Nursing Home Care- A Literature review

Here are some interesting articles highlighting some problems related to lack of physician availability to care for nursing patients in the current health care system.

Although this is a blog with a primary focus on health IT, it is important to have a clear understanding of the problems faced by practitioners in order to create an IT solution.

I have listed some key information from my literature search

..."the quality of care in nursing homes remains inconsistent and in many respects suboptimal."
(11. Scanlon WJ. Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003)


A case for Nursing Home Physician Specialists in the Annals of Internal Medicine, March 2009

Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes (36–38).

Nursing home practice is only 4% of work time among the 20% of physicians who practice in a nursing home, one third of whom are internists (12). Often rooted in reality, perceptions among nursing home physicians of excessive regulation, paperwork, professional liability, and lack of nursing support remain barriers to developing a widespread nursing home specialist culture (13). Perhaps more important, many physicians still find it difficult to overcome logistic challenges (for example, caring for a sufficient number of patients while traveling from one facility to another), even though reimbursement for nursing home visits has increased. Without salary derived from administrative duties associated with being a medical director, many practitioners find nursing home care untenable. Waning interest in primary care and geriatrics (14), coupled with few credible role models (15), further constrains physician involvement in nursing homes. In a survey of graduating residents, fewer than 15% felt "very prepared to provide nursing home care" (16). .

1997 Study on Nursing Home Medical Practice

RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients

CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Physician involvement in nursing home patient care is important in decreasing needless hospital admissions and in improving outcomes:

"Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (33–35). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes"

EMR and the Stimulus Bill

There are many opinions regarding the effects of a government subsidy for EMR adoption. As I blogged earlier, my fear is this may just end up promoting older technologies and "establishment" vendors, potentially preventing smaller, innovative players from entereing the market. There also implications for open source EMR community as well.

Austin Merritt has some interesting thoughts in his article, Get Ready for EHR Failures, But Don’t Blame the Software.
He expresses concern that a free or overly subsidized EMR will not lead to meaningful use by physicians since people tend not to value somthing they did not pay for. I generally agree with this premise. However, if the "free EMR" is trully indispensible to the physician in terms of efficiency, workflow, care quaility, and is easy to use, then it will not matter if the EMR is free- it will be adopted by phyicians.

Addressing Long Term Healthcare worker shortage

Legislation H.R. 468 was introduced in order to expand opportunities for long term care workers to obtain additional training and education in care of our growing geriatric population. It is now well known that there will be a shortage of physicians and nurses in the near future, especially in long term care.
There's a need to widen the educational opportunities for the existing pool of long term care providers.

I'm looking for practical examples of the implications of this bill. Hopefully we will see more educational programs being offered to our nursing homes. Nurses in these facilities are over burdened by the increased complexity of today's long term care patients and often lack clinical support. Educational programs for nurses that can be offered on site at nursing homes in the practical aspects of patient care would be of great value.

Perhaps telemedicine can help fulfill this need by bringing experts remotely via video conferencing to the nursing homes and allowing all facilities equal access to quality education despite their location.


Below is an excerpt from the bill describing their findings:

Text of H.R.468 as Introduced in House

Retooling the Health Care Workforce for an Aging America Act of 2009

SEC. 2. FINDINGS.

Congress finds the following:CommentsClose CommentsPermalink

(1) The United States will not be able to meet near-term demands for chronic, geriatric, and long-term care without a workforce that is prepared for the job.CommentsClose CommentsPermalink

(2) Between 2005 and 2030, it is estimated that the number of adults aged 65 and older will almost double from 37,000,000 to over 70,000,000, increasing from 12 percent of the population of the United States to almost 20 percent of the population.CommentsClose CommentsPermalink

(3) Because the overall size of the population of older adults in the United States will increase rapidly, the number of older adults in the United States who are disabled will soar in the coming decades. Between 2000 and 2040 the number of older adults who are disabled will more than double, increasing from an estimated 10,000,000 to an estimated 21,000,000.CommentsClose CommentsPermalink

(4) A 2008 report by the Institute of Medicine of the National Academies, entitled, ‘Retooling for an Aging America’ concludes that the health care workforce will lack the capacity, in both size and ability, to meet the needs of older patients in the future unless action is taken immediately.CommentsClose CommentsPermalink

