submitted recommendations for possible consideration by

SUBCOMMITTEE TO CONDUCT A STUDY OF POSTACUTE CARE Assembly Bill 242 (Chapter 306, Statutes of Nevada 2015)

Submitted Recommendations for Possible Consideration by the Subcommittee

at the Final Meeting and Work Session on July 6, 2016 This summary presents recommendations submitted to the Subcommittee to Conduct a Study of Postacute Care in response to a February 25, 2016, memorandum soliciting recommendations from all interested parties. The solicitation was forwarded via e-mail to the entire Subcommittee mailing list and posted on the Subcommittee webpage via the link titled “Solicitation of Recommendations Memorandum.” The recommendations constitute a preliminary list of certain recommendations for possible consideration by the Subcommittee at the July work session. The recommendations are organized by the person or entity that provided the recommendation. Some recommendations are duplicates (or very similar) and some recommendations will require greater detail should the Subcommittee desire to include them in the final work session document. Recommendations Submitted by Lucia Mathis, Vice President, Nevada Assisted Living Centers 1. Submit a bill draft request (BDR) to authorize certain employees or members of the staff of

a residential facility for groups (unlicensed assistive personnel) to complete basic Centers for Medicare and Medicaid Services (CMS) defined vital signs for certain residents. The vital signs defined by CMS include taking a resident’s temperature, blood pressure, pulse, apical heart rate, respirations, oxygen saturation, and finger-stick glucose.

2. Require Nevada’s Division of Health Care Financing and Policy (DHCFP), Department of Health and Human Services (DHHS), to review Medicaid Waiver programs and revamp the programs to ensure that funding covers the actual cost of personal care provided in assisted living and residential facilities for groups’ settings.

Recommendations Submitted by Daniel Mathis, President/CEO, Nevada Health Care Association 3. Send a resolution to the Governor of the State of Nevada, the Director of DHHS, and the

Chairs of the Senate Committee on Finance and Assembly Committee on Ways and Means during the 2017 Legislative Session recommending and expressing support for the Governor’s recommended budget and the Legislature-approved budget to fully fund the rate methodology agreed upon in 2003 and to index that rate to increase with inflation in future biennia.

4. Submit a BDR to implement a quality improvement program to analyze data concerning quality of care and to incentivize facilities that provide higher quality of care. Include an

appropriation of $5 to cover the State share for each Medicaid-patient day or approximately $4.75 million. These funds, plus federal match, would provide meaningful payments and incentives to providers for carrying out a program. The quality measures are developed on a collaborative basis between the DHCFP and the skilled nursing industry. Such measures may include, but are not limited to:

a. Clinical outcome measures developed by CMS; b. Employee retention and turnover; c. Hospital readmissions; and d. Avoidance of long-term stays and the promotion of discharges to home- or

community-based settings.

The scoring system and allocation of funding is also developed collaboratively with the skilled nursing industry taking into account existing performance and quality improvement.

Recommendations Submitted by Helen Foley on behalf of the Residential Care Home Community Alliance of Nevada and the Association of Homecare Owners of Northern Nevada 5. Submit a BDR to establish consistent standards for all facilities providing 24-hour,

long-term care for individuals who need supervision, assistance with personal care and medication management, including those under Chapter 449 of Nevada Revised Statutes (NRS) (“Medical Facilities and Other Related Entities”), Chapter 435 of NRS (“Persons with Intellectual Disabilities and Related Conditions”), and Chapter 433 of NRS (“General Provisions”). Specifically provide consistency in the following areas:

a. Quality: State Ombudsman for all Facilities State Oversight Certified Administrators Liability Insurance Minimum High School Diploma Minimum Staffing Ratios Annual State Inspections Internet Access to Inspection Date and Survey Results Enforceable Penalties State’s Ability to Impose Fines Transparency and Disclosure Residential Sprinklers

b. Medicaid Funding:

Consistent and similar payments for comparable services provided.

Recommendations Submitted by

Lucia Mathis

Study of Postacute Care

Recommendations for Possible Consideration:

Submitted by: Nevada Assisted Living Centers

Thousands of Nevadans choose to live in Assisted Living communities and Residential Facilities for Groups. Providing quality person-centered care in a home like setting is our top priority; but it is not always easy as the acuity and demands of our residents’ rise.

At this time AL/RFGs are not able to complete basic observation data including temperature, blood pressure, pulse, apical heart rate, respirations, oxygen saturation and finger stick glucose). Take for example a senior with diabetes. This leaves them and their families in a difficult situation if assistance to manage their insulin and blood sugar is needed. Some assisted living facilities cannot accept residents because the resident cannot manage their diabetes care without assistance. New residents may be reluctant to join the community due to fear of having no help when they need to check their blood sugars. Current residents who develop diabetes may worry about being forced to move to a nursing home to have their diabetes managed.

CDC indicates Nevada has a high rate of diabetes with Clark and Washoe Counties having the highest number of new cases. In the 2013 the age adjusted incidence of diabetes was greater than 9% which is among the highest in the nation. (See Attachment #1). CDC best practice supports the use of individual glucometers. Likewise, the FDA has perimeters in place to assure safety for assisted monitoring of blood glucose. The new process of assisted monitoring of blood glucose was introduced via an editorial in the Journal of Diabetes Science and Technology/ in September of 2010.

Currently there are CMS recommended guidelines for caring for a resident within an AL/RFG. These recommendations became effective in 2015 following a CMS funded study conducted in Texas. (See Attachment #2). These recommended guidelines are available through the Interact Assisted Living Tool. This tool outlines a basic Care Path that includes taking vital signs: temperature, blood pressure, pulse, apical heart rate, respirations, oxygen saturation and finger stick glucose. The Care Path furthermore instructs staff on the next test to take based on the above observations. These Interact tools were developed with the goal of providing improved care and decreasing unnecessary hospitalizations in AL and RFG settings. Nevada’s Quality Improvement Organization (QIO) HealthInsight has initiated education to AL/RFGs using these tools. Currently the only tool within the Interact Assisted Living tool Nevada AL/RFGs is able to utilize is the Stop and Watch Early Warning Tool. Due to current barriers we are not able to take advantage of the next level module with in the Care Path (See Attachment #3 Interact Assisted Living Care Path Stop and Watch).

Taking Falls and Acute Mental Status Change of a resident for example. We know that many factors can play a role in falls and acute mental status change. The first observation task suggested by the Care Path for Falls and Acute Mental Status Change, is to take resident’s vital

signs (temperature, blood pressure, pulse, apical heart rate, respirations, oxygen saturation and finger stick glucose). Due to current Nevada regulations, AL/RFGs are prohibited from making these basic necessary observations. (See Attachment #4 Interact Assisted Living Care Path Falls and #5 Interact Assisted Living Care Path Acute Mental Status Changes).

The financial impact of diabetes is high. Consider the resident who becomes shaky or presents with decrease visual acuity (both or which are associated with diabetes) and unable to monitor his/her own blood sugar. The resident and facility’s only option is to call 911.

Under NRS 629.091 (see attachment #6) a citizen with a disability that is stable and predictable may request and receive any specific medical nursing or personal care services approved by a provider of health care. Although AL/RFGs are licensed as medical facilities they are in reality a provider of personal services to citizens with disabilities who live there. Therefore, our disability citizens and residents should be recognized and be treated equally under the law. Nevada identifies a “Provider of health care” as a physician licensed, a dentist, a registered nurse, a licensed practical nurse, a physical therapist or an occupational therapist.

One solution to allow AL/RFGs to better serve Nevada residents is an NRS similar to 629.091 amended to remove 4.a. which prohibits personal assistance services in a medical facility.

The second option would be to amend NRS 449.0302 (see attachment #7) to include under number 2. b. “and other dementia” and “care to persons with stable chronic health conditions”. This option would also entail adding a definition for health care provider similar to 629.091.

