Journal of the American Medical Directors Association RSS feed: Current Issue.
JAMDA is the official journal of the American Medical Directors Association. Subscribe to JAMDA or join AMDA and
receive JAMDA as a member benefit. Committed to the continuous improvement of the quality of patient care through education, advocacy,
information, and professional development for health care professionals, the Journal of the American Medical Directors Association provides
bimonthly coverage of the issues most important to healthcare professionals providing long-term care. Peer-reviewed articles include
original studies, reviews, clinical experience articles, case reports, and more.
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Initial Diagnosis and Treatment Patterns in Parkinson's Disease
Introduction/Objective: To our knowledge, nationwide patterns of initial Parkinson's Disease (PD) treatments were last described from 1999-2001 claims data and this analysis serves to update the current literature. This study evaluates the diagnosis and treatment patterns in the US of newly identified PD patients by describing the timing and type of initial treatments.
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The Basis for Improving and Reforming Long-Term Care. Part 4: Identifying Meaningful Improvement Approaches (Segment 2)
While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to “fix” the problem have overshadowed efforts to correctly define the problems and identify their diverse causes.This fourth and final article in the series (divided between last month's issue and this one) recommends strategies to make sense of improvement and reform efforts. This month's concluding segment covers additional proposed approaches. Despite the challenges of the current environment, all of the proposed strategies could potentially be applied with little or no delay.Despite having brought vast increases in knowledge, the research effort may be losing its traction as a formidable force for meaningful change. It is necessary to rethink the questions being asked and the scope of answers being sought. A shift to overcoming implementation challenges is needed.In addition, it is essential to address issues of jurisdiction (the apparent “ownership” of assessment and decision making over patient problems or body parts) and reductionism (the excessive management of these issues and problems without proper context) that result in fragmented and problematic care. Issues of knowledge and skill also need to be addressed, with greater emphasis on key generic and technical competencies of staff and practitioners, in addition to factual knowledge.There is a need to rethink the approach to measuring performance and trying to improve quality of care and services. There are significant limits to trying to use quality measures to improve outcomes and performance. Ultimately, vast improvement is needed in applying care principles and practices, independent of regulatory sources. Reimbursement needs to be revamped so that it helps promote care that is consistent with human biology and other key concepts.Finally, improving long-term care will require a coordinated societal effort. All social institutions and health care settings need to address their own shortcomings and contribute constructively in order to improve and reform nursing homes and health care generally. It is not helpful to scapegoat nursing homes for what are far more universal problems of care, practice, and performance.
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A Call to Action
Dr Levenson's 5-article treatise on improving and reforming health care is a call to action for all health care professionals committed to nursing home (NH) practice. Dr Levenson has laid bare many of our current administrative, regulatory, and clinical practices and processes, calling for approaches that are truly evidence based and person centered. Dr Levenson admonishes us to eschew fragmentated care and to reward those holistic approaches that are evidenced by “flexibility, comprehensiveness, and sensitivity.”p600 In addition, we are encouraged to critically evaluate extant quality metrics upon which we are currently judged. Overemphasizing outcomes at the expense of processes of care may not be the optimum approach to improving quality of care.
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Risk of Venous Thromboembolism in Long-Term Care Residents: What Do We Know Now?
The article by Barbara Zarowitz and colleagues on the risk of venous thromboembolism (VTE) in long-term care (LTC) is a brave attempt to stratify thrombotic risk in LTC. Their systematic review of more than 8 years of data identified a total of 1165 publications relating to VTE and immobility. Rating these publications according to accepted quality criteria resulted in selection of 4 articles relating to thrombotic risk, and 1 article (1 of these 4, actually) relating to immobility. Eight mobility-related statements and 30 VTE risk statements were derived from these articles. The authors' final recommendations (reached by modified Delphi method of analysis of the mobility and VTE risk statements) include baseline thrombotic risk screening on admission; prophylaxis for up to 35 days if high risk; then consideration of prophylaxis indefinitely if the risks and mobility are not sufficiently improved. Recommendations for VTE prophylaxis is not within the scope of the article. However, the vast majority of controlled trials in the past 5 to 10 years has focused on low molecular weight heparins (LMWH) or factor Xa inhibitors. The recommendations of the American College of Chest Physicians (ACCP) guidelines for high-risk patients includes an LMWH or factor Xa inhibitor as either a first or second choice for anticoagulant thromboprophylaxis. ACCP recommends against sole use of aspirin or mechanical methods of thromboprophylaxis in general.