(5) Inadequate training in geriatrics, gerontology, chronic care management, and long-term care is known to result in misdiagnoses, medication errors, and inadequate coordination of services and treatments that result in poor care and is costly for the health care system as a whole.CommentsClose CommentsPermalink

(6) Currently, only 1 percent of all physicians (approximately 7,000) in the United States are certified geriatricians, even as the population of older adults is on track to double by 2030.CommentsClose CommentsPermalink

(7) Inadequate amounts of time devoted to geriatric training are reported by 1/4 of graduating medical students, and close to 1/2 of graduating medical students say they are unprepared to care for residents in nursing homes.CommentsClose CommentsPermalink

(8) Less than 1 percent of all nurses are certified gerontological nurses. Absent any change, by the year 2020, the total supply of nurses in the United States is projected to fall 29 percent below requirements, resulting in a severe shortage of nursing expertise relative to the demand for care of medically complex, frail older adults.CommentsClose CommentsPermalink

(9) Estimates suggest that there are currently only 700 practicing geropsychologists in the United States, falling far short of the current need for 5,000 to 7,500 geropsychologists.CommentsClose CommentsPermalink

(10) The Bureau of Labor Statistics of the Department of Labor predicts that personal or home care aides and home health aides will represent the second and third fastest-growing occupations between 2006 and 2016. Yet personal or home care aides are not subject to any Federal requirements related to training or education, and States have very different requirements for personal or home care aides.CommentsClose CommentsPermalink

(11) Research shows that inadequate training is a major contributor to high turnover rates among direct care workers and more training is correlated with better staff recruitment and retention rates.CommentsClose CommentsPermalink

(12) An estimated 44,000,000 family caregivers are being asked to provide increasingly complex medical services to frail and elderly loved ones wishing to live at home. Multiple surveys have documented that basic training and access to other targeted services are necessary for family caregivers to provide


See also for more information:

Bill would expand education, training for workers in LTC

Democrats file bill addressing geriatric provider shortage



See below for Information of Geriatric Education Centers (taken from above H.R.468)

TITLE I--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACTCommentsClose CommentsPermalink

Subtitle A--Health Professions Education Related to GeriatricsCommentsClose CommentsPermalink

SEC. 101. GERIATRIC EDUCATION CENTERS.

Section 753 of the Public Health Service Act (42 U.S.C. 294) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘(d) Grants To Expand and Improve Geriatric Education Centers-CommentsClose CommentsPermalink

‘(1) IN GENERAL- The Secretary shall award grants or contracts under this subsection to entities that operate a geriatric education center pursuant to subsection (a)(1).CommentsClose CommentsPermalink

‘(2) APPLICATION- To be eligible for an award under paragraph (1), an entity described in such paragraph shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.CommentsClose CommentsPermalink

‘(3) USE OF FUNDS- Amounts awarded under a grant or contract under paragraph (1) shall be used to--CommentsClose CommentsPermalink

‘(A) carry out the fellowship program described in paragraph (4); andCommentsClose CommentsPermalink



‘(B) carry out 2 of the 3 activities described in paragraph (5).CommentsClose CommentsPermalink

‘(4) FELLOWSHIP PROGRAM-CommentsClose CommentsPermalink

‘(A) IN GENERAL- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to offer short-term intensive courses (referred to in this subsection as a ‘fellowship’) that focus on geriatrics, chronic care management, and long-term care that provide supplemental training for faculty members in medical schools and other health professions schools with programs in psychology, pharmacy, nursing, social work, dentistry, public health, or other health disciplines, as approved by the Secretary. Such a fellowship shall be open to current faculty, and appropriately credentialed volunteer faculty and practitioners, who do not have formal training in geriatrics, to upgrade their knowledge and clinical skills for the care of older adults and adults with functional limitations and to enhance their interdisciplinary teaching skills.CommentsClose CommentsPermalink