Changes in the NAC will also be necessary to allow us to complete basic CMS defined vital signs ((temperature, blood pressure, pulse, apical heart rate, respirations, oxygen saturation and finger stick glucose). (see attachment #8)

As the resident of an AL/RFG requires more complex care (such as assistance with insulin injections) other states use nurse delegation practices to assure a resident’s needs are met. A nurse may delegate tasks based on the needs and condition of the resident the potential for harm, the stability of the resident’s condition, the complexity of the task, the predictability of the outcomes, the abilities of the staff to whom the task is delegated and the context of the other resident’s needs. All decisions related to delegation and assignment are based on the principals of the protection of the health, safety and welfare of the resident. The National Council of State Boards of Nursing recommended a decision tree for delegation of tasks to unlicensed assistive personnel which was adopted by many states including Nevada. (See attachment #9)

Other states in our region have recognized and met this need. Oregon, Washington, Idaho, South Dakota and others and have implemented regulatory changes that support the social model to allow citizens with disabilities who choose to live in an AL/RFG to direct their own personal health care.

AL/RFG facilities taking residents who are recipients of Medicaid Waiver funds are unable to cover the cost of providing care to these individuals.

Under the current Medicaid Waiver program, funding for personal care of a resident is woefully inadequate to cover the cost. Many of these residents do not receive enough in additional funds (pension, Social Security, Long-term care insurance) to cover the cost of room and board let alone supplement the cost of personal care. As Nevada moves forward with the revamping of the Medicaid waiver program, we encourage a look at the actual cost of personal care in AL/RFGs. On behalf of the AL/RFG community, NVALC thanks you for taking the time to carefully consider needs of Nevada residents. We know you have a daunting task and appreciate your efforts in working through all options as you develop a plan to address the needs in post-acute care. We look forward to the future and our possibilities and hope we can be a part of the conversation and solution. Respectfully,

Lucia Lucia Mathis MOT, OTR/L Vice-President NVALC

Maps of Trends in Diagnosed Diabetes January 2015

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at

http://www.cdc.gov/diabetes/statistics

http://www.cdc.gov/diabetes/statistics

The maps show the trend in age–adjusted prevalence of diagnosed diabetes among adults aged 18 years or older in the United States from 1994 through 2013. During the period, prevalence of diagnosed diabetes has increased across the states in the United States. In 1994, 25 states had prevalence less than 4.5%, 24 states had prevalence of 4.5%–6.0%, and only 1 state had prevalence greater than 6.0%. In 2013, all states had prevalence greater than 6.0%, 25 of these exceeded 9.0%.

Because there were major changes in the survey methods in 2011— the addition of cellular telephone-only households and a new method of weighting the data— caution should be taken when comparing estimates across 2011. The addition of cellular telephone-only households has increased the numbers of certain population groups—respondents who have lower incomes, lower educational levels, or are in younger age groups—that represent populations with higher numbers of risk factors. Thus, estimates of health risk behaviors and conditions have increased. In addition, the move to a new method of weighting the data increased in many states the prevalence estimates of chronic diseases such as diabetes and of risk factors such as obesity. Although raking might cause state prevalence trends for certain risk factors to shift upward, in general, the shape of trend lines over time might not be affected. Please refer to http://www.cdc.gov/surveillancepractice/reports/brfss/brfss.html) for more detailed information. Data Source and Methodology The prevalence of diagnosed diabetes among US adults aged 18 years or older was determined using data from the Behavioral Risk Factor Surveillance System (BRFSS), available at http://www.cdc.gov/brfss. An ongoing, yearly, state–based telephone survey of the non–institutionalized adult population in each state, the BRFSS provides state–specific information on behavioral risk factors for disease and on preventive health practices. Respondents who reported that a physician told them they had diabetes (other than during pregnancy) were considered to have diagnosed diabetes. Rates were age–adjusted to the 2000 U.S. standard population based on age groups 18–44, 45–64, 65–74, and 75 years or older. Data for the Maps

http://www.cdc.gov/surveillancepractice/reports/brfss/brfss.html

http://www.cdc.gov/brfss

Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults

<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%

CDC ’ s Division of Diabetes Translation. National Diabetes Surveillance System available at http:// www.cdc.gov /diabetes/statistics

1994

Age–Adjusted Prevalence of Diagnosed Diabetes Among US Adults, 1994

Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Rhode Island Alabama Arkansas South Carolina

Alaska Connecticut

Arizona Delaware

California District of Columbia

Colorado Florida

Hawaii Georgia

Idaho Illinois

Iowa Indiana

Kansas Louisiana

Kentucky Maryland

Maine Michigan

Massachusetts Mississippi

Minnesota Missouri

Montana Nebraska

Nevada New Hampshire

New Jersey New Mexico

New York North Carolina

North Dakota Ohio

Oklahoma Pennsylvania

Oregon Tennessee

South Dakota Texas

Vermont Utah

Washington Virginia

Wisconsin West Virginia

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


1995


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

District of Columbia Alaska Alabama California

Colorado Arizona Louisiana

Connecticut Arkansas Mississippi

Delaware Florida

Georgia Illinois

Hawaii Indiana

Idaho Iowa

Kentucky Kansas

Maine Michigan

Maryland Nevada

Massachusetts New Hampshire

Minnesota New Jersey

Missouri New Mexico

Montana North Carolina

Nebraska Pennsylvania

New York Rhode Island

North Dakota South Carolina

Ohio Tennessee

Oklahoma Texas

Oregon Vermont

South Dakota West Virginia

Utah Wisconsin

Virginia

Washington

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


1996


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska California Alabama

Arizona Delaware District of Columbia

Arkansas Florida Louisiana

Colorado Georgia Mississippi

Connecticut Hawaii

Idaho Illinois

Iowa Indiana

Kansas Maryland

Kentucky Massachusetts

Maine Michigan

Missouri Minnesota

Montana Nebraska

Nevada North Carolina

New Hampshire Ohio

New Jersey Pennsylvania

New Mexico South Carolina

New York Tennessee

North Dakota Virginia

Oklahoma West Virginia

Oregon Wisconsin

Rhode Island

South Dakota

Texas

Utah

Vermont

Washington

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


1997


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arkansas Alabama

Arizona California Delaware

Colorado Connecticut Illinois

Idaho District of Columbia Maryland

Iowa Florida Mississippi

Kansas Georgia Texas

Minnesota Hawaii

Montana Indiana

Nebraska Kentucky

Nevada Louisiana

New Hampshire Maine

North Dakota Massachusetts

South Dakota Michigan

Tennessee Missouri

Washington New Jersey

Wyoming New Mexico

New York

North Carolina

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

Utah

Vermont

Virginia

West Virginia

Wisconsin


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


1998


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska California Alabama Mississippi

Arizona Colorado Arkansas Oklahoma

Connecticut Florida District of Columbia

Delaware Hawaii Georgia

Idaho Iowa Illinois

Kansas Kentucky Indiana

Maine Maryland Louisiana

Massachusetts Minnesota Michigan

Montana Missouri New York

Nevada Nebraska North Carolina

New Hampshire New Jersey

North Dakota New Mexico

South Dakota Ohio

Wisconsin Oregon

Wyoming Pennsylvania

Rhode Island

South Carolina

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


1999


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Georgia Alabama Mississippi

Arizona Hawaii Arkansas

Colorado Idaho California

Connecticut Iowa Delaware

Nebraska Kansas District of Columbia

New Hampshire Maine Florida

Oregon Massachusetts Illinois

Vermont Michigan Indiana

Minnesota Kentucky

Missouri Louisiana

Montana Maryland


New Jersey South Carolina

New Mexico Texas

New York Virginia

North Dakota West Virginia

Ohio

Oklahoma

Pennsylvania

Rhode Island

South Dakota

Tennessee

Utah

Washington

Wisconsin

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2000


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arizona Alabama Mississippi

Vermont Arkansas California

Colorado Delaware

Connecticut District of Columbia

Hawaii Florida

Idaho Georgia

Iowa Illinois

Kansas Indiana

Maine Kentucky

Massachusetts Louisiana

Minnesota Maryland

Montana Michigan

Nebraska Missouri

New Hampshire Nevada

New Jersey New Mexico

North Dakota New York

Oklahoma North Carolina

Oregon Ohio

Rhode Island Pennsylvania

South Dakota South Carolina

Utah Tennessee

Washington Texas

Wisconsin Virginia

Wyoming West Virginia


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2001


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Minnesota Alaska Arizona District of Columbia Alabama