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Insulin Sliding Scare, Does it Exist in the Nursing Home
Introduction/Objective: The insulin sliding scale is a very frequently used method to help control blood sugar levels in patients in nursing home settings. Many of the patients on sliding scale may not have blood sugars that are well controlled, and physicians many times may be unaware of the lack of glycemic control as coverage will be as per sliding scale. We wanted to look and see how many patients on sliding scales had adverse events defined as blood sugars less than 60 or greater than 400. Secondly we wanted to see how often nursing intervention in terms of orange juice or glucagon was required for sliding scale patients. Finally we wanted to see how often physicians make adjustments to the sliding scale based on adverse events.
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Key Quality Indicator Reports That Tell a Story
Introduction/Objective: PACE (Program for the All-inclusive Care of the Elderly) programs have a wide variety of audiences with whom to share data. Medical Directors and Team members need to know if processes to keep participants safe are functioning. Physicians and Medical Directors are interested in Participant outcomes. Administrators want to assure that resources are being allocated as needed. Participants, Family Members, and Community Advocates who serve on advisory boards need an easily understandable report that communicates the quality of services. Regulators want to assure that processes are meeting requirements. To meet the variety of expectations it is necessary to develop a Key Quality Indicator Report that tells that story.
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Author Guidelines
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General Information
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Cognitive Bias and Planning Error: Nullification of Evidence-Based Medicine in the Nursing Home
Background: Medical error is common, and has a large impact on our national healthcare budget. The elderly and chronically ill are among the largest consumers of the Medicare budget fueling interest in avoiding unnecessary hospitalizations among nursing home residents. In addition to preventive measures involving care coordination and better implementation of advanced directives, this article argues that many nursing home residents have a greatly inflated risk of hospitalization and would benefit from more intensive medical management.Methods: Reflective practice is used to analyze why nullification error (inappropriately omitting evidence-based treatments) regularly occurred among nursing home residents over an 8-year period. The study frames the root causes of clinical inertia and nullification error using terms from cognitive psychology and contemporary philosophy.Results: Unrecognized biases and cognitive pitfalls are the basis for why competent physicians reject evidence-based medicine (EBM) in the nursing home. Six common recurring nullification errors are discussed with the proposed root causes. A glossary of unfamiliar terms is included.Conclusions: The uncertainty over the appropriateness of EBM for the nursing home patient has led to a widespread bias toward undertreatment that has reached alarming proportions. It is true that most elderly patients do not wish to extend their life expectancy, but most do wish to avoid medical complications and unnecessary hospitalizations. Rejecting treatments that extend life expectancy often results in rejection of the very treatments that would improve the probability of achieving their wish to retain fair health. Practitioners do not reject meaningful treatments because of lack of knowledge or lack of concern. They do so because of an incomplete education regarding the biases and cognitive pitfalls that are encountered when planning care for the elderly.
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Table of Contents
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Health Care Employees' Knowledge and Awareness of Pressure Ulcers in Hospitals and Long-Term Care Facilities
Introduction/Objective: Using the Centers for Medicare and Medicaid Services pressure ulcers guidelines (CMS, 2008), we designed a study to examine attitudes and knowledge of pressure ulcers among health care personnel in hospitals and long-term care facilities.
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DVT Prophylaxis on Transfer from Hospital to Nursing Home
Introduction/Objective: Current ACCP guideline suggests a grade (1A) recommendation for high risk medically ill patients, but its use in clinical practice is unknown. Several studies show a large gap between ideal and real-world practice, despite the theoretical possibility that physician awareness might increase use of VTE prophylaxis.