‘(B) LOCATION- A fellowship shall be offered either at the geriatric education center that is sponsoring the course, in collaboration with other geriatric education centers, or at medical schools, schools of nursing, schools of pharmacy, schools of social work, graduate programs in psychology, or other health professions schools approved by the Secretary with which the geriatric education centers are affiliated.CommentsClose CommentsPermalink



‘(C) CME CREDIT- Participation in a fellowship under this paragraph shall be accepted with respect to complying with continuing medical education requirements. As a condition of such acceptance, the recipient shall agree to subsequently provide a minimum of 18 hours of voluntary instructional support through a geriatric education center that is providing clinical training to students or trainees in long-term care settings.CommentsClose CommentsPermalink

‘(5) ADDITIONAL REQUIRED ACTIVITIES DESCRIBED- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to carry out 2 of the 3 activities:CommentsClose CommentsPermalink

‘(A) FAMILY CAREGIVER TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year, at no charge or nominal cost, to family caregivers that are designed to provide practical training for supporting frail elders and individuals with disabilities. The Secretary shall require such Centers to work with appropriate community partners, including family caregivers and family caregiver organizations, to develop training program content and to publicize the availability of training courses in their service areas. All family caregiver training programs shall include instruction on the management of psychological and behavioral aspects of dementia, communication techniques for working with individuals who have dementia, and the appropriate, safe, and effective use of medications for older adults.CommentsClose CommentsPermalink



‘(B) DIRECT CARE WORKING TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year to certified nurse aides, home health aides, personal or home care aides and other types of direct care workers on ‘best practices’ for working with frail elders and individuals with disabilities, including individuals with dementia, urinary incontinence, and problems with balance or mobility, and raising awareness of medication issues for older adults.CommentsClose CommentsPermalink



‘(C) INCORPORATION OF BEST PRACTICES- A geriatric education center that receives an award under this subsection shall develop and include material on depression and other mental disorders common among older adults, medication safety issues for older adults, and management of the psychological and behavioral aspects of dementia and communication techniques with individuals who have dementia in all training courses, where appropriate.CommentsClose CommentsPermalink

‘(6) TARGETS- A geriatric education center that receives an award under this subsection shall meet targets approved by the Secretary for providing geriatric training to a certain number of faculty or practitioners during the term of the grant, as well as other parameters established by the Secretary, including guidelines for the content of the fellowships.CommentsClose CommentsPermalink

‘(7) AMOUNT OF AWARD- An award under this subsection shall be in an amount of $150,000. Not more than 24 geriatric education centers may receive an award under this subsection.CommentsClose CommentsPermalink

‘(8) MAINTENANCE OF EFFORT- A geriatric education center that receives an award under this subsection shall provide assurances to the Secretary that funds provided to the geriatric education center under this subsection will be used only to supplement, not to supplant, the amount of Federal, State, and local funds otherwise expended by the geriatric education center.CommentsClose CommentsPermalink

‘(9) AUTHORIZATION OF APPROPRIATIONS- In addition to any other funding available to carry out this section, there is authorized to be appropriated to carry out this subsection, $10,800,000 for the period of fiscal year 2011 through 2013.’.

Healthcare IT Stimulus and EHRs

The 20 billion dollar Health IT stimulus could potentially force doctors to choose "between VHS or Betamax at a time when we see Blue Ray on the horizon".
I fear that any large scale government spending on health care IT, especially in the area of EHRs (Electronic Health Records), will end up being corporate welfare for the large, established IT vendors. There are a lot of smart people developing the next generation of health care computing, but unfortunately they may be shutout from the market if this spending plan comes to fruition.

I've seen over the past several years how federal and state dollars have been wasted in creating RHIOs. Many of these RHIOs found that after the initial grant money dried up, there really wasn't a compelling business value that would lead to sustainability. The grant funds just made these entities chase some misguided business plan/vision which really did not address true needs in the community for which providers would be willing to pay for.

If EHRs are truly vital to the efficient and safe delivery of health care, and actually help physicians and other providers do their job well, then these end users should pay for the technology themselves. The argument made from the other side is that the cost of EHRs is more than physicians can afford. I think then, the real issue is, perhaps the current crop of EHRs is based on old, clunky, expensive technology. Unfortunately, we may not get to see the future technology for EHRs if the government dumps billions into forcing physicians to buy current systems.

