While the final 2024 SNF PPS pay rule includes 0.3% more than the originally proposed raise, major provider organizations said it would still be too little to offset increasing costs, especially those likely to blossom from an expected federal staffing minimum.

“The final rule … does not address the reality of providers’ operating environments, and will, ultimately, limit older adults’ access to much-needed care and services,” said Katie Smith Sloan, president and CEO of LeadingAge.

The rule also outlined how CMS calculated the $1.4 billion hike and described an extensive series of changes to skilled nursing facilities’ value-based purchasing and quality reporting programs.

A: The primary audience is owners, administrators, managers, nurses, social workers and direct care staff in nursing homes and assisted living residences. 

Q: Why tackle this subject?

A: Many care homes do not have the knowledge and specialized skills necessary to address this phenomenon. The book identifies the risk and protective factors for these incidents and is filled with insights from numerous studies and real-life stories, as well as dozens of prevention and de-escalation strategies. When owners and administrators of care homes recognize the seriousness of this phenomenon, they are more likely to dedicate adequate resources upfront to address it. 

Q: What was surprising to you?

A: The thing that surprises and saddens me is the dangerous normalization of these incidents. My review of hundreds of fatal incidents over the past 15 years suggests that the circumstances surrounding these incidents are often strikingly similar: invasion of personal space, unwanted entries into bedrooms and bathrooms, conflicts between roommates, taking personal belongings and food items from each other.  Left untracked, the phenomenon remains largely invisible. 

Q: What interventions work?

A: A proactive, well-coordinated, multi-level strategy is essential. Key components include safe staff-to-resident ratios at all times, specialized dementia-specific educational programs, supportive guidance by managers, risk assessment, individualized care planning and robust engagement. 

A: For the insulin pens commonly needed by diabetic patients, remember they are to be used on an individual resident, one pen per resident, and only under a physician’s orders, of course.

Those pens should be stored in separate bins in the med cart. 

If they can’t be stored in a separate plastic bin, you must store them in individual plastic bags (usually provided and labeled by your pharmacy). The resident’s name must be on the bag and some states are requiring a label on the pen/syringe too. Check your state’s regulations and make sure your facility policy aligns.

Some may still have questions, such as if we change the needle and wipe off the syringe with an antimicrobial wipe, can the one syringe be used on more than one resident? 

The answer is a hard and firm NO! Under no circumstance can a syringe be used on more than one resident.

When it comes to storing your oxygen tubing, remember that plastic bags breed bacteria.

Try using a WikiPouch (to be clear, I do not work for them). The WikiPouch is composed of a breathable material with a place on the bag for the resident’s name and a drawstring to hang the contents.

You know plastic bags need to be taped onto something to keep them from landing on the floor. As an alternative, nurses can place tubing in the resident’s bedside cabinet drawer, a solution we also have seen work well. 

You can request a WikiPouch sample from the company’s website, which is also a good resource. The company can provide research showing its storage product reduces healthcare-associated infections, which is the dream of every infection preventionist!

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

A: What is the best treatment option for necrotic wounds — collagenase or manuka honey?  Though collagenase is often suggested for pressure ulcers, it is both costly and not easily accessible.

Let’s review a few details regarding these treatment options. Collagenase is the only agent that functions as an enzymatic debridement. Collagenase formulation is an enzyme derived from the fermentation by clostridium histolyticum. It has the ability to digest collagen in necrotic tissue.

Santyl is the only FDA-approved enzymatic debrider. It is indicated for debriding chronic dermal ulcers (diabetic foot ulcers and pressure ulcers) and severely burnt areas. Ointment is applied once a day or as needed. Antibiotics are applied prior to the application of collagenase if a local infection is present. Treatment can last for a few weeks until debridement is complete or granulation tissue is established. 

Manuka honey is a monofloral honey derived from manuka tree (leptospermum scoparium). Its chemical composition is suggested to have antioxidant and antibacterial activity and can help maintain a moist wound environment. It has pro- and anti-inflammatory effects leading to absorption of the devitalized and necrotic tissue as autolytic debridement agent, which promotes healing by better re-epithelializing and decreasing the bioburden on the wound bed. 

Most of the research is expert opinion or meta-analyses that may involve bias.  This makes it difficult to find conclusive evidence. Whatever treatment is chosen, review wound progress daily and weekly, or with every dressing change. There may be many local or systemic factors leading to the maceration of the skin around the wound, worsening infection, or compromised circulation that can stall the wound healing.

In interviews, researchers discovered that patients often wore the off-loading devices less than 100% of the time, but more alarmingly, they often wore them much less than they initially reported to interviewers. Patients took the casts off indoors during sedentary activities but also revealed they’d done so while walking a short distance (such as to the toilet at night) or outdoors.

“Some participants believed that no harm could occur when not wearing the device for short distances and others believed that wearing [the device] for every step was not necessary,” researchers in Australia and Jordan reported. “This potentially reflected the misperception of what optimal (100%) adherence meant to participants.”

They found both wound pain and progression of wound healing motivated participants to adhere to wearing their casts. Engaging patients in those areas was seen as a promising way to enhance adherence.

Chinese researchers noted that international guidelines call for the rate of repositioning to be adjusted based on patient needs, but old standards may be changing.

