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An LTC Recipe? Some Food for Thought

2012; Elsevier BV; Volume: 13; Issue: 10 Linguagem: Inglês

10.1016/j.carage.2012.10.018

2377-066X

Jeffrey Nichols,

Primary Care and Health Outcomes

Dear Dr. Jeff: It seems that every time I am talking about individualized care, everyone else is talking about creating systems and collecting statistics, but whenever I am proposing new care systems, everyone else is talking about person-centered care. When I am advocating on behalf of an individual resident, I am reminded that long-term care is an industry. What am I missing? Dr. Jeff responds: “Every time I call it a game, you call it a business. And every time I call it a business, you call it a game.” I often find myself thinking about these lines from the 1979 profootball movie “North Dallas Forty.” As spoken by the aging Nick Nolte to his coach, they express the same bewilderment we in long-term care often feel, struggling to make sense of the mixed messages we routinely hear in 21st century American medicine. We are, oxymoronically, in the business of caring for the sick. The answer to whether we are primarily concerned with the creation of effective care systems or respecting each separate person's wants and needs has to be “Both” (just as that is the answer to the ancient argument over whether medicine is art or science). Systems remind us that all human organisms are basically the same, while person-centered care reminds us that we are all unique. Long-term care has undergone amazing transformations in the past decade. On one hand, many nursing homes have become step-down units from hospitals, administering intravenous antibiotics and stabilizing patients with decompensated congestive heart failure or chronic lung disease. We admit patients only a few days after surgeries including coronary bypass and craniotomies, and we discharge them a few days later to care systems in the community. Indeed, we now admit patients to stretches of long-term care who look like the patients we used to transfer to the hospital. Where once a facility calculated its typical length of stay in years, many now measure the average stay in days. Facilities that once demanded medical stability as a condition for admission now embrace instability as a justification for dramatically enhanced reimbursement rates from Medicare and private insurers. Care pathways are designed to treat specific diseases. Patients tend to concentrate on recovery rather than adjusting to the facility, much less be concerned with care team organization or breakfast menus. At the same time, many facilities are breaking up traditional units into “neighborhoods” or “care clusters,” with interdisciplinary care teams organized around small groups of residents rather than hierarchical departments. Research studies, such as that by Orah Burack and others in the July 2012 issue of JAMDA, suggest that these culture transformations may positively affect a variety of patient outcomes, including levels of agitation in dementia patients. Previous studies demonstrated positive effects on pressure ulcer rates for high-risk residents and lower utilization of physical restraints. The Pioneer movement, which has been a leading advocate for culture change in nursing homes, also claims positive effects on nursing home censuses and finances. The Quality Indicator Survey process now used in nursing homes by federal and state agencies tries to direct the process back to person-centered care. Even the Joint Commission, often seen as the last holdout for institutional policies, procedures, and structures, is now transforming its survey process to a person-centered approach. Each of these paths needs to incorporate both systems analysis and personalized care. Indeed, effective care systems should make personalizing care easier, rather than more difficult. And the ratio between personal preference and evidence-based care can itself vary from patient to patient. Even the rare patient with a single problem being managed according to a straightforward clinical practice guideline still wants to be treated as an individual. At the same time, simply redesigning care processes or creating small clusters of residents will change neither the physiology of aging nor pharmacology. In a recent issue of the New Yorker, writer and surgeon Dr. Atul Gawande suggested that American medical care could learn from industrial models. After enjoying a family meal at a branch of the Cheesecake Factory, he mused on the production systems that allow these restaurants to produce what he considers excellent-quality food at affordable prices, while the American health care system (or nonsystem) struggles with issues of quality while spending incredible amounts of money. The article describes food-preparation systems that allow employees to achieve reproducible quality with minimal waste. Quality-monitoring systems prevent unsatisfactory dishes from being served. Dr. Gawande contrasted this system, which apparently produces an excellent miso salmon and a crisp beet salad with goat cheese, with that of a local hospital doing knee replacements. There, every orthopedic surgeon uses different procedures and techniques, different anesthesia, different postoperative pain regimens, and different physical therapy preferences. Dr. Gawande noted that medicine is moving rapidly to the chain restaurant model with what may be favorable effects. Physicians are rapidly being converted from managers of independent small businesses to employees of giant chains. The notion that standardizing care can both improve quality and decrease costs seems intuitive. And certainly, medical care has a lot to learn from the rest of the service industry. Many nursing homes are proud to claim that they offer a few alternatives at each meal. Yet fast food restaurants surviving on low prices still boast more individualized service (“Hold the pickles, hold the lettuce …”) than almost any health facility kitchen. Nursing homes often incorporate the worst of mass production techniques, which have been long-abandoned by comparable industries. The cheapest motel does a better job individualizing when beds are made and rooms cleaned than all but the best culture change facility. Unfortunately, quality long-term care is more complicated than simply having our residents clean and fed – although that isn't such a bad start. Clinical pathways are designed to generate some of the reproducible quality results that Dr. Gawande admires. Unfortunately, standard protocols are rarely applicable to long-term care populations because they are designed for healthier, younger adults with a single medical condition, not for frail seniors near the end of life with multiple medical problems. That kind of care isn't as easy to standardize as an elective surgical procedure can be. The original OBRA ‘87 regulations included Resident Assessment Protocols designed to lead clinicians through the evaluation of various common geriatric syndromes. They still are useful reminders for appropriate workups. AMDA has developed several care pathways – clinical practice guidelines that can lead practitioners to improved care systems. They are not like the Cheesecake Factory cookbook, but they combine wise advice about useful approaches that are genuinely evidence-based, and they endorse the elimination of interventions that have been proven ineffective. Well-designed systems remind us to do the right things and assign responsibilities to others appropriately. Did we ask the resident what time he or she likes to get up in the morning? If we did, how does that information get conveyed to the nursing assistant who assists with morning care and to the clerk who makes up the rehab schedule and the dietary aide who needs to assemble a breakfast tray? Did we follow resident weights and address significant changes? Who informed the resident about her right to execute advance directives and followed through on the request for a DNR order? These assignments don't get accomplished on their own. Although a checklist can enumerate things to do and issues to be addressed, solutions need to be individualized. Some patients who are losing weight need a liberalized diet or an extra dessert (cheesecake, anyone?). Others may need an antidepressant. Some should be congratulated that they are following their diet so that the diuretics are finally working. Others need to discontinue medicines that are interfering with appetite. Some deserve a discussion about hospice care. Others might just need encouragement at mealtime or a discussion about the importance of adequate nutrition for health and recuperation. A state surveyor once told me that there are only three kinds of survey deficiencies: failure to assess, failure to care plan, and failure to carry out the care plan. Assessment can be improved through improved systems. Care planning needs to be completely individualized. Carrying out the care plan requires integrating systems with individual needs.