1. 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

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

3. 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.

4. 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 % SNF
February 5, 2019

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

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

7. 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

8. 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

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

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

11. 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

12. 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

14. 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

15. Flacker
February 5, 2019

16. 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

17. 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

18. 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

19. 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

20. February 5, 2019