Colorado Arkansas Louisiana Mississippi

Idaho California South Carolina

Iowa Connecticut Tennessee

Kansas Delaware West Virginia

Massachusetts Florida

Montana Georgia

Nebraska Hawaii

Nevada Illinois

New Hampshire Indiana

North Dakota Kentucky

Oregon Maine

South Dakota Maryland

Utah Michigan

Vermont Missouri

Washington New Jersey

Wisconsin New Mexico

Wyoming New York

North Carolina

Ohio

Oklahoma

Pennsylvania

Rhode Island

Texas

Virginia


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2002


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arizona Alabama West Virginia

Colorado Delaware Arkansas

Connecticut Florida California

Hawaii Idaho District of Columbia

Massachusetts Illinois Georgia

Minnesota Indiana Michigan

Montana Iowa Mississippi

Nebraska Kansas South Carolina

North Dakota Kentucky Tennessee

Rhode Island Louisiana Texas

Utah Maine

Vermont Maryland

Washington Missouri

Wisconsin Nevada

Wyoming New Hampshire

New Jersey

New Mexico

New York

North Carolina

Ohio

Oklahoma

Oregon

Pennsylvania

South Dakota

Virginia


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2003


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arizona Alabama Mississippi

Colorado Arkansas California South Carolina

Connecticut Delaware District of Columbia Tennessee

Kansas Hawaii Florida

Massachusetts Idaho Georgia

Minnesota Illinois Indiana

Montana Iowa Kentucky

New Hampshire Maine Louisiana

New Mexico Maryland Michigan

North Dakota Missouri North Carolina

Vermont Nebraska Ohio

Wisconsin Nevada Texas

Wyoming New Jersey West Virginia

New York

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Dakota

Utah

Virginia

Washington


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2004


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Hawaii Alaska Colorado Arizona Alabama District of Columbia

Connecticut Arkansas California Mississippi

Iowa Delaware Georgia West Virginia

Massachusetts Florida Indiana

Minnesota Idaho Louisiana

Montana Illinois Michigan

North Dakota Kansas North Carolina

Utah Kentucky Ohio

Vermont Maine Oklahoma

Wisconsin Maryland South Carolina

Wyoming Missouri Tennessee

Nebraska Texas

Nevada

New Hampshire

New Jersey

New Mexico

New York

Oregon

Pennsylvania

Rhode Island

South Dakota

Virginia

Washington


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2005


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arizona Arkansas Alabama

Colorado California Delaware Louisiana

Minnesota Connecticut District of Columbia Mississippi

Montana Hawaii Florida South Carolina

Vermont Idaho Georgia West Virginia

Iowa Illinois

Kansas Indiana

Maine Kentucky

Maryland Michigan

Massachusetts Missouri

Nebraska New York


New Hampshire Oklahoma

New Jersey Pennsylvania

New Mexico Tennessee

North Dakota Texas

Ohio

Oregon

Rhode Island

South Dakota

Utah

Virginia

Washington

Wisconsin

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2006


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Colorado Alaska Arizona Alabama

Minnesota Connecticut Arkansas Georgia

Montana Idaho California Kentucky

Vermont Iowa Delaware Louisiana

Kansas District of Columbia Mississippi

Maine Florida North Carolina

Massachusetts Hawaii Oklahoma

Missouri Illinois South Carolina

Nebraska Indiana Tennessee

New Hampshire Maryland West Virginia

New Jersey Michigan

New Mexico Nevada

New York Pennsylvania

North Dakota Texas

Ohio

Oregon

Rhode Island

South Dakota

Utah

Virginia

Washington

Wisconsin

Wyoming


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2007


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+


Minnesota Connecticut Arkansas Georgia

North Dakota Hawaii California Kentucky

Iowa Delaware Louisiana

Kansas District of Columbia Mississippi

Maine Florida Oklahoma

Massachusetts Idaho South Carolina

Montana Illinois Tennessee

Nebraska Indiana Texas

New Hampshire Maryland West Virginia

Oregon Michigan

Rhode Island Missouri

South Dakota Nevada

Utah New Jersey

Vermont New Mexico

Washington New York

Wisconsin North Carolina

Wyoming Ohio

Pennsylvania

Virginia


<4.5% Missing data 4.5 – 5.9% 6.0 – 7.4% 7.5 – 8.9% ≥ 9.0%


2008


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Minnesota Alaska Arizona Alabama

Montana Colorado Arkansas Georgia

Vermont Connecticut California Indiana

Idaho Delaware Kentucky

Iowa District of Columbia Louisiana

Maine Florida Mississippi

Massachusetts Hawaii North Carolina

Nebraska Illinois Ohio

New Hampshire Kansas Oklahoma

North Dakota Maryland South Carolina

Oregon Michigan Tennessee

Rhode Island Missouri Texas

South Dakota Nevada West Virginia

Utah New Jersey

Washington New Mexico

Wisconsin New York

Wyoming Pennsylvania

Virginia

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

Age–Adjusted Prevalence of Diagnosed Diabetes Among US Adults

2009


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+


Vermont Connecticut Delaware Arkansas

Iowa District of Columbia California

Maine Florida Georgia

Minnesota Hawaii Kentucky

Missouri Idaho Louisiana

Montana Illinois Maryland

Nebraska Indiana Mississippi

New Hampshire Kansas North Carolina

North Dakota Massachusetts Ohio

Rhode Island Michigan Oklahoma

South Dakota Nevada South Carolina

Utah New Jersey Tennessee

Wyoming New Mexico Texas

New York West Virginia

Oregon

Pennsylvania

Virginia

Washington

Wisconsin


<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

Age–Adjusted Prevalence of Diagnosed Diabetes Among US Adults

2010


Missing Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% 9.0%+

Alaska Arizona Alabama

Colorado Arkansas Georgia

Connecticut California Indiana

Iowa Delaware Kentucky

Massachusetts District of Columbia Louisiana

Minnesota Florida Michigan

Montana Hawaii Mississippi

Nebraska Idaho North Carolina

New Hampshire Illinois Ohio

North Dakota Kansas Oklahoma

Oregon Maine Pennsylvania

Rhode Island Maryland South Carolina

South Dakota Missouri Tennessee

Utah Nevada Texas

Vermont New Jersey West Virginia

Washington New Mexico

Wisconsin New York

Wyoming Virginia

Major changes to the survey method in 2011

more details at




<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

Age–adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes

2011

Age-adjusted Percent of U.S. Adults Who Have Diagnosed Diabetes, 2011

Missing Data <4.5% 4.5%-5.9% 6.0%-7.4% 7.5%-8.9% 9.0%+

Colorado Alaska Alabama

Iowa California Arizona

Minnesota Connecticut Arkansas

Montana Delaware District of Columbia

Utah Hawaii Florida

Vermont Kansas Georgia

Maine Idaho

Maryland Illinois

Massachusetts Indiana

Nebraska Kentucky

New Hampshire Louisiana

New Jersey Michigan

North Dakota Mississippi

Oregon Missouri

Pennsylvania Nevada

Rhode Island New Mexico

South Dakota New York

Washington North Carolina

Wisconsin Ohio

Wyoming Oklahoma

South Carolina

Tennessee

Texas

Virginia

West Virginia


<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%


2012


Missing Data <4.5% 4.5%-5.9% 6.0%-7.4% 7.5%-8.9% 9.0%+

Alaska Connecticut Alabama

Colorado Delaware Arizona

Hawaii Idaho Arkansas

Minnesota Illinois California

Montana Iowa District of Columbia

Nebraska Kansas Florida

South Dakota Maine Georgia

Vermont Massachusetts Indiana

Nevada Kentucky

New Hampshire Louisiana

New Jersey Maryland

North Dakota Michigan

Pennsylvania Mississippi

Rhode Island Missouri

Utah New Mexico

Washington New York

Wisconsin North Carolina

Wyoming Ohio

Oklahoma

Oregon

South Carolina

Tennessee

Texas

Virginia

West Virginia


<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%


2013


Missing Data <4.5% 4.5%-5.9% 6.0%-7.4% 7.5%-8.9% 9.0%+

Alaska District of Columbia Alabama

Colorado Hawaii Arizona

Connecticut Idaho Arkansas

Minnesota Iowa California

Montana Kansas Delaware

Vermont Maine Florida

Wisconsin Massachusetts Georgia

Missouri Illinois

Nebraska Indiana

New Hampshire Kentucky

New Jersey Louisiana

North Dakota Maryland

Oregon Michigan

Pennsylvania Mississippi

Rhode Island Nevada

South Dakota New Mexico

Utah New York

Washington North Carolina

Wyoming Ohio

Oklahoma

South Carolina

Tennessee

Texas

Virginia

West Virginia

“IMPROVING CARE WITH INTERACT FOR ASSISTED LIVING”

