Today, so much of resident security nomenclature, procedures and equipment are inspired by the emergency preparedness field. Think “situational awareness” and “active shooter,” for two examples.

Behind all that technology today is another, deeper layer that many operators may not even be aware of.

“There’s been a major shift in resident safety technologies like wander management from alerting solutions to management solutions,” observes Steve Elder, director of communications for STANLEY Healthcare.

That deeper layer involves data, which by virtue of how it is mined, collected and analyzed, is arguably another form of technology.

“Wander management solutions are now part of the process for managing residents who show signs of wandering — the information they provide about when wandering is happening can be reflected in care plans so that the behavior is anticipated before it occurs,” Elder adds. “The result is more personalized care and protection of the resident’s dignity, while caregivers are empowered to focus on proactive care delivery rather than just responding to events.”

That extra layer helps nursing homes and others that care for the frail elderly to have a more holistic view of risk. As Elder explains, protection systems now offer a lot more visibility over current status — not just of individuals who need help, but of the community overall.

Various technologies, some borne out of military and industrial applications, are now prevalent, especially in tracking. These include radio frequency, infrared and global positioning systems.

Some of the more nascent resident security tech is now beginning to use facial and noise recognition — far more robust proactive measures that ward off unwanted intrusions while identifying frequent flyers among those most susceptible to elopement.

‘Added staff member’

James Jansen, technology solutions product manager for Direct Supply, notes how these technologies are integrated into video surveillance.

“Cameras can act as a deterrent for challenges involving violence, theft and other behavior communities wish to curb,” he says. “These same cameras have a growing list of analytics, such as facial recognition and noise detection, to essentially act as an added staff member to notify and respond to events such as elopement or active shooter scenarios.”

Take a camera. It could recognize a certain individual, and when integrated to an access control system, tell the door to lock or unlock based on a facial recognition analytic, Jansen adds. Or the camera could hear a loud noise, such as a gunshot, and send a notification to staff while telling the building doors to go into lockdown mode.

Facial recognition is rapidly becoming more sophisticated, and can be a powerful tool in anticipating and preventing potential gun violence, according to Dan Wicker, product consultant for HD Supply.

“Because not every threat is a known person, systems can also be programmed to look for common abnormalities such as a long coat in summer, covered face, or threatening objects,” Wicker says. This can easily be paired with a modern notification system that most communities are already using, and the systems can send a text, email and/or phone call, lock or unlock doors, and even call the police department simultaneously, he adds.

The role of artificial intelligence cannot be understated.

Both AI and predictive analytics “allow you to respond to the exact door the resident exited from or intervene before two residents meet,” Wicker notes. In addition, modern systems can store photos of all residents, and when an elopement is discovered, the report is accompanied with a current photo.

“I can tell you from experience that looking for a person you don’t know well or not at all can easily end with you walking right past them,” he says.

Real-time location systems  another technology generated in military applications, is one of the most widely used in many security devices like wearables inside skilled nursing facilities. One of the most popular applications is elopement detection and prevention, and more recently, falls detection and prevention, says Martin Rokicki, chief executive officer of Skynet Healthcare Technologies.

The core of its value lies in speed, adds Wicker.

“Two key benefits with current and emerging tech are the access to quality information and the speed in which this data can be delivered,” he says.

The tech becomes even more interesting when it’s combined with embedded cameras programmed to detect things like movement, heat, height, facial and object recognition.

Chief Business Officer Jerry Wilmink says his company, CarePredict Inc., utilizes “deep learning,” a sophisticated type of sensor- and wearables-based machine learning, to mine data around residents’ activities of daily living. The data is coupled with what Wilmink calls “contextual cues” to gather insights like self-neglect, fall prediction, unusual behavior patterns, malnutrition and dehydration, “all without any self-reporting by the senior or need for a constant human observer.”

People power

Until robots replace caregivers, all of this sophisticated technology can easily be hacked and handicapped if it’s managed by people who aren’t vigilant, lack common sense or are unable to think on their feet.

