by Debra Bakerjian, PhD, APRN, FAAN, FAANP

It is hard to believe that it is already December, it seems like I just finished writing the last update – how time flies by!  I hope everyone had a wonderful Thanksgiving Holiday!  As I think back on the months since I last wrote, it has been an eventful six months that has had a great impact on all of us!  I am sharing some of my own reflections about a few key issues and hope that will spur your thinking as well.

Giving Tuesday has come and gone, but I would like to make one more call out to all of the readers in the spirit of holiday giving.  CALTCM has worked hard to provide a wide variety of education and quality services to our members and other interested stakeholders.  As a 501(c)(3) organization, we rely upon donations and conference fees to support all of these activities.  I hope that you will consider donating to CALTCM for one of our worthy causes – you can even specify which cause.  Right now, I’m really trying to collect money so that we can support a physician and/or nurse practitioner to attend the AMDA Futures program.  We have a goal of $3,500 - If you can donate any amount, we make it really easy.  Go to the website and click on DONORS & SPONSORS in the upper right corner of the Home page and then clinic on Donate Now.  When donating you will have some options to choose from, but we urgently need funding for the AMDA Futures program, so I hope you will select that program to support!  

CALTCM Fall Conference:  For the first time in several years, CALTCM held a fall conference in October.  The conference incorporated some of the presentations from the spring conference along with some regulatory updates.  We held the conference at the University of CA, Davis Health System campus, which is actually located in Sacramento.  The 1-day conference was well attended and feedback was positive.  We hope to repeat this next year with a more expanded focus.

Spring Conference Planning and Best Practices:  The Education Committee has been in full swing, planning our Annual Conference, “Quality Through Best Practices” on April 28 & 29, at the Omni Hotel, Los Angeles, CA.  The focus this year is capturing an interdisciplinary approach to common conditions in the NH – Diabetes Management, Pain Management, and select Patient Safety issues.  We will also have session updates on new regulations (The Final Rule is discussed below) for facilities and clinicians (MACRA).  Given the new administration coming in to place, there might be a lot to discuss if the promises to repeal and replace the Affordable Care Act are actualized. STAY TUNED!

Thanks to the generosity of SCAN Health Plan and Health Services Advisory Group (HSAG), we will be repeating our highly successful “Best Practices Summit” with the $125 pre-conference fee waived!  Yes, you will be able to attend for FREE! The summit was extremely well received last year and I am looking forward to learning from another five groups this year.  That’s right! We listened to the feedback – this year you will be able to hear from all five of the “Best Practices”, instead of only three!

Final Rule: Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities. Certainly, one of the most impactful event is the Final Rule for long-term care facility residents, published on October 4, 2016 that can be found in the Federal Register (click here.).  This is the most comprehensive update of nursing home regulations since OBRA 1991 and significantly changes various areas of practice, particularly those related to quality and safety.

The following information gives an overview of changes contained in the final rule and is taken directly from the CMS website press release:

• Strengthening the rights of long-term care facility residents, including prohibiting the use of pre-dispute binding arbitration agreements.

• Ensuring that long-term care facility staff members are properly trained on caring for residents with dementia and in preventing elder abuse.

• Ensuring that long-term care facilities take into consideration the health of residents when making decisions on the kinds and levels of staffing a facility needs to properly take care of its residents.

• Ensuring that staff members have the right skill sets and competencies to provide person-centered care to residents. The care plans developed for residents will take into consideration their goals of care and preferences.

• Improving care planning, including discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up after discharge, and ensuring that instructions are transmitted to any receiving facilities or services.

• Allowing dietitians and therapy providers the authority to write orders in their areas of expertise when a physician delegates the responsibility and state licensing laws allow.

• Updating the long-term care facility’s infection prevention and control program, including requiring an infection prevention and control officer and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Important take-aways are that NHs need to focus on providing person-centered care that facilitates resident choice. There is a greater emphasis on resident rights (§483.10 Resident rights), equal access to quality care, equal treatment to same-sex spouses, choice of roommates, timing of visitors, and self-determination.  That self-determination is a key feature of this section because it includes language that residents have choices about their life within the facility; choices of activities, schedules, providers, AND the opportunity to participate in their care-planning process!

Section §483.15 addresses admission, transfer, and discharge rights of residents and includes language that physicians, nurse practitioners and physician assistants must document the basis of transfers, specific resident needs that cannot be met by the facility, and the service available at the receiving facility.  Further, practitioners must provide more comprehensive information to the receiving provider: contact information of the responsible practitioner, advance directives, any special instructions or precautions, identification and contact information of the resident representative, comprehensive care plan goals, and a discharge summary.

§483.21 Comprehensive person-centered care planning is expanded in the Final Rule and requires a baseline care plan to be developed within 48 hours of admission that must include directions necessary to provide effective and person-centered care with a copy to be provided to the resident and/or their representative.  There are also expanded requirements for discharge planning including that facilities must assist residents in selecting a post-acute provider.  Discharge summaries must include a recap of medications.

§483.50 Laboratory, radiology, and other diagnostic services clarifies that advanced practice nurses and physician assistants may order diagnostic tests and directs that they be notified of results that are outside the normal parameters.

§483.75 Quality assurance and performance improvement (QAPI) will be a requirement for all facilities and they must submit their QAPI plan by 11/28/17.  As part of that process, NHs must establish QI priorities, have a process for identifying, reporting and analyzing adverse events, root cause analyses, measure performance and implement Performance Improvement Projects (PIPs).

Facilities must establish an Infection and Control Program or IPCP (§483.80 Infection control) that includes, prevention, identification, surveillance, investigation and controlling infections and communicable disease for ALL staff, residents, and ALL types of visitors including clinical consultants.

These regulations will be implemented in three phases:

• The regulations included in Phase 1 must be implemented by Nov. 28, 2016.
• The regulations included in Phase 2 must be implemented by Nov. 28, 2017.
• The regulations included in Phase 3 must be implemented by Nov. 28, 2019.

There are just a few highlights of the Final Rule.  Interested stakeholders should take time to become familiar with the relevant changes as it will affect how we all provide care in the future.

ALL in ALL, an eventful few months and so much more to look forward to in 2017. I want to thank you for being a supporter of CALTCM, we cannot do all that we do without your support. Don’t forget to register for the Annual Conference and, please, help us raise funds for our California clinicians to attend the AMDA Futures program!

I hope that everyone has a wonderful holiday season and I look forward to seeing you in the New Year!

With gratitude,