Aging in Place Planning - New Geriatrics Research Offers Roadmap for Person-Centered Care

Person-centered care (PCC) is an approach to health care that puts personal values and preferences of the patient at the forefront of decision-making. Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations. Person‐centered care is an approach to meeting these aims in a way that assures the primacy of individuals’ health and life goals in their care planning and in their actual care.

Person‐centered care means that individuals' values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person‐centered care is achieved through a dynamic relationship among individuals, in and out of the health care system, and others who are important to them, and all relevant providers. The required  collaboration informs decision‐making to the extent that the individual desires. See, "Implementing “Patient‐Centered Care”: A Revolutionary Change in Health Care Delivery." Person-centered care is consistent with, and one could argue, the objective of "supported decision-making," upon which Aging in Place Planning is based.  

According to an article published in the American Geriatrics Society Newsletter, two new research articles and a corresponding commentary from leaders in the the American Geriatrics Society (AGS) describe ways to make person-centered care more actionable for seniors. The study authors explain that the time is ripe for reform of senior care toward PCC: 

"The U.S. healthcare system is finally at a much anticipated and long‐needed tipping point. For more than half a century, the predominant paradigm for organizing and financing health care in the United States has been based on [two] 2 major factors: care focused on organ systems and reimbursement based on volume rather than quality of service. This system has too rigidly driven what can be done and reimbursed and does not foster care that addresses disorders of multiple organ systems (multimorbidity) and the effect of multimorbidity on overall functional ability, considerations that are critically important in the care of older people. Given recent developments in our healthcare system, the time is ripe for geriatricians to leverage their unique expertise to advocate for a person‐centered approach to healthcare design and delivery that encourages healthcare professionals to organize care around patient priorities, rather than an outdated taxonomy and payment system."

"Making person-centered care a reality for older adults with complex care needs will take time and effort, including significant research to move promising approaches from the lab bench to the clinic,” wrote William B. Applegate, MD, MPH, AGSF, Editor-in-Chief of JAGS and lead author of the editorial addressing the two new studies (DOI: 10.1111/ jgs.15536). “This work is helping test innovative strategies, which will move us toward a broader and more balanced approach to care.”

Though critically important, eliciting and documenting personal values remains uncommon in routine older adult care, particularly for people with multiple health concerns that complicate pinpointing broader health priorities. In “Development of a Clinically Feasible Process for Identifying Patient Health Priorities” a research team describes Patient Priorities Care (PPC), a novel process to identify health goals and care preferences for older people with multiple health conditions. Expertly trained facilitators help older adults and caregivers work through health priorities sensitively, in a process that could be completed across just two sessions totaling 45 minutes or less. According to the research team:

 “Results of this study demonstrate that healthcare professionals can be trained to perform the patient priorities identification process as part of their clinical encounters…[through a process that is] rewarding and enjoyable but requires training and formal feedback.”

A separate team put the PPC processes into practice, reporting their findings in “Feasibility of Implementing Patient Priorities Care for Patients with Multiple Chronic Conditions” Their study involved using Patient Priorities Care among more than 100 patients working with nine primary care providers and five cardiologists in Connecticut. While researchers still hope for improvements in the time needed to complete the process and in avenues for embedding it within practice workflows, they noted that the vast majority of patients returned to their physician with clear goals and care preferences. Follow-up discussions between patients and providers suggest that moving from disease-based to priorities-aligned decisions is “challenging but feasible.”

The foregoing work represents only the latest steps forward for high-quality, person-centered care for older people, and also builds on an even lengthier legacy at  AGS.  Implementation of these strategies for all seniors, even those receiving care outside of institutions, while aging in place, will be a welcome development.  

OIG Finds State Survey Agencies Are Not Verifying Facilities’ Corrections of Deficiencies

State survey agencies ("State agencies") are required to verify that nursing homes have corrected identified deficiencies, such as the failure to provide necessary care and  services, before certifying that the nursing homes are in substantial compliance with Federal participation requirements for Medicare and Medicaid. The Office of the Inspector General (OIG) recently conducted a survey, and its resulting Report says that State Agencies aren’t doing enough to make sure that nursing homes are correcting deficiencies.

