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Long-Term Care (LTC) Information Series

AMDA’s information series tool kits are designed to guide the reader through basic geriatric medicine and the long term care environment. For example — how does this condition typically present itself in a frail older person? What is its incidence and impact in long-term care? What things should a practitioner consider about this environment that differs from an acute care setting such as workforce, regulations, accessibility of diagnostic equipment, etc.?

The following topics are covered in our LTC Information Series:

Antithrombotic Therapy
Atrial Fibrillation
Clinical Collaboration
Constipation and Diarrhea
Determination of Medical Necessity of Rehabilitation Therapy Services
Influenza Immunization and the Health Care Worker (DVD)
Oral Health in the Long-Term Care Setting
Palliative Care
The Younger Adult - NEW 2013

Anemia in the Long-Term Care Setting

Anemia is a common problem in the LTC setting and appears to be associated with increased morbidity and reduced quality of life. Anemia is associated with increased disability, decreased physical performance, decreased muscle strength, increased risk of cardiovascular events, impaired quality of life, increased risk of falls, and increased mortality. The condition is common in LTC patients, but it is often unrecognized, undiagnosed, and untreated. Recent research suggests that anemia, even in frail, older patients, is potentially treatable.

The purpose of this tool kit is to raise the awareness of the incidence of anemia in the elderly and the impact it has on the elderly population. This information tool kit also gives advice on how to set up a QA program and discusses the role of the medical director in anemia management. It briefly discusses treatment options as well.

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Antithrombotic Therapy in the Long-Term Care Setting - Revised 2012

Antithrombotic therapy represents the mainstay of treatment and preventive measures in patients with atherothrombotic diseases. Both the incidence and prevalence of these diseases increase with age. Patients residing in the LTC setting are highly susceptible to atheroembolic events by reason of their age and general vulnerability. Clinical decisions are challenging in this setting because of the paucity of data specific to treatment of the frail elderly and the predisposition of this patient population to adverse drug reactions.

Antithrombotic Therapy in the Long-Term Care Setting is a succinct and practical reference manual designed to fill an important void in thrombi and thromboemboli reference materials. Drawn from evidence-based and best practices this tool kit helps practitioners quickly find answers to questions they face every day such as:

  • What is the best antiplatelet regimen to prevent myocardial infarction or ischemic stroke?
  • What is the safest way to begin, titrate and monitor warfarin therapy for a frail elderly patient?
  • Which patients are at greatest risk for deep vein thrombosis (DVT), and what are the best regimens to prevent and treat DVT?
  • What adjustments to antiplatelet or antithrombotic therapy are needed when a patient has an invasive procedure or major surgery?

Filled with easy to read tables, this one-of-a-kind manual includes:

  • Introduction to antithrombotic therapy in the LTC setting
  • Prevention of venous thromboembolism
  • Treatment and secondary prophylaxis of venous thromboembolism
  • Antithrombotic therapy for stroke or stroke prevention and in atrial fibrillation
  • Antithrombotic therapy in cardiovascular disease
  • Managing the risks of major bleeding events associated with antithrombotic therapy
  • Antiplatelet agents in antithrombotic therapy
  • Warfarin in antithrombotic therapy
  • Other oral anticoagulants in antithrombotic therapy
  • Parenteral anticoagulants in antithrombotic therapy
  • Heparin-induced thrombocytopenia
  • Perioperative management of antithrombotic therapy
  • Ten helpful appendices

The 2012 revision of the Antithrombotic Therapy in the Long-Term Care Setting Information Tool Kit is intended to help practitioners optimally manage the use of antithrombotic therapies in elderly patients in the LTC setting. The manual incorporates evidence-based guidelines and expert opinion from several specialty organizations, including the American College of Chest Physicians American College of Cardiology, American Heart Association, and the American Stroke Association. To assure the accuracy and applicability of the information contained in the tool kit the authors collaborated with experts in geriatric cardiology, warfarin risk assessment, prevention of deep vein thrombosis, peri-procedural anticoagulation, heparin-induced thrombocytopenia, pharmacology and the practice of long term care medicine. To the extent possible, this document draws on evidence from large, well-designed, randomized clinical trials; when such evidence does not exist, it presents suggested best practices based on the available literature and expert consensus. This information tool kit focuses on issues related to atherothrombotic diseases that are addressed within the LTC facility.

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Atrial Fibrillation in the Long-Term Care Setting

Atrial Fibrillation (AF) is a serious health problem, the most common arrhythmia requiring hospital admission and is associated with an increase in mortality. Because the prevalence of AF increases steadily with age, the number of patients in the LTC setting who have or are at risk for AF can be expected to rise in the near future. An urgent need therefore exists for LTC interdisciplinary teams to understand AF and to be able to address it promptly and effectively. Members of the LTC interdisciplinary team need to understand the importance of AF and contribute to an individualized management plan to reduce complications and optimize quality of life for patients with AF.

