Use of Advance Care Planning Billing Codes in a Tertiary Care Center Setting.

INTRODUCTION: The Centers for Medicare and Medicaid Services released the final payment rules for reimbursement of advance care planning (ACP) effective January 2016. In its first year, 23,000 providers nationwide submitted 624,000 claims using the Current Procedural Terminology codes 99497 and 99498. The objectives of our study were to 1) assess the frequency of ACP codes used at a single academic tertiary care center in Iowa, 2) determine when and by whom the codes were used, and 3) summarize ACP clinical notes. METHODS: Using the electronic medical record data warehouse from a single tertiary teaching hospital and affiliated clinics, date of service, department where service was provided, provider name and type, patient medical record number, date of birth, and gender linked to the ACP codes 99497 and 99498 were collected. The content of ACP clinical notes were reviewed and summarized. Study period was from January 1, 2016 through September 19, 2018. RESULTS: During the 33 months, code 99497 was used 17 times and code 99498 was never used. Code 99497 was successfully reimbursed 4 times. DISCUSSION: Charges were not reimbursed if the ACP visits did not meet the minimum time requirement or were conducted by an individual not considered a qualified health care professional per Medicare rules. CONCLUSION: ACP codes 99497 and 99498 were very rarely used at this tertiary care center during the initial 33-months after the Medicare rules went into effect. Interventions are needed to promote the use of ACP codes, so the time spent in important ACP discussions are properly compensated.

A Needs Assessment of Family Physicians to Inform Development of Educational Resources on Antipsychotic Use in Dementia.

OBJECTIVES: Objectives of this study were to (1) assess the needs and preferred resources of Iowa physicians to inform the development of educational resources for best practice dementia care and (2) compare the responses of nursing home medical directors with nonmedical directors. METHODS: Of 498 physicians, 101 (20%) completed and returned the survey. Family physicians were obtained from a list of family physicians from the Iowa Board of Medical Examiners. Respondent answers were summarized and presented as total numbers and percentages in tables. Significant differences between medical directors and nonmedical directors were evaluated using chi-square tests, Fisher exact tests, and Wilcoxon rank-sum tests. RESULTS: Medical directors and nonmedical directors had similar preferences for resources used and information needs. Online resources, pocket guides, a handbook, consulting pharmacists, and facility in-services were the most commonly preferred sources of new information. Medical directors were significantly more aware of the Food and Drug Administration warning on antipsychotic use in dementia and treated more nursing home patients. No differences were observed between groups related to confidence in and use of nondrug strategies instead of antipsychotics to manage behavioral symptoms of dementia. CONCLUSION: The results of this survey illustrate physician preferences for information and resources on the management of behavioral and psychological symptoms in dementia. Information was used to inform the development of resources to aid physicians and other health care providers in making decisions about managing these symptoms.

Caring for people with dementia and challenging behaviors in nursing homes: A needs assessment geriatric nursing.

An estimated 50% of nursing home residents have a dementia diagnosis. The purpose of this research was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with Behavioral and Psychological Symptoms of Dementia. DON responses were linked to Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (OSCAR/CASPER) data to examine how facility characteristics may be associated with use of and confidence in non-drug management strategies. From 431 questionnaires mailed to DONs, 160 (37%) were returned. Regression analysis showed that those who were more confident in managing challenging behavior were more likely to have satisfaction with current training on managing challenging behaviors and had a psychiatrist available to visit the facility. Facilities with a larger proportion of patients with challenging behaviors being treated with non-drug approaches instead of antipsychotics had DONs who were more likely to be confident in non-drug management strategies and have knowledge about the FDA antipsychotic medications risks.

Domestic and institutional elder abuse legislation.

Statutes pertinent to elder abuse vary widely. This article provides examples of organizational structure, dependency and age of the victim, definitions of abuse, classification of penalties, and investigation processes. Health care providers must learn their state's elder abuse laws and review any operating manuals produced from the statutes or regulations. All health care workers must know and implement the law to protect the welfare of older persons.