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Additional Research on the Cost of Caring for Obese Nursing Home Residents is Critical to Maintaining Adequate Resources in the Long-Term Care Industry
To the Editor: A startling trend in the US population threatens the quality of care available in the long-term care setting. The proportion of nursing home residents who are obese (body mass index > 30) is increasing and now represents approximately 25% of the US nursing home population. Obese residents require specialized bariatric equipment and supplies, which are costly and unavailable in many facilities, and extensive personal care assistance to perform activities of daily living. These equipment and staffing needs present significant challenges for nursing homes now and in the future as the US population ages. This problem is exacerbated in an economic context because, unlike costs, daily reimbursement rates do not vary systematically with size of the resident.
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Integrated Medical Model Project Plan at Rowan Community
Introduction/Objective: Culture Change has had a major positive impact on the social environment in long-term care (LTC) facilities providing residents with more control of their lives and increasing quality of life and independence. However, despite the great strides in expanding the social environment of LTC residents, many medical models have lagged behind in terms of an “integrated medical care” focus that would support and enhance resident control of their own health care decisions. In response to this need, the Integrated Medical Model was developed with the following principles:
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Chart Review at the Department of Elder Affairs in Central Florida of Disease Prevalence Among Recipients of Elderly Services
To the Editor: The Department of Elder Affairs is responsible for administering human service programs for the elderly population in an effort to try to help them keep their self-sufficiency and self-determination in all possible ways. These services include case management, home-delivered meals, adult day care, caregiver support and training, medical equipment and supplies, respite care, assisted living, and many others. It is estimated that more than 20% of the US population is now 60 years of age and older. As baby boomers continue to age, this percentage is expected to rise. Some individuals suffer from chronic conditions that began long before they reach age 60, whereas others may be able to live their entire lives without needing long-term medical or social services. However, some chronic conditions can put great strain on the ability to provide these services. For example, it is estimated that more than 5 million people in the United States are affected by Alzheimer's disease, and by 2050 this figure may rise to between 11 and 16 million. Knowledge of disease prevalence and commonality among recipients of services by the Department of Elder Affairs may help in developing models for better distribution and allocations of these services and creating budgets.
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End of Life Care in the Nursing Home Setting
Introduction/Objective: For this study a cross-sectional mailed survey to explore next of kin's perspectives on end-of-life care in the nursing home setting was developed. It tested the feasibility of the method in terms of recruitment and response rate, and pilot tested the survey instrument. Decedents who received Hospice services in addition to traditional nursing home care were compared to those who received traditional care alone.
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Long Term Care Medicine 2010 Poster Abstracts
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Improving End-of-Life (EOL) Care in California Nursing Homes through Education: The End-of-Life Nursing Education Consortium (ELNEC) Geriatric Program
Introduction/Objective: Nursing's mandate is to provide compassionate care and dignity to persons at the EOL. Approximately, 25% of US deaths occur in nursing homes and the proportion increases with age of residents. The ELNEC Project is a partnership of the City of Hope and the American Association Colleges of Nursing (AACN). ELNEC's Geriatric train-the-trainer program is a synthesis of knowledge in EOL care and teaching methodology to develop expertise and skills for nurses responsible for care of older adults in nursing homes, skilled nursing facilities, hospices, home care, assisted living, etc., as well as in staff education programs. In 2003, Robert Wood Johnson Foundation funded a report, Means to a Better End, grading states on their ability to provide end-of-life care. Most states’ grades indicated a need for improvement including California which rated a “C.” From 2007 through 2009 four ELNEC Geriatric courses supported by grants from the California HealthCare Foundation and the Archstone Foundation have been offered to California nurses and nursing home staff. The purpose of this presentation is to describe the curriculum, implementation, survey results pre and post course and examples of ELNEC trainers’ work following ELNEC Geriatric training.
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AMDA Disclaimer Statement
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Depression in Elderly Nursing Home Residents Taking Antiepileptic Medications
Introduction/Objective: We are currently evaluating elderly nursing home residents who are on antiepileptic drug (AED) therapy and assessing for a number of problems including depression. This abstract gives an updated report on depression as recorded by the Geriatric Depression Scale (GDS-5) and Depression Rating Scale (DRS).
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