Out of nine state agencies that OIG selected for review, seven did not always verify that nursing homes’ had corrected issues, as required. More specifically for 326 of the 700 sampled deficiencies, these State Agencies did not obtain any evidence of nursing homes' correction of deficiencies or maintain sufficient evidence that they had verified correction of deficiencies.  For less serious deficiencies, the practice of six of the seven State agencies was to simply accept a nursing home's correction plan as confirmation of substantial compliance with Federal participation requirements without obtaining from the nursing home any evidence of correction of deficiencies. 

Further, three of the seven State agencies had technical issues with maintaining supporting documentation in the software-based system used to support the survey and certification process; as a result, they did not have sufficient evidence of correction of deficiencies.  The OIG report does not state clearly whether state agencies claimed to have collected any evidence, or if that supporting documentation may not have been available to the OIG. 

The Report offered an example of a serious deficiency where the state survey agency did not follow up and verify the correction of the deficiency:

“A state agency completed a nursing home survey and identified several deficiencies, including a G-rated deficiency related to quality of care (42 CFR § 483.25). The surveyor noted:

• Based on observation, interview and record review, the facility failed to provide the necessary care and services . . . in accordance with the comprehensive assessment and plan of care for 1 of 4 diabetic residents . . . reviewed for medication administration. This failure occurred when the resident received too much diabetic medication and sustained a life threatening event requiring emergency medical intervention.

The state agency conducted the required follow up survey; however, it did not have documentation supporting that it had verified the correction of the deficiency.”

Resident health may be compromised.  "If State agencies certify that nursing homes are in substantial compliance without properly verifying the correction of deficiencies and maintaining sufficient documentation to support the verification of deficiency correction, the health and safety of nursing home residents may be placed at risk" reads the OIG Report. 

In addition, the OIG said, the Centers for Medicare & Medicaid Services’ (CMS) guidance to state agencies on such verification “needed to be improved.” Officials laid out several steps that the agency can take to respond, moves with which CMS has concurred.

LeadingAge spokeswoman Lisa Sanders told McKnight's Long-term Care News, that  it agrees with the OIG’s recent findings, urging federal officials to ensure that state agencies have adequate funding to complete their reviews:

“The unevenness of surveyors’ findings and enforcement actions taken by state surveyors is well documented,” she told McKnight’s. “State survey agencies are frequently short-staffed, and turnover at these agencies is often rampant, which means that those responsible for surveying nursing homes may have neither the training nor the experience to know what they are seeing and whether conditions comply with federal standards and requirements.”

The prestigious law firm Hall, Render, Killian, Heath, and Lyman,  which specializes in health-related businesses identified the following "Practical Takeaways" from the Report:

•  Skilled nursing facilities should expect that state survey agencies will pay increased attention and take actions to confirm that the actions and corrections promised in a facility’s plan of correction were implemented.
• Skilled nursing facilities may see changes to the CMS forms related to the survey and certification process, such as the Forms CMS-2567, CMS-2567B and CMS-1539, so that surveyors can explicitly indicate how a state survey agency verified correction of deficiencies and what evidence was reviewed.
• Skilled nursing facilities should review and establish practices and procedures for proactively documenting the corrective actions promised for any deficiency. Facilities should have those records ready, expecting that the state survey agency will more actively confirm that the actions occurred. 

As CMS reinvigorates state agencies' oversight, resident health will find greater protection.  

The "Human Touch" in Aging in Place Planning

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Laizer Kornwasser, writing for HomeCare Magazine, reminds that although technology can improve health outcomes, human hands are still needed.  In his article entitled, The Importance of the Human Touch, Kornwasser, President and Chief Operating Officer at CareCentrix, a post-acute benefits management company, suggests that "the future of better health care in this country is not people versus machines," it is in fact, "just the opposite."  