An assessment of attitudes, behaviors, and outcomes of patients with type 2 diabetes.

OBJECTIVES: Patient self-care behaviors, including taking medication, following a meal plan, exercising regularly, and testing blood glucose, influence diabetes control. The purpose of this research was to identify (1) which barriers to diabetes management are associated with problem behaviors and (2) which patient behaviors and barriers are associated with diabetes control. METHODS: This was a cross-sectional study of linked medical record and self-reported information from patients with type 2 diabetes. A randomly selected sample of 800 clinic patients was mailed an investigator-developed survey. The study sample consisted of 253 (55%) individuals who had measured glycosylated hemoglobin (HbA1c) within 3 months of the survey date. RESULTS: The barriers to each diabetes self-care behavior differed. Cost was the most common barrier to the 4 self-care behaviors. In a multivariable regression model, the belief that type 2 diabetes is a serious problem and depression were strongly associated with higher HbA1c levels. Lower HbA1c levels were significantly associated with being married and greater self-reported adherence-satisfaction with taking medication and testing blood glucose. CONCLUSION: This study expanded earlier research by focusing on 4 specific self-care behaviors, their barriers, and their association with HbA1c. Barriers that were significantly associated with HbA1c were specific to the behavior and varied across behaviors.

State policies and nursing home characteristics associated with rates of resident mistreatment.

BACKGROUND: A federal complaint/incident system was implemented in 2004 with the stated purpose of promoting and protecting the health, safety, and the welfare of residents receiving health care services. This system provided the first national database of mistreatment in the nursing home setting. METHODS: The purpose of this research was to identify state and nursing home characteristics associated with the rates of nursing home resident mistreatment. Outcomes were incident reports filed by nursing home staff and complaints filed by persons other than service providers obtained from the federal complaints/incidents tracking system. Predictor variables used in the analysis of the reporting system included state legislation, census demographic data, and characteristics of the nursing home including aggregate characteristics of the residents. RESULTS: In 2004, based on complaint and incident reports, 1.6% of the nursing home population was reported to be mistreated. The average rates per 1000 residents were 16 reports, 14 investigations, and 4 substantiations. Incident report rates per 1000 ranged from 0.04 in Virginia to 46 in Alabama. Complaint report rates ranged from 0.42 in Hawaii to 52 in New Mexico. Incident outcomes were significantly lower in states that had nursing home statutes that require the facility, rather than the individual, to report mistreatment or in states that defined mistreatment in the nursing home differently from the definitions used by adult protective service statutes. Higher complaint outcomes were associated with lower levels of staffing. After controlling for resident characteristics, mistreatment measures remained associated with nursing home staffing levels but not with elements of statutes. CONCLUSIONS: Documentation of nursing home mistreatment shows substantial differences in report rates across states. These differences cannot be explained by variations in the laws.

County government resources associated with dependent-adult abuse investigations in Iowa.

This study evaluated on a county level the association of Iowa's domestic dependent-adult abuse investigations with the location of adult protective services (APS) offices, rurality, government resources, felony charges and prosecutions, child abuse reports, and census demographics. In 2003, the rate of dependent-adult abuse investigations for Iowa was 0.70 per 1,000 population age 18 and older. Higher rates of child abuse investigations, felony prosecutions, sheriff's annual salary, and lower rates of child abuse substantiations are associated with higher rates of dependent-adult abuse investigations and substantiations.

Iowa nursing home characteristics associated with reported abuse.

OBJECTIVE: To evaluate the association of nursing home abuse reported by employees in Iowa licensed nursing homes with nursing home characteristics, inspection results, nursing staff hours, and census demographics. DESIGN: Mailed survey. SETTING: Iowa's 409 Medicare-certified stand-alone nursing homes. PARTICIPANTS: Administrators and directors of nursing. RESULTS: The annual rate of abusive events was 20.7 per 1000 nursing home residents, with a rate of 18.4 reported events and 5.2 substantiated events. A higher number of residents and a higher number of certified beds were significantly associated with higher incident, report, and substantiation rates. Higher incident and report rates were associated with nursing homes in metropolitan areas. Higher substantiation rates were associated with for-profit nursing homes. CONCLUSION: Recognized abuse in nursing homes is not uncommon. Approximately 90% of events are reported to the state authorities with 29% of those being substantiated. Differences associated with nursing facility abuse rates are metropolitan area, ownership, occupancy rate, and number of residents and certified beds.