Says Brad Hyder, marketing manager at TekTone Healthcare Communications: “From hiring the right staff to choosing the right medical equipment, management teams must be confident that the solutions they are choosing will yield the highest amount of resident protection.”

Paul Larson, vice president, new product development and engineering services for RF Technologies, believes today’s most effective resident security melds resident behavior monitoring with the use of a wander management system.

“Infrequently-used doors should always be locked with a delayed egress lock, and frequently-used doors should be monitored during the day and locked during the night, even when a wander management system is used,” he says.

Experts agree that being attentive to resident behaviors of all kinds — whether aberrant or normal — is something even today’s most sophisticated artificial intelligence and predictive analytics could miss.

“Sensors, sensor fusion, algorithms, learning abilities of AI systems and prediction capabilities are all improving and enhancing the prevention capabilities,” says Majd Alwan, Ph.D., senior vice president of technology for LeadingAge. “However, the human assessment and observer’s input is extremely valuable when it comes to identifying, and trying to avoid or eliminate such triggers or problematic behaviors or root causes.”

Alwan, who also serves as executive director of the Center for Aging Services Technologies (CAST), evaluates myriad tech of all kinds for senior living. He believes the old adage about an ounce of prevention being worth a pound of cure. This includes assessing residents, addressing causes for adverse events like falls and wandering, having multiple in-depth defense and prevention measures and regular re-assessment and evaluation of the residents and all measures taken to protect them.

Given all of the tech and people power, meanwhile, it’s safe to say the risks are greater than ever.

Some observers believe more residents today are hostile and unpredictable, arguing they are merely a reflection of a society that is arguably more hostile and unpredictable. Powerful and sometimes unpredictable medications also can be a culprit.

“As facilities expand and organizations consolidate and migrate from serving limited specific populations to offering a broad range of care models, such as independent living to dependent care to skilled nursing, the range of security challenges increases,” explains Michele York, product marketing manager for Secure Care Products LLC.

“Certainly with rising acuity levels and other factors, communities face a more complex safety landscape,” adds STANLEY’s Elder. “This is what is driving the adoption of more sophisticated technologies,” Elder adds.

Like anything, the wave of innovation sweeping resident security could leave some staff feeling overwhelmed. Still, tech adoption in this space is a fait accompli.

“Predictive technology and AI are much more widely available now than they were just a few years ago, and seemingly finding new applications all the time,” observes York. “While we have not seen long-term care making significant investments in such high technology yet, it’s only a matter of time.”

Intriguing future

Larson believes the use of artificial intelligence for predictive analytics “will be part of a big trend in the future to take advantage of the mountains of data collected by today’s top systems. As tracking capabilities and battery life improve, and the associated costs come down, solutions like geo-fencing and outdoor tracking of elopers will become more prevalent.”

In the years to come, the operative word is integration.

“We’re going to see integration of more kinds of systems to provide a detailed and nuanced view of each resident,” Elder says. “This will include more, and more sophisticated, systems within the senior living community — the EMR, wellness monitors, real-time location systems and others — but also consumer devices like wearables, smart medication management systems and connected health monitors like scale sand blood pressure monitors.” 

A bout of the flu or pneumonia, for example, can be life-threatening in immunocompromised residents and may lead to secondary complications and community outbreaks. Beyond that, a case of herpes zoster (shingles) can prompt acute and debilitating nerve pain for months or even years after the blisters heal.

Despite the proven benefits of immunization and the fact that influenza and pneumococcal vaccines — the two most widely recommended for long-term care residents — are covered under Medicare Part B, many residents still aren’t getting them.

Lingering misconceptions about immunization, particularly that vaccines cause illness or are often ineffective, pose one of the greatest obstacles.

“This challenge is exacerbated by the fact that vaccines may not fully prevent infection or a disease in seniors,” says Joe Kramer, VP of sales for Geri-Care Pharmaceuticals Corp. Certain residents and their loved ones also may mistakenly believe vaccines are meant for those who are ill and not necessarily meant as part of a proactive wellness approach, he notes.

Beyond the personal pain and health concerns, a lack of vaccinations can bring havoc to facility operations.