17th Annual HCANJ Assisted Living Conference

Patrice Evans, MBA, BSN, RN, CPHQ Grant Site Manager – Brookdale

1

Bio/Disclosures

Patrice Evans MBA,BSN,RN,CPHQ is the CMS Grant Site Manager for Brookdale. She is a graduate of the State University of New at

Buffalo and Mountainside Hospital School of Nursing with over 40 years of varied nursing experience. She currently holds a certification as a Certified Professional in Healthcare Quality. She has been a Skilled Nursing Home Administrator as well as an Executive Director of both Assisted Living and Independent Living communities for Brookdale. Her nursing career has allowed her to work in the acute, long-term, hospice and home-care fields. She has been with Brookdale since 2010.

Disclaimer Re: CMS Health Care Innovations Award • The project described was supported by Grant Number

1C1CMS331037 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

• The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

3

Acknowledgements of Contributions to this Presentation Kevin O’Neil, M.D. Chief Medical Officer Brookdale Senior Living Practiced and taught geriatric medicine for over 30 years. Clinical Professor in the Department of Aging Studies at the University of South Florida. Certified by the American Board of Internal Medicine in both Internal Medicine and Geriatric Medicine. Co-Director for the Center for Medicare Services (CMS) Health Innovations Challenge Grant for application of INTERACT in IL, AL, and HH settings.

Joseph G. Ouslander, M.D. Professor /Senior Associate Dean for Geriatric Programs Interim Chair, Department of Integrated Medical Sciences Charles E. Schmidt College of Medicine Professor (Courtesy), Christine E. Lynn College of Nursing Florida Atlantic University Executive Editor, Journal of the American Geriatrics Society

4

OBJECTIVES

Describe the development of the INTERACT QI program for Assisted Living as it relates to the CMS Innovations Challenge grant Identify the goals of the INTERACT Quality Improvement program and the 4 categories of INTERACT tools ( http://Interact.fau.edu) Identify strategies to prevent avoidable hospitalizations & improve the quality of resident care Describe the role of direct care staff in identifying/reporting acute changes in resident condition Identify barriers to the implementation of the INTERACT process and use of best practices Discuss the tools of INTERACT as they relate to Advanced Directives/end of life care

5

Assisted Living Landscape

Fastest growing segment of elder care Over 31,000 ALFs 971,900 beds

Acuity level has increased* 86% need assistance with taking meds 72% with bathing 57% with dressing 41% with toileting 36% with transferring 23% with eating

6

*Source: National Center for Health Statistics, 2010

Triple Aim of CMS

• Better health of populations • Better care for individuals while lowering the per-capita costs

of care over time • Improve the care experience

7

Costs of Care are Unsustainable

8

Total Medicare Expenditures: 1997-2017

Source: Thorpe K and Howard D, “The Rise in Spending Among Medicare Beneficiaries: The Role of Chronic Disease Prevalence and Changes in Treatment Intensity,” Health Affairs, 379, August 2006; Innovations Center Futures Database; Health Care Advisory Board interviews and analysis.

Courtesy: Advisory Board Company

Functional Limitations Exacerbate the Challenge

9

$15,833

$7,926

$3,559 $2,245

Chronic Disease &FunctionalLimitations

3 or More ChronicConditions Only

1-2 ChronicConditions Only

No ChronicConditions

Average Annual Medicare Spending per person in 2006

Source: Avalere Health, LLC analysis of the 2006 Medicare Current Beneficiary Survey, Cost and Use File

Why it matters - Going to the Hospital …

• Disrupts our resident’s/patient’s life • May cause health complications • Is difficult for families and friends • Costs billions of dollars to Medicare and Medicaid each year

10

Why Focus on Care Transitions?

• 20% of Medicare beneficiaries readmitted within 30 days •Negative physical, emotional, psychological impact • Costs Medicare billions of dollars1

–$26 billion annually –$17.5 billion on in-patient spending

• Avoidable hospitalizations/readmissions a key strategy –25-42% of readmissions are avoidable2

1. Jordan Rau. Medicare Revises Hospitals’ Readmissions Penalties, Kaiser Health News. Oct. 2, 2012. 2. Long-Term Quality Alliance. Improving Care Transitions: how quality improvement organizations and innovative communities can work together to reduce hospitalizations among at-risk populations. June 2012.

11

Was the Hospitalization Avoidable? Definitely/Probably

YES Definitely/Probably

NO Medicare A 69% 31%

Other 65% 35% HIGH

Hospitalization Rate Homes 75% 25%

LOW Hospitalization Rate Homes

59% 41%

TOTAL 68% 32%

CMS Special Study in Georgia Expert Ratings of Potentially Avoidable Hospitalizations

Ouslander et al: J Amer Ger Soc 58: 627-635, 2010

Based review of 200 hospitalizations from 20 NHs

12

Why Assisted Living Providers Need To Focus

13

Courtesy: Advisory Board Company

Ineffective Transitions Lead to Poor Outcomes

• Wrong treatment • Delay in diagnosis • Severe adverse events • Resident complaints • Litigation • Increased healthcare costs • Increased length of stay

14

Source: Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005.

“BOOST” (Better Outcomes for Older Adults

Through Safe Transitions) http://www.hospitalmedicine.org

“Project RED” (Re-Engineered Discharge)

https://www.bu.edu/fammed/projectred

• Enhanced hospital discharge planning

“Care Transition Program” http://www.caretransitions.org

• Transition coach • Trained volunteers • Empowered patients and caregivers

“POLST” (or “MOLST”) (Physician (or Medical) Orders For life Sustaining Treatment)

http://www.ohsu.edu/polst

• Advance care planning

“Bridge Model” http://www.transitionalcare.org/the-bridge-model

• Social Worker coordinating Aging Resource Center Services at hospital discharge

“Transitional Care Model” http://www.transitionalcare.info/index.html

• APN coordinates care during and after

discharge • Home, SNF, and clinic visits

“INTERACT” (Interventions to Reduce

Acute Care Transfers) http://interact2.net

• Communication Tools, Care Paths,

Advance Care Planning Tools, and QI tools for nursing homes and SNFs

High Quality Care Transitions for

Older Adults &

Caregivers

Overview of QI Programs

Slide used with permission of Dr. Joseph Ouslander

Courtesy: Joseph Ouslander, MD

15

CMS Health Innovation Challenge Grant

• 3-Year Grant - Awarded July 1, 2012 to University of North Texas Health Science Center in partnership with Brookdale Senior Living

• Goal is to revise and implement the INTERACT Program in skilled nursing, assisted living, and home care settings to reduce avoidable readmissions and emergency room transfers

• Quality Nurse Leaders will evaluate data and guide quality improvement programs

• Implementing electronic data exchange between healthcare providers

• Implementing in 67 Brookdale Communities (Florida/Texas/KS/Denver) during grant period and share lessons learned with acute and post-acute care partners

• Expected savings of more than $9 million

16

Key Program Partners & Roles

Organization Main Role Key Individuals

University of North Texas Health Science Center (UNTHSC)

Manages the grant and coordinates interactions between partners

Dr. Thomas Fairchild Shelby Bedwell

Brookdale Senior Living (BSL) Coordinates transitional care and leads program dissemination

Dr. Kevin O’Neil Kim Estes RN

Florida Atlantic University (FAU) Oversees the implementation INTERACT Dr. Joe Ouslander Nancy Henry RN, ARNP