Comparison of health and effective functioning in Russia and the United States.

BACKGROUND: Global aging may increase the societal burden of providing more resources to augment elders' disabilities. The implications of functional disabilities can vary depending on the society in which they occur. OBJECTIVE: To determine differences in US and Russian elder citizens' function. RESEARCH DESIGN: Convenience sample of persons 60 years and older were surveyed and evaluated. SUBJECTS: One hundred community dwelling residents, half from Galesburg, Illinois and half from Moscow, Russia. MEASUREMENTS: An interviewer administered questionnaire and functional assessment examination. RESULTS: The Russian sample was younger than the American sample with a mean age of 67 years versus 78 years, and less likely to be widowed or living alone. Sixty percent of Russians took no medications compared with 14% of Americans, but Russians reported more cardiovascular disease, angina, and hypertension. Forty-four percent of Russians screened as being depressed and only 4% of the Americans. Self-assessed health was good for 77% of Americans and only 6% of Russians. The Medical Outcomes Study SF-36 Health Survey (MOS) eight health concepts showed favorable results for the Americans except for physical functioning, which indicated no difference. CONCLUSIONS: Marked health and functional differences exist between our samples. Russians had more cardiovascular disease, took less medication, drank and smoked more and were much more likely to be depressed than the US subjects.

A nursing home telehealth system: keeping residents connected.

Live video and detailed images of nursing home residents can be transmitted in real time via the Internet. This telehealth system allows residents and long-term care health professionals to connect with experts not available on-site. Electronic stethoscope, otoscope, dermascope, dentalscope, and electrocardiogram are available for use via the Internet. Impediments to implementing telehealth systems in long-term care include costs and the lack of reimbursement for telehealth services. Reimbursement for telemedicine in nursing homes is limited by originating site, current procedural terminology codes, and facility location.

Association of knowledge of adult protective services legislation with rates of reporting of abuse in Iowa nursing homes.

OBJECTIVE: To determine if there is an association between abuse reporting to state authorities by nursing home administrators and directors of nursing and their characteristics and knowledge of the law. DESIGN: Survey. SETTING: Iowa's 409 Medicare certified nursing homes. PARTICIPANTS: Four hundred nine administrators and 409 directors of nursing. MEASUREMENTS: Nursing home abuse incidents, reports, and substantiations, Medicare's Nursing Home Compare Reports, Urban Influence Codes, and county census demographics. RESULTS: A single or double response was received from 369 (90%) of the 409 nursing homes. Being a male administrator and having a higher level of education is associated with higher substantiation rates. A greater knowledge of the dependent adult protective services law is associated with higher incident and report rates for directors of nursing. CONCLUSIONS: Nursing home administrators' and directors of nursing's knowledge of the law and their characteristics are associated with nursing home incident, report, and substantiation of abuse allegations.

Domestic elder abuse and the law.

OBJECTIVES: The authors evaluated the impact of state adult protective service legislation on rates of investigated and substantiated domestic elder abuse. METHODS: Data were collected on all domestic elder abuse reports, investigations, and substantiations for each US state and the District of Columbia for 1999. State statutes and regulations pertaining to adult protective services were reviewed. RESULTS: There were 190 005 domestic elder abuse reports from 17 states, a rate of 8.6 per 1000 elders; 242 430 domestic elder abuse investigations from 47 states, a rate of 5.9; and 102 879 substantiations from 35 states, a rate of 2.7. Significantly higher investigation rates were found for states requiring mandatory reporting and tracking of numbers of reports. CONCLUSIONS: Domestic elder abuse documentation among states shows substantial differences related to specific aspects of state laws.