Kornwasser concedes that a "future of improved health outcomes and lower health care cost comes when health care providers use technology to not only inform diagnoses, but also to catch early signs of medical problems, create the most effective treatment plans and recommend the most appropriate post-acute care environment for the patient:"  

"One of the latest health care advancements currently being tested is the use of sensors to track the activity of elderly people in their homes and in their cars, as part of an effort to enable them to live longer and more safely in their own homes. The Collaborative Aging (In Place) Research Using Technology (CART) initiative is a national study currently in progress that tracks seniors’ pill consumption, weight, computer use and movement in and around their home and in their vehicles to generate real-time activity and monitor for any health changes, such as cognitive decline or increasing frailty issues, so that intervention can happen earlier to help prevent or shorten a potential hospital stay.

There are a number of commercially available sensor-based products that can monitor individuals at home, but no company has mastered the logistics of installing and configuring the sensors so an alert can be acted upon, as CART is pursuing. Sending up a red flag with no one to interpret what the red flag means and how to best intervene is like creating a computer system without a backup."

The "human touch" necessary involves connectivity, communication and collaboration among providers, patients, payers and caregivers utilizing technology intelligently and humanely:

While a machine can be programmed to perform given tasks more efficiently and extrapolate needed and advanced learnings better than its human counterparts, the artistry is in the execution of the information and in being able to adjust to the subtleties that may be required in a given situation.

The CART study is an excellent example of the exciting new research being conducted in the “technology meets touch” space, but there are many examples where the practice is already in use. Consider the task of getting prescriptions filled at a pharmacy. What was once an onerous paper-based process that was often filled with roadblocks and safety concerns due to lack of information, multiple providers and polypharmacy is now streamlined through electronic health records, real-time benefit checks and e-prescribing capabilities that allow physicians to make better prescribing decisions for a patient at the point of care.

Within the home health industry, technology is consistently opening new paths that deliver improved patient outcomes, while achieving lower overall health care costs. Nowhere is this transformation more evident than in the adoption of artificial intelligence (AI) and machine learning technology, which is quickly changing the face of patient care.

Using petabytes (1 million gigabytes) of data, clinicians can quickly analyze past results of clinical settings and providers to recommend future paths for better care. For example, a physician can now match the characteristics of an individual in need of a hip replacement to a facility and/or provider with measurable success in caring for patients with similar clinical and socioeconomic characteristics. Matching patients with the right provider at the start of care improves outcomes, increases patient satisfaction and provides cost-saving solutions that can avoid hospital re-admissions.

AI and machine learning, combined with new modes of communication, are making it possible to create smart networks that match the patient’s needs with the best-possible providers. But, it is still the uniquely human ability to deliver on those care needs, once identified, that brings to fruition the highest quality of care, while lowering health care costs.

As technology continues to evolve and predictive analytics advance, we need to challenge the industry to develop products that not only improve the machine learning process, but also seamlessly connect a patient’s clinical care team with real-time medical and pharmacy claims data that will help the team make more informed care decisions.

By teaming technology with the human touch, we will be able to place patients in the center of the care team—whether they are in the hospital, a post-acute care facility or healing at home.

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Even more tangible than the "Human Touch" about which Mr. Kornwasser writes, is actual physical contact. Research suggests that the physical contact plays a fundamental role in human communication and  physical and emotional health.  Lack of human touch is a real concern for the medically frail elder, leading to feelings of isolation, anxiety, poor trust in caregivers, insecurity and decreased sensory awareness. 

Older adults living with serious conditions are often especially receptive to touch. Unfortunately, they are also among the least likely to receive expressive human touch from health care providers. Nursing students have been shown to experience anxiety about touching older patients. Yet elders report that touch communicates safety, care, reassurance and makes them feel more trust in caregivers.

For individuals with dementia, human touch plays an important role in promoting overall well-being. Since touching the hands is so familiar, hand massage may be gladly accepted by elders living with dementia. Even five-minutes of hand massage have been shown to elicit a physiological relaxation response and decreases cortisol levels. Cortisol is a stress hormone that is produced by the adrenal glands during prolonged stress and is often used as an objective marker of stress. When cortisol levels are lowered it enhances sleep quality and the immune system. Massage has also been shown to increase serotonin levels. Serotonin is a neurochemical that regulates mood; feelings of calm; and subdues anxiety and irritability.

A five or ten-minute hand massage protocol has resulted in:

• Significantly decreased agitation immediately and sustained the decrease for up to one hour;
• Decreased the frequency and intensity of agitated behavior during morning care routines;
• Strengthened the relationship between the person with dementia and their family care partner.