Loopback, LLC

Oversees integration of clinical data needed for rapid cycle learning

Neil Smiley Ron Trevino Shari Robertson

University of South Florida (USF)

Facilitates program implementation and dissemination

Kathryn Hyer

Florida Medical Quality Assurance, Inc. (FMQAI)

Provides input on reports and expertise on measures and data analytics

Amy Osborn

17

PROCESS • Organization of the CMS Grant Team Summer 2012 • October to December 2012: Began a Review of the INTERACT version 2 tools &

made recommendations for changes for AL and HH. • External survey of tools conducted with NCAL/AALNA through December 2012

– Stop & Watch tool – SBAR for AL Nurses – SBAR for Caregivers-AL

• December 2012: External survey conducted to gather additional feedback on tools. Goal of 30-40 survey participants for AL:

– Internal experts: Brookdale Senior Living – External experts: National organizations (NCAL, AALNA, CEAL, ALFA, The Greenhouse

Project, AMDA, Leading Age. Pioneer Network , AARP, and Advanced Practice Nurses). • Pilot tools finalized Spring 2013 & training initiated August 2013 • Training of approx. 71 communities (Skilled/AL) completed in June 2014. • May 2014: Initiated use of “select” Interact tools for Independent Living

18

Geriatrics is a TEAM Sport!

19

It’s a lot easier if we all pull together!

Interprofessional Team

20

Care Associates Dining Services Housekeeping Maintenance Administrative Therapy Nursing Activities/Program Staff

1. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition

2. Managing some conditions in the assisted living without transfer when this is feasible and safe

3. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents

Can help safely reduce hospital transfers by:

21

The goal of INTERACT is to improve care, not to prevent all hospital transfers In fact, INTERACT can help with more rapid transfer of residents who need hospital care

22

Quality Improvement Tools

Communication Tools

Decision Support Tools

Advance Care Planning Tools

23

Communication

The single biggest problem with communication is the illusion that it has taken place.

-George Bernard Shaw

24

Using the INTERACT Early Warning Tool:

Stop and Watch

25

SBAR 2 SBAR Types for AL Nurse: Situation/Background/Assessment/Request

Caregiver or Supervisor: Situation/Background/Appearance/Ready to Call

• Situation: What is going on with the resident?

• Background: What is the clinical background or context?

• Assessment/Appearance: What do I think the problem is?

• Request/Ready to Call: What do I think needs to be done for the

resident?

26

SBAR

27

Decision Support Tools • Change of condition file cards • Care paths

28

Decision Support Tools

29

Change in Condition File Cards

30

Vital Signs

31

Lab Tests/Diagnostic Procedures

32

Checklists

33

PDSA Cycle • On-going review of processes and practices • Evaluating the Process/Outcomes

34

Plan

Do

Study

Act

Quality Improvement Tool

35

Advanced Care Planning • Advance Care Planning Tracking Form • Advance Care Planning Communication Guide • Identifying Residents Who May be Appropriate for Hospice or

Palliative/Comfort Care Orders • Comfort Care Order Set

36

Advance Care Planning

37

ACP should occur at some time shortly after admission Decisions should be reviewed regularly and at times of acute changes in condition

ACP Tracking Form

38

ACP Communication Guide

39

INTERACT Assisted Living Version 1.0 Tools

ng

• These are a modification of the INTERACT Quality

Improvement Program 3.0 Tools based on feedback from

an Assisted Living Facility (ALF) usability pilot-testing

program.

• The majority of ALF participants reported usability of the tools

– and experts in ALF care provided suggestions for improving the tools

for use in every day care of residents.

40

© 2014 Florida Atlantic University

INTERACT AL Tools

41

Do you think this INTERACT AL is a useful tool?

Percentage of respondents agreeing that the tool is useful

SBAR Communication Form and Progress Note for RN/LPN/LVNs in AL/HH

70%

SBAR Communication Form and Progress Note for Caregiver in AL/HH

53%

Medication Reconciliation Worksheet for Post-Hospital Care

47%

Stop and Watch Early Warning Tool 88%

Communication Tools

Percentage of respondents agreeing that the tool is useful

Assisted Living Capabilities List 69%

AL to Hospital Transfer Form 61%

AL to Hospital Transfer Data List 48%

AL Acute Care Transfer Checklist 53%

Hospital To Post Acute Care Transfer Form 47%

Hospital To Post Acute Care Data List 37%

For Communication Between AL and Hospital

42 Final Assisted Living Pilot Site Ratings (N=33*) Response rate varies from 26-33 participants

Pilot Sites Conclusions • ALF tools are rated as very useful • Highest ranked tools are Communication tools (SBAR

and Stop and Watch) • Decision support and Advance Care Planning tools were

well received • ALFs with Electronic records were more likely to complain

the INTERACT forms duplicate work • Staff indicated improvements but admitted it was work to

implement • Many pilot sites used communication forms but did not

enact QI process for full use of all tools

43

INTERACT Implementation

44

Hospitalization Rate

45

Readmission Rate

46

Emergency Room Transfers

47

Challenges/Opportunities

• Turnover • Lack of support by Leadership • Lack of embracing the process as part of the culture – a “just

more paperwork” attitude

48 48

Success Stories

Those communities that have embraced the process believe they have a more focused communication throughout their community (associates to the nurse) and the feedback they have received from their physicians also allows for more organized and complete information to the physician at the time of the call/fax. We were able to provide the associates with supportive documentation of a recent case where an associate completed a stop and watch form, submitted it to the charge nurse, the charge nurse initiated the SBAR, assessed the resident, communicated this information to the doctor, labs and urinalysis were ordered and ultimately it was determined she had a severe UTI that we were able to successfully treat in house without the need of a transfer to an acute care setting/ER.

49 49

I had a resident that was showing signs and symptoms of pneumonia, using SBAR, continued to decline and was able to send him to our skilled unit for care avoiding hospitalization. I have a resident that keeps a stop and watch book for herself so she can update nurses on any condition change with other residents. Our Program Assistant noticed that a resident was coughing each time she would have a drink. She reported via Stop and Watch which resulted in speech therapy and diagnosis of aspiration. Diet was altered and she is doing much better.

50 50

• Able to analyze each hospital visit thoroughly, provide a more well-rounded care to the resident, and identify the need for staff training to reduce # of transfers or to be aware of preventative measures. Staff reports that they love the stop and watch tools and the SBAR form.

I Will hold an in-service on interact training for all existing and new hires the month of August, since we have recently hired quite a few new employees and to refresh the program for our existing employees. The QI meetings being held every 2 weeks in conjunction with our CCM meeting has seemed to make quite a difference in keeping our residents out of the hospitals. We had only 1 transfer in May and 0 in June. The meetings really keep the lines of communication open between myself and staff, as well as Home Health and Therapy. We can all brainstorm and come up with ideas to help keep our residents safe and healthy in our community. All in the program has been a positive in our community.

51 51

• Also, the benefit I am seeing is the improvement in

communication with the ER doctors and staff. Also, it is helpful to newer nurses to find the right path to take to figure out what to look for. It is also a great reminder for the older nurses to use the paths.

• “We have found that family use of the Stop & Watch tool to be helpful in giving them a voice in their loved one’s care. They feel that no matter what time of day they visit, and whether the nurse is present or not, they have a tool available to them to express a medical concern and know it will be followed up on. We have a small table in our lobby with the Stop & Watch box with the trifold pamphlet as well as the booklet for them to fill out a slip. First thing in the door and last before they leave.”

52 52

What We Have Learned…

• Importance of Leadership & Communication • Role of Champions/Co-Champions is critical • Sustaining gains & training new associates • Integrating QI/tools into the culture • Opportunities with turnover • Family education on INTERACT is important • Advanced Care Planning discussions make a difference • Involve all associates in quality improvement • Role of a Transition Team

53

Resources • Paper versions of the INTERACT Tools are available at:

– www.interact.fau.edu or www.interact2.net • Electronic versions of the INTERACT Tools are only available

from authorized providers • Theconversationproject.org

54

“ Alone we can do so little; together we can do so much.”

—Helen Keller

55

©2014 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.

