Tim Gieseke, MD, CMD

If my elderly mother were discharged home from the acute hospital, she would have been seen by her physician on the day of discharge, and would have had a well-defined discharge summary executed based on a robust, evidence-based Care Transition literature. This discharge summary would be dictated (legible) on the day of discharge and would be comprehensive with documentation of Medication Reconciliation and a detailed "Handoff" care plan. 

If my elderly mother were too sick and disabled to be discharged home, she would be transferred for post acute rehabilitation. Now she would experience a very different discharge process based on tradition and not best practice.  Typically in my community, upon discharge from a postacute stay in a SNF, she would not be seen by her attending, and formal medication reconciliation would not be done.  The physician generally receives a fax requesting discharge home on current medicines with suggested DME and Home Health services. Medical records will then mail a request for a written d/c summary (facility defines the content elements), which is to be completed by memory off-site within one month of discharge.

Joseph M. Bestic, NHA, BA Director, Nursing Home ·Health Services Advisory Group of California, Inc.

As many of you are aware, Health Services Advisory Group of California, Inc. (HSAG), the Medicare Quality Improvement Organization (QIO) for the state of California, is currently leading a project (Phase-One) to reduce the use of physical restraints and the prevalence of pressure ulcers among nursing home residents. To kick off the current three-year QIO quality improvement cycle (August 2011–July 2014), the Centers for Medicare & Medicaid Services (CMS) selected 142 California nursing homes for HSAG to engage to improve their physical-restraint and/or pressure-ulcer rates. In order to qualify for the project, nursing homes had to have a Long Stay High-Risk Pressure Ulcer rate of ≥ 11 percent and/or a Physical Restraint rate of ≥ 4 percent. This was based on a combination of Q4 2010–Q1 2011 Minimum Data Set (MDS) 3.0 data.
 
As efforts are underway to work with these nursing homes to improve their quality measure outcomes, many challenges still exist to reduce and/or eliminate the practice of physical restraint utilization. According to the CMS RAI MDS 3.0 Manual,1 “Growing evidence supports that physical restraints have a limited role in medical care. Restraints limit mobility and increase the risk for a number of adverse outcomes, such as functional decline, agitation, diminished sense of dignity, depression, and pressure ulcers. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by restraints. It is vital that restraints used on this population be carefully considered and monitored. In many cases, the risk of using the device may be greater than the risk of not using the device. The risk of restraint-related injury and death is significant.

by Tim Gieseke, MD, CMD

In 2013, each of our facilities will be challenged to adopt performance improvement projects (QAPI) that involve all of the departments within our facilities with the goal of sustainable implementation of significant best practices. This new process will be a mandatory part of our clinical practice in 2014.
 
One obvious QAPI is the inappropriate use of Sliding Scale Insulin (SSI) in our facilities. This year, the AGS updated the Beers Criteria for Potentially Inappropriate Medication use in the Elderly. SSI is included in this list for the first time as a strategy to avoid because of the higher risk of hypoglycemia without improvement in management of hyperglycemia regardless of the setting of care. They rate the quality of the evidence as Moderate and the strength of the recommendation as Strong.

Mira Cantrell, MD, CALTCM Education Chair

It is with much gratitude to the members of the CALTCM Education Committee that I can announce to all CALTCM members and friends an impressive lineup of talks and topics for our upcoming annual conference on April 26 and 27, 2013, again at the Omni Hotel in Los Angeles. (Please take note of the slightly earlier time frame this coming year.)  The overarching theme of the upcoming conference – overwhelmingly requested for by our membership – is communication, communication, communication!  Communication among disciplines, communication in conflict resolution, forging partnerships, communication that eases relationships between SNFists and hospitalists; all will be discussed in the context of long-term, palliative and managed care.