recognizing the nuances of each facility’s practice guidelines around incontinence care. 

“Sometimes each community may have a very different protocol and quality perspective while being good stewards of our financial resources,” Hamm said.

Empowering lower level clinicians has been key. 

“Rather than making decisions at the ‘ivory tower’ level, they do what they know works for them,” said Capela. “It seems small, but empowering staff to choose the products makes such a big difference. You have their buy-in. It’s invaluable.”

Because when employees care, care improves. Buildings become more home-like and a good reputation grows.

“If you walk into the front doors of any senior community and the first thing you notice is the smell of urine or feces, they shouldn’t be in business,” Hamm said. “That is straightforward poor care. That is nothing more than poor care or inadequate staffing levels and with the products that we have today and all the resources and technology that should not be happening.”

Keeping engaged 

Long-term care leadership must find better ways to give staff the tools they need to do their jobs. It’s become increasingly difficult in an age of declining and unpredictable reimbursement.

Everyone has witnessed supply hoarding, which even the most qualified caregivers do at times in order to ensure their residents get the care they need and deserve.

Bishnoi believes the real culprit isn’t necessarily money. 

“The problem isn’t the supply closet or the surveyor,” she said. “The problem is a breakdown in communication to get more supplies. If staff is telling their supervisors they need more resources and the supervisors don’t care, they’re naturally going to get frustrated.”

Merritt Hord agreed. “Leadership has to set the standard. What demotivates someone is not feeling important, not feeling valued or listened to. Key things for senior leaders at any facility level is to listen and engage with your CNAs and frontline staff and ask why they are hoarding.”

Acute, but not cute

Nothing will challenge staff more than having to deal with sicker residents in the years to come.

“We’re taking med-surg patients but we’re not staffing at med-surg levels, and CNAs are the primary caregivers,” said Anderson-Black. “I see that as a huge opportunity and a challenge that’s rather daunting because the patients are going to get even more challenging than they are today.”

Gillman, like others, openly embraces the challenges facing senior living providers today.

“What we need to do is clearly identify the rules of the road, engage employees in something that’s exciting for the future and then drive quality where people stand. If we can do that, then this industry is going to be wildly successful.”