V 1.0 Too lAss is ted L iv ing

Stop and WatchEarly Warning Tool

If you have identified an important change while caring for or visiting a resident, please circle the change and notify a nurse or supervisor.

Name of Resident

Your Name

Observation Reported to: Date and Time (am/pm)

Nurse/Supervisor Response Date and Time (am/pm)

Nurse/Supervisor Name

This form is also intended for other residential health care facilities including those listed by

the National Center for Assisted Living ( www.ahcancal.org/ncal/).

Seems different than usualTalks or communicates lessOverall needs more help Pain – new or worsening; Moans or grimaces (for residents with severe dementia), participated less in activities

S T O P

a n d

W A T C H

Ate less No bowel movement in 3 days; or diarrhea Drank less

Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual

Check here if no change noted while monitoring high risk resident

©2014 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.

V 1.0 Too lAss is ted L iv ing

CARE PATH Fall

YES

Fall • Unintentional change in position coming to rest on the ground or onto the next lower surface.

Manage in Facility1

• Document Fall per facility policy

• Monitor VS (including orthostatic) x 24-72˚2

• Monitor Neuro checks³ x 24-72°

• Check for pain level• Check for new bruising or

other evidence of injury• Review of orders for

medications associated with increased fall risk⁴

Take Vital Signs• Temperature• BP, pulse, apical HR (if pulse irregular)

• Respirations• Oxygen saturation• Finger stick glucose (diabetics)

Vital Sign Criteria (any met?)• Temp > 100.5˚F• Apical heart rate > 100 or < 50• Respiratory rate > 28/min or < 10/min• BP < 90 or > 200 systolic

• Oxygen saturation < 90%• Finger stick glucose < 70 or > 300• Resident unable to eat or drink

YES

YESNO

Notify MD / NP / PA

Initial Nursing Evaluation for injuryand/or Mental Status Changes• DO NOT move off floor until a complete exam has been performed• Suspected fracture or new bone deformity• Head trauma• Altered mental status (decreased LOC, unresponsiveness, suspicion of

seizure, new or worsened cognitive impairment)• Laceration requiring sutures/staples

TestsOrdered

¹ See link to Fall Management Program at http://interact.fau.edu

² Obtain only if symptoms of urinary tract infection

³ Neuro Checks should be according to your facility policy and procedure

⁴ Many classes of medications can increase risk of falls

Eval Signs and Symptoms for immediate Notification• Abnormal lung sounds• New irregular pulse• Chest Pain• Acute decline in ADL’s• New/worsened incontinence• Signs or symptoms suggestive

of a stroke (weakness, numbness or tingling)

• New or worsened pain unrelated to head trauma

or a suspected fracture

Consider Contacting MD/NP/PAfor the following Orders • CBC • Xray (if needed) • BMP • UA/C&S¹• EKG

MonitorResponse• Vital signs criteria met• Worsening condition and/or immediate notification

criteria met

YESNO

NO

EvaluateResults• Urine result

suggests infection• EKG shows

new changes suggestive of MI or arrhythmia

• WBC > 14,000 or neutrophils > 90%• Infiltrate or

pneumonia on chest X-ray

NRS 629.091 Personal assistant authorized to perform certain services for person with disability if approved by provider of health care; requirements. 1. Except as otherwise provided in subsection 4, a provider of health care may authorize a person to act as a personal assistant to perform specific medical, nursing or home health care services for a person with a disability without obtaining any license required for a provider of health care or his or her assistant to perform the service if: (a) The services to be performed are services that a person without a disability usually and customarily would personally perform without the assistance of a provider of health care; (b) The provider of health care determines that the personal assistant has the knowledge, skill and ability to perform the services competently; (c) The provider of health care determines that the procedures involved in providing the services are simple and the performance of such procedures by the personal assistant does not pose a substantial risk to the person with a disability; (d) The provider of health care determines that the condition of the person with a disability is stable and predictable; and (e) The personal assistant agrees with the provider of health care to refer the person with a disability to the provider of health care if: (1) The condition of the person with a disability changes or a new medical condition develops; (2) The progress or condition of the person with a disability after the provision of the service is different than expected; (3) An emergency situation develops; or (4) Any other situation described by the provider of health care develops. 2. A provider of health care that authorizes a personal assistant to perform certain services shall note in the medical records of the person with a disability who receives such services: (a) The specific services that the provider of health care has authorized the personal assistant to perform; and (b) That the requirements of this section have been satisfied. 3. After a provider of health care has authorized a personal assistant to perform specific services for a person with a disability, no further authorization or supervision by the provider is required for the continued provision of those services. 4. A personal assistant shall not: (a) Perform services pursuant to this section for a person with a disability who resides in a medical facility. delete (b) Perform any medical, nursing or home health care service for a person with a disability which is not specifically authorized by a provider of health care pursuant to subsection 1. (c) Except if the services are provided in an educational setting, perform services for a person with a disability in the absence of the parent or guardian of, or any other person legally responsible for, the person with a disability, if the person with a disability is not able to direct his or her own services. 5. A provider of health care who determines in good faith that a personal assistant has complied with and meets the requirements of this section is not liable for civil damages as a result of any act or omission, not amounting to gross negligence, committed by the provider of health care in making such a determination and is not liable for any act or omission of the personal assistant. 6. As used in this section: (a) “Guardian” means a person who has qualified as the guardian of a minor or an adult pursuant to testamentary or judicial appointment, but does not include a guardian ad litem. (b) “Parent” means a natural or adoptive parent whose parental rights have not been terminated. (c) “Personal assistant” means a person who, for compensation and under the direction of: (1) A person with a disability;

(2) A parent or guardian of, or any other person legally responsible for, a person with a disability who is under the age of 18 years; or (3) A parent, spouse, guardian or adult child of a person with a disability who suffers from a cognitive impairment, performs services for the person with a disability to help the person with a disability maintain independence, personal hygiene and safety. (d) “Provider of health care” means a physician licensed pursuant to chapter 630, 630A or 633 of NRS, a dentist, a registered nurse, a licensed practical nurse, a physical therapist or an occupational therapist. (Added to NRS by 1995, 749; A 2005, 69)

https://www.leg.state.nv.us/nrs/NRS-630.html#NRS630

https://www.leg.state.nv.us/nrs/NRS-630A.html#NRS630A


https://www.leg.state.nv.us/Statutes/68th/Stats199504.html#Stats199504page749

https://www.leg.state.nv.us/Statutes/73rd/Stats200501.html#Stats200501page69

NRS 629.091 Personal assistant authorized to perform certain services for person with disability if approved by provider of health care; requirements. 1. Except as otherwise provided in subsection 4, a provider of health care may authorize a person to act as a personal assistant to perform specific medical, nursing or home health care services for a person with a disability without obtaining any license required for a provider of health care or his or her assistant to perform the service if: (a) The services to be performed are services that a person without a disability usually and customarily would personally perform without the assistance of a provider of health care; (b) The provider of health care determines that the personal assistant has the knowledge, skill and ability to perform the services competently; (c) The provider of health care determines that the procedures involved in providing the services are simple and the performance of such procedures by the personal assistant does not pose a substantial risk to the person with a disability; (d) The provider of health care determines that the condition of the person with a disability is stable and predictable; and (e) The personal assistant agrees with the provider of health care to refer the person with a disability to the provider of health care if: (1) The condition of the person with a disability changes or a new medical condition develops; (2) The progress or condition of the person with a disability after the provision of the service is different than expected; (3) An emergency situation develops; or (4) Any other situation described by the provider of health care develops. 2. A provider of health care that authorizes a personal assistant to perform certain services shall note in the medical records of the person with a disability who receives such services: (a) The specific services that the provider of health care has authorized the personal assistant to perform; and (b) That the requirements of this section have been satisfied. 3. After a provider of health care has authorized a personal assistant to perform specific services for a person with a disability, no further authorization or supervision by the provider is required for the continued provision of those services. 4. A personal assistant shall not: (a) Perform services pursuant to this section for a person with a disability who resides in a medical facility. (b) Perform any medical, nursing or home health care service for a person with a disability which is not specifically authorized by a provider of health care pursuant to subsection 1. (c) Except if the services are provided in an educational setting, perform services for a person with a disability in the absence of the parent or guardian of, or any other person legally responsible for, the person with a disability, if the person with a disability is not able to direct his or her own services. 5. A provider of health care who determines in good faith that a personal assistant has complied with and meets the requirements of this section is not liable for civil damages as a result of any act or omission, not amounting to gross negligence, committed by the provider of health care in making such a determination and is not liable for any act or omission of the personal assistant. 6. As used in this section: (a) “Guardian” means a person who has qualified as the guardian of a minor or an adult pursuant to testamentary or judicial appointment, but does not include a guardian ad litem. (b) “Parent” means a natural or adoptive parent whose parental rights have not been terminated. (c) “Personal assistant” means a person who, for compensation and under the direction of: (1) A person with a disability;

