John F. Loome, M.D., CMD Sr. VP Medical Affairs Genesis HealthCare Charting the Course of Post-Acute and Long Term Care Medicine “How to Think About Patient Care in Current Times” John F. Loome, M.D., CMD Sr. VP Medical Affairs Genesis HealthCare

Speaker Disclosures Dr. Loome is employed by Genesis HealthCare as Senior Vice President of Medical Affairs and is a stock holder of that organization

Objectives Identify strategies to implement meaningful, sustained improvement in a nursing facility, using efficient and effective clinical and management strategies; Identify and address challenges to improvement, including the major impact of cognitive biases on care quality; and Clarify the critical role of medical directors and practitioners in leading a nursing home to analyze and improve its approaches to care.

Skilled Nursing Facility More comorbidities More medications More physical dependence Highest risk population Costliest population BPCI/MSSP ACO Higher comparative readmission rates 19% FFS vs. 23-24% SNF February 5, 2019

Medical Care Process Comprehensive information Patient assessment Care planning Manage expectations Goal setting Daily rounding Advance care planning February 5, 2019

Assessment Vital signs Exam Skin Cognition (BIMS) Diagnoses Function Active/relevant Past history/chronic conditions Function Prognosis February 5, 2019

Geriatric Principles Start low/go slow Less is better Treat in place ED/Hospital not the best place Good communication Multidisciplinary approach Early mobilization Functional restoration February 5, 2019

Care Philosophy Internal focus > full control of patient care KNOW YOUR PATIENTS Use consultants for their expert advice DO NOT RELY on them DO NOT let them drive the care of the patient DO NOT let them write orders Keep family members/POAs informed > do not ask them “what should we do?” or “what would you like to do?” DO NOT let nursing staff drive unfounded decision making > collect data and make an assessment Tighten On Call practice February 5, 2019

Areas of Focus Establish and Define Diagnoses Medication Reduction Advance Care Planning

Define the Diagnosis “CHF” Systolic or Diastolic? Left sided or Right Sided? Ejection Fraction? Functional capability? Recent hospitalizations? Past therapies tried?

Define the Diagnosis Leads to a clearer picture on PROGNOSIS NYHA Classification BODE Index (COPD) Use objective data to estimate prognosis Easier to explain to patient, family, other team members

Medication Reduction Medication burden biggest iatrogenic problem in the industry Studies establish # of meds related to poor outcomes Adverse effects Drug-drug interactions Beers list medications

Advance Care Plan Discuss prognosis with each patient and/or family Estimate prognosis (Flacker) Multiple chronic conditions (multimorbidity) Cancer Dementia Stage of disease process Direct, honest, compassionate Document plan Billable CPT codes (99497, 99498) February 5, 2019

Flacker February 5, 2019

Case Study 89 yo female LTC resident Hx of Dementia, CHF, CKD, HTN Hospitalized 4 times in last 12 months for CHF exacerbation, rising serum creatinine, frequent falls Full code per DPHCA No ACP discussion Prognosis? Meds: Entresto, Torsemide, ASA, Aricept, Colace, Miralax, Senokot, KCl, Prozac, Xanax, Norvasc BMI 19.5 Orthostatic, dry SOB at rest Dependent in all ADLs February 5, 2019

Case Study Define Prognosis Inform DPHCA Manage medication burden Dementia > BIMS 6 CHF > LVEF= 15% w/MR CKD > Stage 3B, GFR= 30-35 Flacker = 9.38 (50.5% mortality in next 12 mos) Inform DPHCA Guide Adjust ACP Manage medication burden Eliminate duplicative therapy, unnecessary, and high risk meds February 5, 2019

Case Study Team sat down with daughter and explained severity of situation and prognosis They all decided on a comfort care approach with no hospitalization Norvasc, Aricept, Miralax, Colace, Entresto all stopped Xanax weaned off Torsemide dose halved Nephrologist appointments stopped Oxygen applied No more falls No hospitalizations in 2 months! February 5, 2019

Summary Demand complete/comprehensive information KNOW YOUR PATIENT Collect all data Estimate prognosis Utilize your team Communicate with patients, families, decision makers Outline an appropriate advance care plan Deliver highest quality care while avoiding hospitalization Know your referring hospital Safe discharge with clarity of plan, meds, rapid follow-up Home health/case management February 5, 2019

February 5, 2019