One study evaluated the effects of hand massage on physical and mental function and behavioral and psychological symptoms consistent hand massage protocol. Both aggressive behaviors and stress levels decreased significantly.

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Slow-stroke back massage (SSBM) uses effleurage, moving the palm of the hand in long, rhythmic, firm strokes. One method applies effleurage in a figure-eight formation on both sides of the back. Massage stimulates production of endorphins which are compounds produced by the body that suppress pain and uplifts mood. Massage also has a generalized effect on the autonomic nervous system, producing a relaxation response.

Three-to-five minute protocols have shown slow-stroke back massage to:

• Help people fall asleep;
• Decrease anxiety;
• Decrease physical expressions of agitation such as pacing, wandering and resisting care;
• Ease pain;
• Decrease blood pressure and heart rate indicating a physiological relaxation response.

One study investigated the effect of SSBM on anxiety and shoulder pain in hospitalized elderly patients who had suffered a stroke. The study compared scores for pain, anxiety, blood pressure and heart rate of two groups of patients. The intervention consisted of 10 minutes of SSBM for seven consecutive evenings. The results revealed that the massage intervention significantly reduced the patients' levels of pain perception and anxiety and blood pressure and heart rate changed positively, again indicating relaxation.

While institutional nursing is employing these techniques in an effort to  to reduce unnecessary use of anti-psychotic medication by replacing or supplementing them with non-medicinal approaches and strategies, home care, too, should incorporate these techniques.  "Touch" initiated by family by hugs, pats, and simple hand holding or affectionate touching,  initiated as greeting and comforting touch by professional caregivers, or scheduled hand, back, or foot massage, can go a long way in comforting an elder, and contributing to positive physical, emotional, and psychological health outcomes.  

"Human Touch," as it refers to both the human component of collaborative information gathering, consideration, decision-making, and implementation, and to human tactile communication and care, is undoubtedly an important component of an Aging in Place plan. 

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Care.com Rocked By WSJ Investigation - Conducts only Preliminary Screen of Caregivers

Care.com pledges to “help families make informed hiring decisions."  The company, however, undertakes only a "preliminary screening," of referred caregivers, leaving the heavy lifting up to the families themselves, sometimes with tragic consequences, according to Kirsten Grind, Gregory Zuckerman and Shane Shifflett writing in the WSJ.

The Journal found some nine instance in the last six years where caregivers on the site had police records, and later were accused of crimes while caring for customers' children or elderly relatives. The paper's probe also found hundreds of instances of day-care centers being improperly listed as state-licensed.

"Care.com is a marketplace platform," said CEO Sheila Marcelo."  The marketplace is designed for “shared responsibility overall," she adds.  Look for a greater effort by Care.com, but in the meantime, and nonetheless, family members should remain vigilant and conduct their own background checks.  Those who will take advantage of the most vulnerable will always seek others to confer upon them some imprimatur of integrity and responsibility.  Wisdom suggests caution in accepting referrals from any third party, especially where there is profit for the listing or referring service.

Opioids Sending More Seniors to ER

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If you thought that the current opioid crisis is relegated primarily to younger people, you are sadly mistaken.  According to an article in McKnight's Long-Term Care News, Emergency room visits by seniors who have misused opioids more than tripled between 2006 and 2014. Visit rates to ERs by adults older than 65 for opioid misuse increased a tragic 217% during the study period.

The statistic comes as a result of a new study which suggests that misuse of painkillers has had a snowball effect for seniors, leading to an increase in the number of chronic conditions, greater injury risk and higher rates of mental health diagnoses:

“Findings demonstrate the breadth and scope of opioid misuse and dependence among older adults visiting emergency departments — and indicate that targeted programs aimed at screening, intervention and treatment specifically geared toward older adults are warranted,” authors wrote in Innovation in Aging. “Results from this study also highlight the complexity of treating opioid dependence in this population, which reflect in part, high rates of coexisting mental health and other substance abuse disorders.”

Researchers studied multiple years of nationally representative data from the Nationwide Emergency Department Sample, which includes more than 950 hospitals, across 34 states and the District of Columbia.