The treatment of AF involves choosing treatment goals and strategies and deciding whether to pursue certain medical or surgical treatments. The practitioner and patient has several goals to consider in managing AF, prevention of stroke and systemic thromboembolism; prevention of tachycardia-induced cardiomyopathy; control of symptoms and; restoration and maintenance of sinus rhythm. Treatment to achieve these goals in this population has many challenges. The information in this tool kit discusses the challenges of this population and will help guide the practitioner in that decision making. The information presented in this tool kit will also help the IDT recognize both the descript and non descript sign and symptoms of AF as well as the risk factor to be able to know when to call in the practitioner for that medically necessary visit.

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Clinical Collaboration in the Long-Term Care Setting

The use of advance practice nurses (APNs) and physician assistants (PAs) is increasingly common in many practice settings, including LTC. Market developments, such as the higher acuity of patients and increased oversight required by managed care companies, have encouraged widespread use of APNs and PAs. With this tool kit you will be prepared and able to take advantage of the changing structure.

This kit addresses the Medicare Program (e.g., education/certification requirements for APNs and PAs, PA services, clinical nurse specialist services, Medicare coverage of these services, medically necessary visits, physician supervision and collaboration), Medicaid coverage and payment rules (e.g., coverage of APN and PA services, contract arrangements), resources and references, frequently asked questions, a glossary, and a sample collaborative agreement.

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Constipation and Diarrhea in the Long-Term Care Setting

Constipation and diarrhea are common problems in the LTC setting. Up to 80% of patients are affected. Chronic constipation has been shown to affect both overall psychological well being and quality of life. Diarrhea is a major cause of morbidity and mortality in this population. Given the prevalence of these two disorders, their morbidity and mortality rates, and their impact on patients’ quality of life, it is important that IDT members of the LTC team are trained to recognize common signs and symptoms and report them to the practitioner in a timely manner.  The guidance in this tool kit helps the members of the interdisciplinary (IDT) carefully recognize, assess, treat, and monitor these conditions in the frail elder person, leading to more effective patient specific interventions that can reduce the burden of constipation and diarrhea.

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Determination of Medical Necessity of Rehabilitation Therapy Services

Medicare defines medical necessity as a determination that a service is reasonable and necessary for the diagnosis or treatment of illness or injury. However, the use of this term in health care settings is controversial and often confusing. Applying the concept of medical necessity to rehabilitation therapy services is challenging for several reasons. The issue of the medical necessity of therapy services presents many questions and challenges for long term care medical directors, attending physicians, and patients. AMDA is providing this tool kit to help medical directors and attending physicians determine medical necessity and identify the appropriate use of therapy services. Physicians will appreciate the guidance in this tool kit about the appropriateness and potential benefits of therapy services and the ability of individuals in the long term care setting to tolerate these services. The tool kit defines common abbreviations and therapy services, has a glossary of terms, FAQs, and sample procedures and forms.

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Immunizations in the Long-Term Care Setting

Take the lead in initiating and implementing activities to address and prevent influenza and pneumococcal disease in LTC facilities. With this tool kit, you’ll:

  • Learn how to boost vaccination compliance among both residents and staff;
  • Find out what the barriers are and learn strategies for overcoming them;
  • Get an overview of federal regulations;
  • Learn processes for managing influenza outbreaks in LTC facilities;
  • Go beyond standard flu preparedness plans and learn additional steps you can take to ensure your facility is prepared; and
  • Provide education on other potentially relevant immunizations in the LTC setting shuch as herpes zoster, tetanus, pertusis and diptheria.

The tool kit is 53 pages and includes 2 DVDs: Influenza Immunization and the Health Care Worker and Caring in the Community:   Immunization and the Older Adult and a CD-ROM that includes helpful tools, many customizable to fit your facility’s needs

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Influenza Immunization and the Health Care Worker (DVD)

Vaccination of health care workers against influenza has been shown to protect patients by potentially reducing illness and by decreasing mortality by as much as 40%, independent of patient vaccination status. Unfortunately, health care worker influenza immunization rates remain inexcusably low at 37% to 42%, and those rates have changed little over the past decade. Experts show that the main reason surrounding this low rate is the myths and misconceptions around influenza vaccination, not making employee vaccination a priority and not having a good educational program in place to dispel myths about influenza vaccination. AMDA has come up with your solution in one powerful 18 minute DVD. Let Dr. Gregory Poland, the nation’s immunization expert break down those myths and barriers in lay terms for your staff. Then they will hear from a wide variety of health care workers speak to them unscripted, peer-to-peer, about why they get immunized and why they want their peers to get immunized. A very moving and heartfelt DVD that will raise your employee immunization rates!

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Oral Health in the Long-Term Care Setting

A wealth of epidemiological evidence demonstrates that the oral health status of LTC patients is poor and that the oral care provided in the LTC setting can be greatly improved. An equally abundant body of evidence supports the view that diseases of the oral cavity contribute to the total disease burden and illness of LTC patients and that good oral care plays a role in improving health outcomes and quality of life in this population. Use of the guidance and tools found in this tool kit can assist LTC facilities to:

  • Develop and maintain an institutional culture that values oral health and instills a facility-wide commitment to achieving and maintaining an oral health care program;
  • Identify oral health care resources in their communities and develop relationships with oral health professionals who have expertise in providing care to patients with special needs;
  • Develop and implement an oral health plan, policies, and procedures, and an ongoing process for monitoring and evaluating the quality of oral health care;
  • Integrate oral health care into the facility’s overall program of daily patient care;
  • Develop and implement ongoing oral health training programs for both new and existing facility staff; and
  • Develop and maintain individualized oral hygiene care plans for every facility patient that are followed and reviewed at regular intervals.