(2) A parent or guardian of, or any other person legally responsible for, a person with a disability who is under the age of 18 years; or (3) A parent, spouse, guardian or adult child of a person with a disability who suffers from a cognitive impairment, performs services for the person with a disability to help the person with a disability maintain independence, personal hygiene and safety. (d) “Provider of health care” means a physician licensed pursuant to chapter 630, 630A or 633 of NRS, a dentist, a registered nurse, a licensed practical nurse, a physical therapist or an occupational therapist. (Added to NRS by 1995, 749; A 2005, 69)


https://www.leg.state.nv.us/nrs/NRS-630A.html#NRS630A




NRS 449.0302 Board to adopt standards, qualifications and other regulations. 1. The Board shall adopt: (a) Licensing standards for each class of medical facility or facility for the dependent covered by NRS 449.030 to 449.2428, inclusive, and for programs of hospice care. (b) Regulations governing the licensing of such facilities and programs. (c) Regulations governing the procedure and standards for granting an extension of the time for which a natural person may provide certain care in his or her home without being considered a residential facility for groups pursuant to NRS 449.017. The regulations must require that such grants are effective only if made in writing. (d) Regulations establishing a procedure for the indemnification by the Division, from the amount of any surety bond or other obligation filed or deposited by a facility for refractive surgery pursuant to NRS 449.068 or 449.069, of a patient of the facility who has sustained any damages as a result of the bankruptcy of or any breach of contract by the facility. (e) Any other regulations as it deems necessary or convenient to carry out the provisions of NRS 449.030 to 449.2428, inclusive. 2. The Board shall adopt separate regulations governing the licensing and operation of: (a) Facilities for the care of adults during the day; and (b) Residential facilities for groups, which provide;

(i) Care to persons with Alzheimer’s and other dementias; and (ii) Care to persons with stable chronic health conditions.

3. The Board shall adopt separate regulations for: (a) The licensure of rural hospitals which take into consideration the unique problems of operating such a facility in a rural area. (b) The licensure of facilities for refractive surgery which take into consideration the unique factors of operating such a facility. (c) The licensure of mobile units which take into consideration the unique factors of operating a facility that is not in a fixed location. 4. The Board shall require that the practices and policies of each medical facility or facility for the dependent provide adequately for the protection of the health, safety and physical, moral and mental well-being of each person accommodated in the facility. 5. In addition to the training requirements prescribed pursuant to NRS 449.093, the Board shall establish minimum qualifications for administrators and employees of residential facilities for groups. In establishing the qualifications, the Board shall consider the related standards set by nationally recognized organizations which accredit such facilities. 6. The Board shall adopt separate regulations regarding the assistance which may be given pursuant to NRS 453.375 and 454.213 to an ultimate user of controlled substances or dangerous drugs by employees of residential facilities for groups. The regulations must require at least the following conditions before such assistance may be given: (a) The ultimate user’s physical and mental condition is stable and is following a predictable course. (b) The amount of the medication prescribed is at a maintenance level and does not require a daily assessment. (c) A written plan of care by a physician or registered nurse has been established that: (1) Addresses possession and assistance in the administration of the medication; and (2) Includes a plan, which has been prepared under the supervision of a registered nurse or licensed pharmacist, for emergency intervention if an adverse condition results. (d) The prescribed medication is not administered by injection or intravenously. (e) The employee has successfully completed training and examination approved by the Division regarding the authorized manner of assistance. 7. The Board shall adopt separate regulations governing the licensing and operation of residential facilities for groups which provide assisted living services. The Board shall not allow the licensing of a facility as a

https://www.leg.state.nv.us/NRS/NRS-449.html#NRS449Sec030













residential facility for groups which provides assisted living services and a residential facility for groups shall not claim that it provides “assisted living services” unless: (a) Before authorizing a person to move into the facility, the facility makes a full written disclosure to the person regarding what services of personalized care will be available to the person and the amount that will be charged for those services throughout the resident’s stay at the facility. (b) The residents of the facility reside in their own living units which: (1) Except as otherwise provided in subsection 8, contain toilet facilities; (2) Contain a sleeping area or bedroom; and (3) Are shared with another occupant only upon consent of both occupants. (c) The facility provides personalized care to the residents of the facility and the general approach to operating the facility incorporates these core principles: (1) The facility is designed to create a residential environment that actively supports and promotes each resident’s quality of life and right to privacy; (2) The facility is committed to offering high-quality supportive services that are developed by the facility in collaboration with the resident to meet the resident’s individual needs; (3) The facility provides a variety of creative and innovative services that emphasize the particular needs of each individual resident and the resident’s personal choice of lifestyle; (4) The operation of the facility and its interaction with its residents supports, to the maximum extent possible, each resident’s need for autonomy and the right to make decisions regarding his or her own life; (5) The operation of the facility is designed to foster a social climate that allows the resident to develop and maintain personal relationships with fellow residents and with persons in the general community; (6) The facility is designed to minimize and is operated in a manner which minimizes the need for its residents to move out of the facility as their respective physical and mental conditions change over time; and (7) The facility is operated in such a manner as to foster a culture that provides a high-quality environment for the residents, their families, the staff, any volunteers and the community at large. 8. The Division may grant an exception from the requirement of subparagraph (1) of paragraph (b) of subsection 7 to a facility which is licensed as a residential facility for groups on or before July 1, 2005, and which is authorized to have 10 or fewer beds and was originally constructed as a single-family dwelling if the Division finds that: (a) Strict application of that requirement would result in economic hardship to the facility requesting the exception; and (b) The exception, if granted, would not: (1) Cause substantial detriment to the health or welfare of any resident of the facility; (2) Result in more than two residents sharing a toilet facility; or (3) Otherwise impair substantially the purpose of that requirement. 9. The Board shall, if it determines necessary, adopt regulations and requirements to ensure that each residential facility for groups and its staff are prepared to respond to an emergency, including, without limitation: (a) The adoption of plans to respond to a natural disaster and other types of emergency situations, including, without limitation, an emergency involving fire; (b) The adoption of plans to provide for the evacuation of a residential facility for groups in an emergency, including, without limitation, plans to ensure that non-ambulatory patients may be evacuated; (c) Educating the residents of residential facilities for groups concerning the plans adopted pursuant to paragraphs (a) and (b); and (d) Posting the plans or a summary of the plans adopted pursuant to paragraphs (a) and (b) in a conspicuous place in each residential facility for groups. 10. The regulations governing the licensing and operation of facilities for transitional living for released offenders must provide for the licensure of at least three different types of facilities, including, without limitation: (a) Facilities that only provide a housing and living environment;

(b) Facilities that provide or arrange for the provision of supportive services for residents of the facility to assist the residents with reintegration into the community, in addition to providing a housing and living environment; and (c) Facilities that provide or arrange for the provision of alcohol and drug abuse programs, in addition to providing a housing and living environment and providing or arranging for the provision of other supportive services. The regulations must provide that if a facility was originally constructed as a single-family dwelling, the facility must not be authorized for more than eight beds. 11. As used in this section, “living unit” means an individual private accommodation designated for a resident within the facility. (Added to NRS by 1969, 946; A 1971, 934; 1973, 1281; 1985, 1738; 1987, 990; 1989, 1036, 2155, 2156; 1991, 1975; 1993, 1214; 1995, 1600; 1999, 3608; 2001, 1341; 2003, 1921; 2005, 2165, 2350, 2693; 2007, 1921; 2009, 1441; 2011, 2250)—(Substituted in revision for NRS 449.037)










https://www.leg.state.nv.us/Statutes/71st/Stats200110.html#Stats200110page1341

https://www.leg.state.nv.us/Statutes/71st/Stats200110.html#Stats200110page1341

https://www.leg.state.nv.us/Statutes/72nd/Stats200315.html#Stats200315page1921





https://www.leg.state.nv.us/Statutes/75th2009/Stats200915.html#Stats200915page1441

https://www.leg.state.nv.us/Statutes/76th2011/Stats201118.html#Stats201118page2250