Anti-vaxers’ effect

Some pharmaceutical experts say the anti-vaccine movement, which is largely targeted toward infant and child vaccinations, has begun infiltrating long-term care. In particular, healthcare workers’ negative beliefs about vaccines can have trickle-down effects on residents, says Marci M. Wayman, PharmD, a consultant pharmacist for Turenne PharMedCo.

“If vaccinations are not a priority for the nursing staff, perhaps the residents will not be offered vaccines or encouraged to take them,” she explains.

Even with a robust hygiene program, unvaccinated employees in nursing homes place residents at risk for infection, experts assert. When employees avoid shots for themselves or their children, they further increase the odds of disease transmission in the resident population.

Staffing shortages in the long-term care segment further compound the problem. Although some states and individual facilities require annual flu shots for employees, some operators in non-vaccine-mandated states fear vaccination requirements could pull qualified candidates from the hiring pool.

When it comes to long-term care resident immunization programs, pharmaceutical and clinical experts agree that influenza and pneumococcal vaccines are most vital. Appropriate administration of those vaccines is even used as a quality measure by the Centers for Medicare & Medicaid Services. The flu shot — either the recombinant or inactivated version — should be offered to residents each year.

The Centers for Disease Control and Prevention makes no recommendations for which type of influenza vaccine to give to seniors — standard dose or high dose, trivalent or quadrivalent, adjuvanted (a substance added to vaccines to boost immunity response that allows a smaller dose to be used) or unadjuvanted. But “there have been small differences seen in clinical trials that may suggest the high-dose version may provide superior effectiveness for some populations,” notes Mark Boe, president of Guardian Pharmacy of Minnesota.

This is the last season the trivalent flu vaccine will be offered, however, adds TJ
Griffin, RPh, chief pharmacy officer at PharMerica. “Only the quadrivalent vaccine will be available after this season and the price will go up as a result.”

What some might consider a “simple flu” can prove deadly in immunocompromised elderly. More than 20,000 people die annually from the flu and 90% are over age 65, Boe reminds.      

“Among the elderly, flu outbreaks in nursing homes can be deadly as the median infection rate in long-term care is 33 percent,” he explains. “Since the mortality rate among our elderly is about 6.5 percent, these risks are pressing matters.”

Double-whammy risk

Many residents who contact the flu end up with pneumonia, warns one clinician.

“One season, I had seventeen patients die from flu complications,” says Shari Carson, RN, BSN, chief clinical officer for Metron Integrated Health Systems.

With a well-matched flu vaccine, the shot will reduce the risk of flu illness by 40% to 60%, according to the CDC. When the flu is contracted in a vaccinated individual, the vaccine may still have triggered a positive immune response, so symptoms could be lessened, Griffin reminds. It’s a message that should be shared frequently with employees, residents and their family members.

Only about 10% of Metron Integrated Health residents refuse flu vaccine, and consistent vigilance can be largely credited to that success. The organization offers the influenza vaccine to every resident admitted from September through April. Those admitted outside those typical flu season months who will be staying in long-term are asked if they wish to receive the vaccine when it is given later that year.

“In October, all who have been signed consent are given the influenza vaccine once we go over the new year’s information,” Carson says. “Those who refused are offered again.”

The elderly also should receive the pneumococcal vaccine, administered in two different doses, and clinicians must follow proper dose timing intervals. The first dose, the PCV13, covers 13 strains of bacteria; the follow-up dose, the PPSV23, covers 23 strains and should be given at least one year after the PCV13. The CDC recommends this vaccine dosing/timing for most immunocompetent residents 65 years or older, including those who have not received any prior pneumococcal vaccines or have an unknown vaccination history.

Those age 65 or older who previously received a dose of PPSV23 but not the PCV13 dose should be given the PCV13 dose at least one year after the PPSV23 dose, regardless of medical conditions. The CDC does not generally recommend administering additional doses in seniors.

Beyond the Big 2

In addition to the flu and pneumococcal vaccines, many clinicians and pharmacists strongly recommend the shingles vaccine for senior residents. Many operators will be happy to learn that as of press time, the shingles vaccine shortage was easing, although its availability was still spotty, due to ongoing high demand and resulting waiting lists.