Outcomes that facilities may achieve as a result of implementing the guidance and tools found in this tool kit include but are not limited to the following:

  • Improved competence of caregiving staff in the provision of oral care and greater staff confidence in their ability to perform such care;
  • Better management of patients who are resistant to oral care and a decrease in aggressive behaviors during oral care;
  • Decreases in the number or proportion of patients who experience weight loss related to oral pain, poorly fitting dentures, or other oral conditions; and
  • Decreases in the number or proportion of patients diagnosed with serious oral infections or with extraoral infections subsequent to oral health conditions.

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Palliative Care in the Long-Term Care Setting

Professionals caring for frail older adults understand that the percentage of patients dying in hospitals is decreasing while the percentage of patients dying at home or in PA/LTC facilities is increasing. Patients may experience physical, emotional, and spiritual suffering for months or even years before they enter the active phase of dying from their illness. To ensure that long term care patients with chronic and progressive illnesses receive optimal care; all members of the interdisciplinary team should be proficient in the assessment and relief of suffering. Such a "whole-person" approach to the care of patients whose diseases are not responsive to curative treatment is called palliative care. This tool kit provides helpful and practical guidance to PA/LTC professionals who are motivated to improve palliative and end-of-life care by providing organizational leadership, promoting education, developing best practice guidelines, and implementing quality assurance.

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Seizures in the Long-Term Care Setting

The Seizures in the Long-Term Care Setting Information Tool Kit is intended to help the interdisciplinary team in the long-term care facility to:
  • Become aware of the prevalence of seizures in the long-term care population
  • Identify the signs and symptoms of a seizure in an elderly long-term care patient
  • Determine which patients should undergo diagnostic evaluation for seizures
  • Manage seizures effectively and appropriately
  • Use anti-epileptic medications appropriately

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The Younger Adult in the Long-Term Care Setting - NEW 2013

LTC is no longer synonymous with "geriatric care." In the past 10 years, adults ages 31 to 64 have been the fastest growing population in nursing homes. The last national nursing home survey sponsored by the Centers for Disease Control and Prevention (CDC) in 2008 estimated that nearly 12% of nursing home residents are aged less than 65 years.

For this tool kit, younger adults are defined as those as those aged 18 to 64 years. Younger adults are differentiated from their older counterparts in more ways than merely age, and this poses unique challenges and opportunities. For example, the clinical syndromes afflicting the various groups differ. Compared with older residents, younger adults in LTC have:

  • More diagnoses related to mental retardation and developmental disabilities
  • A higher prevalence of hemiplegia and quadriplegia, especially related to trauma
  • Suffer an increased prevalence of chronic and neurological disorders, such as Huntington's disease (HD), muscular dystrophy (MS), Amyotrophic lateral sclerosis (ALS), cerebrovascular accident, Alzheimer's disease, Parkinson's disease, peripheral vascular disease, and cardiac diseases
  • Psychiatric diagnoses are significantly higher
  • More likely to have residential histories of prior stays in psychiatric facilities

In general, the younger residents of LTC fall into three general groups on the basis of the etiology of their illnesses and disabilities, which require different approaches by LTC staff. The main categories of younger adults are those with

  • Illnesses from capricious fate, including chronic, progressive, psychiatric, or neurologic illnesses such as MS, HD, ALS, or schizophrenia that they have been coping with for years;
  • Illness and possibly institutionalization from birth or childhood; or
  • A sudden onset of physical problems related to injury (such as a traumatic brain injury), misfortune, or lifestyle choices.

AMDA's The Younger Adult in the Long-Term Care Setting Information Tool Kit addresses questions that must be considered by LTC organizations in the care of younger adults include the following:

  1. What are the care needs and goals of care for these patients?
  2. How will these residents' psychological, social, psychiatric, sexual, and other basic human needs be met?
  3. How do facilities assist younger residents in coping with the possibility of spending 30, 40, or even 50 years or more of their life in a nursing home?
  4. What activities does the facility offer specifically for younger adults?

The tool kit is designed for use by all professionals of the interdisciplinary team, including practitioners and medical directors, social workers, nurse clinicians and administrators, psychologists, and recreational and rehabilitation professionals, and aims to be practical rather than theoretical. The tool kit also addresses problem-solving methodology that can be applied to other populations and concerns within the LTC field. Specifically, the goals of this tool kit are:

  • To expand our view about what a LTC patient "looks like"
  • To provide a resource for managing difficult cases in LTC settings along with care planning tips and effective interventions
  • To identify best practices and specific tools used by facilities with a higher proportion of younger residents that can be adapted to other settings

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