NAC 449.0072 “Treatment” defined. “Treatment” means any medication, drug, test or procedure conducted or administered to diagnose or remedy a physical or mental illness or condition. NAC 449.197 Medical services may be provided only by medical professional. (NRS 449.0302) A member of the staff of a residential facility shall not provide medical services to a resident of the facility unless the member of the staff is a medical professional. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)

(Y 0080) Medical services may be provided only by medical professional. A member of the staff of a residential facility shall not provide medical services to a resident of the facility unless the member of the staff is a medical professional. Per NAC 449.169, a medical professional is a physician or a physician assistant, nurse practitioner, registered nurse (RN), physical therapist, occupational therapist, speech pathologist or practitioner or respiratory care who is trained and licensed in Nevada to perform medical procedures and care prescribed by a physician. *Notice Licensed Vocational Nurses (LVNs) are not in the list because Nevada does not license LVNs. Licensed Practical Nurses (LPNs) must work under the direct supervision of a Nevada Licensed RN to be considered a medical professional. At odds with NAC 449.2726

(No employees of the facility may assist residents with their blood glucose testing, unless the facility has obtained a medical laboratory license.) delete

(No employees of the facility may give a medication to a resident by injection or IV, including nurses or other medical professionals.) delete) from NAC REGULATIONS AND

INTERPRETIVE GUIDELINES FOR ASSISTED LIVING FACILITIES

NAC 449.2726 Residents having diabetes. (NRS 449.0302) 1. A person who has diabetes must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident’s glucose testing is performed by: (1) The resident himself or herself with out assistance; (2) A medical laboratory licensed pursuant to chapter 652 of NRS; and (b) The resident’s medication is administered: (1) By the resident himself or herself with out assistance; (2) By a medical professional, licensed practical nurse, or UAP who is: (I) Not employed by the residential facility; delete (II) Acting within his or her authorized scope of practice and in accordance with all



https://www.leg.state.nv.us/NRS/NRS-652.html#NRS652

applicable statutes and regulations; and (III) Trained to administer the medication; or (3) If the conditions set forth in subsection 2 are satisfied, with the assistance of a caregiver employed by the residential facility. 2. A caregiver employed by a residential facility may assist a resident in the administration of the medication prescribed to the resident for his or her diabetes if: (a) The resident’s physical and mental condition is stable and is following a predictable course. (b) The amount of the medication prescribed to the resident for his or her diabetes is at a maintenance level and does not require a daily assessment. (c) A written plan of care by a physician or registered nurse has been established that: (1) Addresses possession and assistance in the administration of the medication for the resident’s diabetes; and (2) Includes a plan, which has been prepared under the supervision of a registered nurse or licensed pharmacist, for emergency intervention if an adverse condition results. (d) The medication prescribed to the resident for his or her diabetes is not administered by injection or intravenously. delete (e) The caregiver has successfully completed training and examination approved by the Division regarding the administration of such medication. 3. The caregivers employed by a residential facility with a resident who has diabetes shall ensure that: (a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility; (b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place; and (c) The caregivers responsible for the resident have received instruction in the recognition of

the symptoms of hypoglycemia and hyperglycemia by a medical professional who has been trained in the recognition of those symptoms. 4. The caregivers employed by a residential facility with a resident who has diabetes and requires a special diet shall provide variations in the types of meals served and make available food substitutions in order to allow the resident to consume meals as prescribed by the resident’s physician. The substitutions must conform with the recommendations for food exchanges contained in the Exchange Lists For Meal Planning, published by the American Diabetes Association, Incorporated, and the American Dietetic Association, which is hereby adopted by reference. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)

NAC 449.2728 Residents requiring regular intramuscular, subcutaneous or intradermal injections. (NRS 449.0302) 1. A person who requires regular intramuscular, subcutaneous or intradermal injections must not be admitted to a residential facility or be permitted to remain as a resident of the facility unless the injections are administered by: (a) The resident; or (b) A medical professional, licensed practical nurse, or UAP acting within his or her authorized scope of practice and in accordance with all applicable statutes and regulations, who has been trained to administer those injections. 2.The caregivers employed by a residential facility with a resident who requires regular intramuscular, subcutaneous or intradermal injections shall ensure that: (a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility; and (b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)


Recommendations Submitted by

Daniel Mathis

35 E. Horizon Ridge Pkwy #110-137 * Henderson, NV 89002 866-307-0942

www.nvhca.org

Recommendations from the Nevada Health Care Association to the

Subcommittee to Conduct a Study of Postacute Care

Recommendation 1

Finance

On February 17, 2016, the Nevada Health Care Association provided testimony and information demonstrating

the need for additional funding for skilled nursing home care. The key elements of the presentations

demonstrated:

1. The rate methodology established collaboratively by the Medicaid state agency and the nursing home

industry has never been fully funded. That disparity between the agreed upon rate and the actual rate

for FY 15 exceeded $28 per Medicaid resident day;

2. The State is only funding $40.91, the State share, of the base rate of $116.66, which has not been

increased in over a decade;

3. The State share of skilled nursing facility funding as a percentage of the total rate has dropped from

42.8% to 20.7%;

4. All rate increases since 2003 have been the result of provider taxes- taxes the providers have agreed to

pay in order to spare the cost to the state- and increases in federal match rates; and

5. Future provider tax resources are limited because provider taxes are at the federal maximum. There is

no possibility of future increases because increases are limited to the percentage increase in provider

revenues.

The Nevada Health Care Association requests that the Subcommittee to Conduct a Study of Postacute Care

send a resolution to the Governor, the Director of the Department of Health and Human Services and the

Chairs of the Committees on Finance and Ways and Means during the 2017 Legislative Session recommending

and expressing support for the Governor’s recommended budget and Legislature-approved budget to fully

fund the rate methodology agreed upon in 2003 and to index that rate to increase with inflation in future

biennia. This will require an additional State share of $8.26 per patient day for the first fiscal year (or

approximately $8 million) and $10.69 per patient day for the second fiscal year (or approximately $10 million)

of the biennium, and will help to compensate for the evolution from “nursing homes” to “transitional care

facilities.”

http://www.nvhca.org/

35 E. Horizon Ridge Pkwy #110-137 * Henderson, NV 89002 866-307-0942

www.nvhca.org

Recommendation 2

Quality

The Subcommittee has heard quality data and several recent news reports have focused on the quality of care

in postacute settings. In order to better understand the quality of care and to continuously improve care, the

Subcommittee must prioritize incentives for quality improvement efforts. New quality initiatives have suffered

due to the lack of resources to fund such programs. This funding will allow for better quality of care

resources.

The Nevada Health Care Association requests that the Subcommittee submit a bill draft request to implement

a quality improvement program to analyze data concerning quality of care and to incentivize facilities which

provide higher quality of care. The bill will include an appropriation of $5 state share per Medicaid patient day

or approximately $4.75 million. These funds, plus federal match, would provide meaningful payments and

incentives to providers for carrying out a program. The quality measures would be developed on a

collaborative basis between the Medicaid state agency and the skilled nursing industry. Such measures may

include, but not be limited to:

1. Clinical outcome measures developed by the Centers for Medicare and Medicaid;

2. Employee retention and turnover;

3. Hospital readmissions; and

4. Avoidance of long term stays and discharges to home or community-based settings.

The scoring system and allocation of funding would also be developed collaboratively with the skilled nursing

industry taking into account existing performance and quality improvement.

http://www.nvhca.org/

submitted recommendations for possible consideration by

Documents