Even if the vaccine were readily available, some facilities aren’t pushing shingles vaccination due to reimbursement concerns and, perhaps, a lack of awareness on the vaccine’s benefits. 

“With the influenza and pneumococcal vaccines, it’s very clear that those are covered under Medicare Part B, but [the shingles vaccine] is covered under Medicare Part D,” explains Jennifer Hardesty, PharmD, FASCP, chief clinical officer for Remedi SeniorCare. “If you have a [resident] in a nursing home under a Part A stay, it could be a challenge getting the vaccine covered by Part D. You may need to pay and then get reimbursed.”

The intermittent shingles vaccine shortage shouldn’t keep operators from trying to access the shots and administering them whenever they become available, according to Griffin. Because the vaccine is administered in two increments — an initial dose, followed by an identical dose six months later. He recommends administering the first whenever possible.

“You’ll still have time for the supply to pick back up before that second dose is needed,” he explains.

The CDC assures there’s little cause for concern for residents who received the first dose nearly six months ago and may miss their second dose due to supply shortages — they’ll still be covered. Still, the agency recommends residents receive the second dose as soon as it becomes available, as it offers more than 90% immunity. 

Skilled nursing operators also should ensure residents are current on their tetanus-diphtheria-acellular pertussis (Tdap) boosters. Pertussis (whooping cough), has made a resurgence due to unvaccinated rates rising, and previously vaccinated adults who don’t get their booster shots are susceptible.

Setting records straight

Incomplete or altogether absent vaccination records for residents admitted to skilled nursing from hospitals, assisted living facilities or the general community leads to confusion and, perhaps, duplicated vaccines being administered unnecessarily.

“Since some vaccines aren’t supposed to be administered more than once, this is a big concern,” Hardesty notes.

When Amanda Kistler, RN, president of the National Association of Directors of Nursing in Long Term Care, worked in the skilled nursing environment, she says it was common for the hospital’s or discharging facility’s records to be incomplete.

The pneumococcal vaccine can be one of the most challenging when there is an unclear immunization history, according to Sarah Barker, PharmD, General Manager of Turenne PharMedCo-Montgomery. Having two vaccines that are given in separate years makes it more difficult.

Often, a resident or family member knows the resident received a pneumococcal vaccine but is unsure if it was PCV13 or the PPSV23, Barker explains.

“An incomplete history makes continuing the correct pneumococcal vaccination schedule more complicated,” she says.

Upon admission, vaccination history should be captured and documented, if possible, and any gaps in immunization should be addressed with an individualized vaccination plan. When a resident is transferred or discharged, it’s equally important that his or her immunization status is updated and included in the electronic medical record.

Beyond that, simple vaccination cards that identify the types and doses of vaccines received and the date they were administered also should be considered. These can be given to the resident or a family member and then handed off to the next doctor or stop in the care continuum, Hardesty says.

Experts agree community-wide education for staff, residents, family members and all other visitors remains the best approach for increasing vaccination awareness and participation and keeping more accurate immunization records.

“Staff members should be educated so they can educate residents on the usefulness of the vaccines,” says Julie Stafford, RN, CDP, CDONA, CADDCT, FACDONA, IP-BC, nursing home administrator at Genesis HealthCare-Alleghany Center in Sparta, NC.

Information tailored to skeptics often wins them over, she adds. 

The long-term services and supports thinktank detailed existing labor shortages and the roles foreign-born workers already play in senior care.

About one-quarter of today’s CNAs in the United States and one-third of homecare workers are immigrants, said author Natasha Bryant, managing director and senior research associate with the LTSS Center.

“We hear again and again of our members’ difficulties in recruiting the staff they need. This is a crisis,” she told
McKnight’s. “Foreign-born workers are one solution.”

The LTSS Center reviewed existing literature and interviewed providers in Australia, Canada, the United Kingdom and the U.S. for its reports.

LeadingAge said providers should use formal channels to verify the trustworthiness of potential employers and employees, possibly establishing a registry, and implementing effective workforce enforcement procedures.