Telemedicine in 1924?

The Concept of Telemedicine existed in 1924!
The only problem, the technology did not exist at that time. This magazine cover is quite remarkable in that it demonstrates the current concept of telemedicine, complete with videoconferencing, remote stethoscope and even an printer! Perhaps this young patient is receiving a prescription.
Also see this interesting article.

Bail out Money, how far does it go?

The folks at Powerline blog posted some interesting facts about the nearly trillion dollars in bail out funds:

A Dozen Fun Facts About the House Democrats' Massive Spending Bill

1. The House Democrats' bill will cost each and every household $6,700 additional debt, paid for by our children and grandchildren.

2. The total cost of this one piece of legislation is almost as much as the annual discretionary budget for the entire federal government.

3. President-elect Obama has said that his proposed stimulus legislation will create or save three million jobs. This means that this legislation will spend about $275,000 per job. The average household income in the U.S. is $50,000 a year.

4. The House Democrats' bill provides enough spending - $825 billion - to give every man, woman, and child in America $2,700.

5. $825 billion is enough to give every person living in poverty in the U.S. $22,000.

6. $825 billion is enough to give every person in Ohio $72,000.

7. Although the House Democrats' proposal has been billed as a transportation and infrastructure investment package, in actuality only $30 billion of the bill - or three percent - is for road and highway spending. A recent study from the Congressional Budget Office said that only 25 percent of infrastructure dollars can be spent in the first year, making the one year total less than $7 billion for infrastructure.

8. Much of the funding within the House Democrats' proposal will go to programs that already have large, unexpended balances. For example, the bill provides $1 billion for Community Development Block Grants (CDBG), which already have $16 billion on hand. And, this year, Congress has plans to rescind $9 billion in highway funding that the states have not yet used.

9. In 1993, the unemployment rate was virtually the same as the rate today (around seven percent). Yet, then-President Clinton's proposed stimulus legislation ONLY contained $16 billion in spending.

10. Here are just a few of the programs and projects that have been included in the House Democrats' proposal:

· $650 million for digital TV coupons.
· $6 billion for colleges/universities - many which have billion dollar endowments.
· $166 billion in direct aid to states - many of which have failed to budget wisely.
· $50 million in funding for the National Endowment of the Arts.
· $44 million for repairs to U.S. Department of Agriculture headquarters.
· $200 million for the National Mall, including grass planting.
· $400 million for "National Treasures."

11. Almost one-third of the so called tax relief in the House Democrats' bill is spending in disguise, meaning that true tax relief makes up only 24 percent of the total package - not the 40 percent that President-elect Obama had requested.

12. $825 billion is just the beginning - many Capitol Hill Democrats want to spend even more taxpayer dollars on their "stimulus" plan.

CMS Nursing Home Quality Measures

Here is a table of Nursing Home quality measure as defined by CMS.

Quality Measures	MDS Observation Time Frame *
Long Term Measures
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season	October 1 thru March 31
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	Looks back 5 years
Percent of Residents Whose Need for Help With Daily Activities Has Increased	Looks back 7 days
Percent of Residents Who Have Moderate to Severe Pain	Looks back 7 days
Percent of High-Risk Residents Who Have Pressure Sores	Looks back 7 days
Percent of Low-Risk Residents Who Have Pressure Sores	Looks back 7 days
Percent of Residents Who Were Physically Restrained	Looks back 7 days
Percent of Residents Who are More Depressed or Anxious	Looks back 30 days
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder	Looks back 14 days
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder	Looks back 14 days
Percent of Residents Who Spent Most of Their Time in Bed or in a Chair	Looks back 7 days
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse	Looks back 7 days
Percent of Residents with a Urinary Tract Infection	Looks back 30 days
Percent of Residents Who Lose Too Much Weight	Looks back 30 days
Short-Stay Measures
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season	October 1 thru March 31
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	Looks back 5 years
Percent of Short-Stay Residents With Delirium	Looks back 7 days
Percent of Short-Stay Residents Who Had Moderate to Severe Pain	Looks back 7 days
Percent of Short-Stay Residents With Pressure Sores	Looks back 7 days