“Modern advancements in the repositioning field have sparked newfound attention in repositioning procedures, repositioning systems, nursing time, nursing time cost, nurses’ compliance, nurses’ and subjects’ preferences, comfort, and acceptability, use of turning teams, repositioning complications, and wearable subject sensors,” they wrote in the International Wound Journal.

Two- to four-hour repositioning had significantly lower PU rates than four- to six-hour repositioning in at-risk adults. Previous research also backed a turning system using two, 30-degree body wedges. A turning team also considerably reduced formation of pressure ulcers, though the authors acknowledged the expense might make such an approach impractical.

Respect from supervisors, burnout and exhaustion, as well as the need for better pay and ongoing training opportunities were other sore spots highlighted in the eight-question survey taken by nearly 3,000 certified nurse assistants.

“The survey results and comments show how little has changed in the past year,” said NAHCA Board Chair Sherry Perry. “Efforts to recover from the pandemic and enable healthcare settings to move forward must include attention to the needs of CNAs. These are care team members who know the residents best and yet are paid very little and recognized even less. They deserve living wages and respect.”

The No. 1 way to retain more aides in their current jobs would be to improve wages and benefits, according to survey respondents. Nearly all (92%) said they wanted to continue as a CNA if the position came with additional educational opportunities, pay raises and recognition. Among the vocational education and training topics most desired: end-of-life care, infection control and fall prevention.

NAHCA CEO and co-founder Lori Porter said survey responses will help shape NAHCA’s policy priorities and advocacy efforts, particularly with the White House’s planned first-ever minimum staffing mandate still in the works.

A: Providing a reconciled medication list to subsequent providers or the resident/caregiver improves care coordination and decreases adverse events. Beginning with fiscal year 2024 (Oct. 1, 2023), the MDS-collected current reconciled medication list will inform the SNF QRP Transfer of Health Information quality measures. 

When preparing for this change, first consider who will provide the list at the time of discharge. Educate these individuals on how to deliver and document this information. The MDS offers several options for route of delivery, including electronic health record, health information exchange, paper-based, text or email.

It can be verbal, in writing, or both, but the person providing the reconciled medication list must know how to deliver it. If the information is going to the subsequent provider, clarify the provider’s preferences for receipt. If the information is going to residents or caregivers, consider how they learn best. Health literacy may affect routes of transmission. When communicating, use language that the resident or caregiver understands. 

Some residents may not be on any medications, prescribed or over-the-counter. If so, document this in the medical record and code the MDS as yes, the current medication list was provided. If the facility does not give a current reconciled medication list, the discharging nurse should document the reason.

In summary, it is critical that you review your current process, revise policies, educate on new processes, and document delivery of current reconciled medications upon discharge. 

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

However, a group of computer scientists at Yale University is examining a potential solution: training artificial intelligence tools on “noisy” electrocardiograms that simulate the kind of messy data readings a wearable would generate. 

Their research suggests that by mimicking the challenges of wearable-derived data right away, such as poor contact with the skin, AI can better detect heart problems. In fact, the team’s “noise-adapted” AI model designed to detect heart failure performed much better than a standard version, according to research published in Nature in July.

The team is now putting together a follow-up study with actual patients. Future goals are to clarify how the AI accounts for different demographics and whether the noise-tested AI can be “device agnostic” or only works with specific wearables.

The main disease the study tested for, left ventricular systolic dysfunction, is a common concern among older adults. Although the condition is underdiagnosed, LVSD could be detected early in roughly 90% of patients, previous studies have shown. Heart disease overall is the leading cause of death among older adults.

Wearable heart monitors are increasingly popular, with tools such as portable EKGs, smartwatches and patches in development or on the market. The ability for wearables such as an Apple Watch or FitBit to accurately detect heart disease would particularly benefit patients within long-term care settings, the researchers noted. 

“The noise-adapted approach defines a novel paradigm on how to build robust, wearable-ready, single-lead ECG cardiovascular screening models from clinical ECG repositories, with significant potential to expand the screening of LV structural cardiac disorders to low-resource settings with limited access to hospital-grade equipment,” the researchers wrote.

A:There are no changes to the Patient Driven Payment Model calculations planned for Oct. 1. But updates to some data elements and your facility processes could theoretically impact reimbursement. 

Currently, the Patient Health Questionnaire (PHQ-9) or Resident Mood Interview in Section D of the MDS can contribute to increased reimbursement under the Nursing Component of PDPM if the total severity score for the interview equals 10 or greater. This depression “end-split” affects the Nursing Case-Mix Groups of Special Care High, Special Care Low, and Clinically Complex. The total severity score is the sum of the frequency responses for symptoms present. 

As of Oct. 1, the PHQ-9 will be revised to the PHQ-2 to 9. This will allow the mood interview to be stopped after the first two questions, depending on the resident’s responses. The positive here is that this may shorten the time the appointed staff member spends completing the Resident Mood Interviews. The question that remains is whether this shortened interview may lead to fewer residents with a total severity score of 10 or greater, and thus a dip in reimbursement. 

For example, one may not be bothered by “little interest or pleasure in doing things,” or “feeling down, depressed, or hopeless,” — the two questions posed in the PHQ-2. But, if one was bothered by “feeling tired or having little energy,” or “poor appetite or overeating,” these questions will not be asked if the interview is concluded early. 

Also, with the removal of Section G from federally required assessments, Section GG will stand as the assessment of functional abilities, and facilities should refocus efforts on GG assessment practices. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.