Challenges such as language and cultural barriers, racial and ethnic discrimination, and stressful working conditions can be improved with training and support.

The Department of Health and Human Services’ National Toxicology Program has preliminarily recommended adding light-at-night to its list of substances “known to be human carcinogens,” potentially putting it alongside other dangers such as arsenic, plutonium and tobacco.

After a two-year review of existing studies from around the globe, government researchers found the strongest link between light at night and increased breast cancer rates.

The extensive analysis looked at overnight light’s impact on circadian rhythm, connected hormonal changes and other behaviors or conditions common in shift workers.

“Few night shift workers are able to adapt their circadian rhythms to their altered sleep-work cycle, and women with more persistent shift work may have health problems,” report authors noted.

Preliminary conclusions will be peer-reviewed and will be the focus of a public meeting in October.

Many nursing leaders are reeling from the 2% payment penalty implemented under the Value-Based Purchasing program effective Oct. 1. It’s too late to change your current VBP payment rate, but improving your facility’s discharge process can benefit future payment years by improving readmission rates.

The Agency for Healthcare Research and Quality designed its recently released Re-Engineered Discharge (RED) Toolkit to improve the discharge process by teaching residents self-care at home. Facility leaders can learn from AHRQ’s research, which found that the RED process improved resident satisfaction and outcomes and reduced hospital costs.

The RED toolkit spells out 11 steps to improving facility processes. A critical first step is selecting a senior management team member as sponsor and assembling a team of staff members to champion the rehospitalization-reduction process with strong commitments and clear goals.

Performance scores shown on Nursing Home Compare are outdated. The RED toolkit details a process for analyzing your current readmission rates and setting an improvement goal. This analysis should be parsed out by facility, by specialty, by unit and by diagnosis.

Next, consider developing a process map to enable easy visualization of each person’s role and of the gaps, incomplete tasks, and potential problems.

Another notable step in the RED process is post-discharge phone calls. The toolkit includes scripts that can help assess residents’ knowledge of their discharge instructions, assess medication compliance, and identify potential complications.

The object of my concern was a no-doubt well-intentioned joint press release from consumer advocacy groups LTCCC and the Center for Medicare Advocacy.

Their push is to create medical-loss ratio rules for nursing homes. In other words, leveraging providers to prove that X amount of public funding is going toward direct resident care, or other designated uses. Until the case-building against skilled providers gains more credence, it’s going to be an uphill battle.

The lead argument is that nursing homes have experienced double-digit Medicare profits for the last 17 years, per MedPAC calculations.

The March 2018 MedPAC report refers to an 11.4% profit margin. That, however, is for fee-for-service Medicare only. That represents just 11% of total facility days and 20% of facility revenue.

In other words, 89% of days and 80% of revenue come from other payers, mostly Medicaid, which sport a -2.3% margin. Combined, the Medicare and non-Medicare margin for providers is only 0.7%.

The tortured logic and statistic abuse gets worse. Still in the first paragraph of the consumer groups’ joint letter, they say that the Centers for Medicare & Medicaid Services “finalized a new payment system” that gives providers $820 million in increased pay.

The new payment system is not responsible for the $820 million increase. The pay raise is mandated by law and represents a 2.4% market basket update. Last year, the raise was just 1%, which also was specified by law.

Then the advocates claimed providers will reap a huge windfall from the Trump administration’s new tax scheme. The only problem is providers struck out and are NOT going to enjoy any extra tax cuts.

It’s reasoning like the above that makes it tough to take anything that follows too seriously. It doesn’t help the consumer advocates’ case, and being overzealously tarred this way surely doesn’t help nursing homes’ image.

One can only hope for the day when this type of irresponsible behavior no longer takes place.

The “spectacle” is arranged by Exceptional Care for Children, Delaware’s only pediatric skilled-nursing facility. With 42 beds, the facility provides long-term and end-of-life care for kids up to 21 years old, all of whom depend on medical technology to survive.

Staff plans to take eight children to Disney World in Orlando next year, hoping to give them a slice of sunshine in their frequently trying lives. This will be the fourth such trip, dating back to 2011. It’s all part of its “Exceptional Care for Children Magical Journey” program, which was recently named the American Health Care Association’s 2018 Not-for-Profit Program of the Year.

Exceptional Care has kept the tradition going every other year, with a break in 2017. The group of staff and residents will spend six days and seven nights in a 12-bed villa. Though it may seem extraordinary to an outsider, Annette Moore, administrator of ECC, said each is just another day for the kids, and that’s exactly how she wants it.

“They don’t understand the capacity of what it takes to get them there, and that’s the most satisfying to me as the administrator, and to this organization,” she said. “It’s just another day.”

—Marty Stempniak

Executives previously had said they expected to finalize the affiliation by Jan. 1.

“For several months we’ve talked about the advantages of bringing Society professionals together with the healthcare experts at Sanford Health,” Good Samaritan President and CEO David J. Horazdovsky said in a statement. “This clears a major hurdle in advancing the care for those we serve.”

The Good Samaritan membership voted overwhelmingly in favor of revising the organization’s articles of incorporation, clearing the way for an affiliation agreement with Sanford Health. The organizations’ boards had approved the affiliation agreement before that vote.

The merger of one of the country’s largest senior living and skilled nursing organizations with one of the nation’s largest healthcare systems, both headquartered in Sioux Falls, SD, will result in an organization with about 47,000 employees in 26 states.

“We feel strongly that this visionary plan will be modeled throughout the United States to offer a continuum of care throughout one’s life,” Sanford Health President and CEO Kelby Krabbenhoft said. “Having no objections during the government’s regulatory review confirms our beliefs.”

It seems like hardly a day goes by without a new app, gizmo or software application riding to the rescue. But as anyone who has ever had to deal with tech support can attest, technology is great — when it works as intended.

When it doesn’t? Let’s just say that keyboards, smartphones, monitors and printers may face a higher injury risk.

Which brings me to a recent announcement that the new Apple Watch Series 4 will offer electrocardiogram readings. The same watch has also received federal clearance for another feature that detects atrial fibrillation.

There’s no doubt these additions are going to help save lives going forward. The early warnings they provide will in many cases be the difference between life and death. They probably also will play a key role in preventing and minimizing the non-lethal consequences of postponed caregiving.

But it may not be all crimson and clover for skilled care operators here, for a few reasons.

The first is what might politely be called the risk of false positives. In other words, some of your residents or aides may look at readings and conclude a health crisis is in progress. An ambulance ride and several hours at the hospital later, it might be determined that the alarm was false.

This is no mere hypothetical. The Seattle Times reported that a growing number of cardiologists are concerned about the implication of wrapping fitness- and medical condition-trackers around wrists.

Then there’s the flip side of overreacting: Doing nothing. Should the data indicate a possible problem and the staff concludes it’s nothing serious, a whole new set of legal exposure issues could arise if something serious plays out.

Plus, all that data the staff did not respond to will be well-preserved for future consideration by plaintiffs’ attorneys and others who might be interested.

It’s possible some facilities may soon be advised by legal counsel to prohibit the use of wearable devices on the premises. And they say irony is dead?

What is new related to AMDA-The Society for Post-Acute and Long-Term Care Medicine’s flu vaccination guidance?

A: We are now recommending mandatory vaccinations for all long-term care healthcare personnel,  unless there’s a medical contraindication. We mean volunteers, employees and those family members visiting residents — really anyone in close proximity.

Q: What has the response been?

A: It’s been extremely positive from our members.

Q: What do you say to people concerned about getting the shot?

A: It is true last year’s flu season was brutal. The effectiveness was about 30%. People think 70% ineffective, and it wasn’t the case: The rest of the population will have a less severe case.

People often ask if they can get the flu from the flu shot. It’s categorically impossible. The biggest symptom is a sore arm.

Q: What is your advice for facilities struggling with whether or not to make this mandatory?

A: My advice is to try it. The reason being is that of all of healthcare, long-term care is lagging. We have extremely low vaccination rates compared to other segments.