Abstract Background Respiratory tract infections (RTI) cause high morbidity and mortality among nursing home (NH) residents, yet their etiology and frequency remain understudied. We implemented multiplex respiratory panel (MRP) testing to describe RTI epidemiology in NH residents to inform efforts to reduce respiratory virus transmission in NH. Figure 1 Flow diagram and multiplex respiratory panel testing results of SNF residents in NH-PHRN, February–April, 2024. Methods The Nursing Home Public Health Response Network (8 academic sites and 22 affiliated NHs) is conducting RTI surveillance with MRP testing. Staff collect nasal swab (NS) specimens and clinical data from symptomatic residents with suspected RTI. Specimens are collected within 72 hours of symptom onset and tested with the Roche ePlex Respiratory Pathogen Panel 2 (17 viral and bacterial pathogens, Figure 1) in a central laboratory. We describe MRP results, symptoms, and characteristics of residents tested during February–April 2024. We compared symptoms between NH residents with and without viral detection on MRP with Chi-Squared and Fisher Exact tests. Figure 2 Multiplex respiratory pathogen testing results among 81 enrolled residents in 19 nursing homes in NH-PHRN, February – April 2024, United States. *One resident tested positive for both Human Rhinovirus/Enterovirus and Coronavirus. **Influenza A subtype was H3 for all four specimens. Results Of 106 symptomatic residents with suspected RTI, 81 (72%) were tested (Figure 1). MRP detected ≥1 virus in 36/81 (44%) specimens; SARS-CoV-2 was the most common (14%), followed by seasonal coronavirus (12%) (Figure 2). Among residents tested, cough (78%), runny nose (43%), and sore throat (31%) were the most common symptoms. Sore throat was more common among residents with viral detection (53% vs. 13%; P=0.0001) (Figure 3). Of 75 tested residents with demographic and clinical data, median age was 80 (range 53–90), 59% were female, 19% were Black, 68% were long stay ( >100 days), and 99% had received a COVID-19 vaccine. Among 52 tested residents with treatment and outcome data, 14 (27%) received antibacterials, 11 (21%) were hospitalized, and 3 (6%) died. Of 25/52 residents with viral detection on MRP and complete treatment and outcome data, 4 (16%) received antibacterials, 6 (24%) were hospitalized (SARS-CoV-2 = 3, seasonal coronavirus = 2, Influenza A = 1) and none died. Figure 3 Frequency and percentage of symptoms and other clinical characteristics among 81 residents who underwent multiplex respiratory pathogen specimen collection in 19 nursing homes in NH-PHRN, February – April 2024, United States. We used Chi-Square and Fisher Exact tests to compare the type and frequency of symptoms among residents who had multiplex tests with and without pathogens detected. One asymptomatic resident who had no pathogen detected was tested due to leukocytosis. *Comparison P=0.04. **Comparison P=0.01. ***Comparison P=0.0001. Conclusion MRP testing identified a virus in almost half of tested NH residents with suspected RTI at the end of the viral respiratory season. Ongoing surveillance will help describe the burden and clinical relevance of viral respiratory pathogens in NH residents and identify areas of improvement for respiratory virus infection prevention. Disclosures Yasin Abul, MD, Moderna: Grant/Research Support|Moderna, Abt, CDC: Grant/Research Support David Canaday, MD, Moderna: Grant/Research Support|Pfizer: Grant/Research Support Jon P. Furuno, PhD, Merck & Co., Inc: Grant/Research Support Stefan Gravenstein, MD, MPH, CDC: Advisor/Consultant|CDC: Grant/Research Support|Genentech: Advisor/Consultant|Genentech: Grant/Research Support|Genentech: Honoraria|GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support|GlaxoSmithKline: Honoraria|Janssen: Advisor/Consultant|Janssen: Grant/Research Support|Janssen: Honoraria|Moderna: Advisor/Consultant|Moderna: Grant/Research Support|Moderna: Honoraria|NIH: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi: Honoraria|Seqirus: Advisor/Consultant Lona Mody, MD, MS, Nanovibronix: Grant/Research Support Morgan Katz, MD, MHS, Ageless Innovation: Advisor/Consultant

ObjectivesSevere obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors.DesignCross-sectional nationwide survey of NH administrators (2021-2022).Setting and Participants290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66).MethodsA survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables.ResultsOf the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity.Conclusions and ImplicationsThe decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.

BACKGROUND AND OBJECTIVES:The prevalence of resident obesity in nursing homes has increased dramatically from 22% to 28% between 2005 and 2015. To provide care for people with obesity, nursing homes have changed their admissions, staffing, and equipment, but underlying these changes are increased resources and financial costs of care. The purpose of this study is to describe nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership. RESEARCH DESIGN AND METHODS:This qualitative study used descriptive approaches; data were collected through semistructured telephone interviews. Of 77 nursing home staff and leaders identified as potential study participants, 6 were ineligible, and 71 participated in the study through interviews conducted from 2019 to 2022. RESULTS:A total of 4 primary themes described the issues surrounding the cost of care for obesity in nursing homes: inefficient and risky use of staff time in a setting of persistent staff shortage, expensive and unique equipment needs, inadequate general reimbursement with an absence of obesity-specific reimbursement supplements, and competing short- and long-term management solutions. DISCUSSION AND IMPLICATIONS:This qualitative study of nursing home staff and leadership underscores a need for improved approaches to funding obesity care within existing nursing payment models. The increasing prevalence of obesity and the burden of the costs of obesity care for nursing homes will escalate this need over the coming decade.

This paper proposes an approach to assess digital health readiness in clinical settings to understand how prepared, experienced, and equipped individual people are to participate in digital health activities. Existing digital health literacy and telehealth prediction tools exist but do not assess technological aptitude for particular tasks or incorporate available electronic health record data to improve efficiency and efficacy. As such, we propose a multidomain digital health readiness assessment that incorporates a person’s stated goals and motivations for use of digital health, a focused digital health literacy assessment, passively collected data from the electronic health record, and a focused aptitude assessment for critical skills needed to achieve a person’s goals. This combination of elements should allow for easy integration into clinical workflows and make the assessment as actionable as possible for health care providers and in-clinic digital health navigators. Digital health readiness profiles could be used to match individuals with support interventions to promote the use of digital tools like telehealth, mobile apps, and remote monitoring, especially for those who are motivated but do not have adequate experience. Moreover, while effective and holistic digital health readiness assessments could contribute to increased use and greater equity in digital health engagement, they must also be designed with inclusivity in mind to avoid worsening known disparities in digital health care.

This editorial comments on the article by Bhatia et al . in this issue.

OBJECTIVE:The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.MATERIALS AND METHODS:The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.RESULTS:The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.DISCUSSION:Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.CONCLUSION:The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

Background/Objectives: We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk. Design: Prospective cohort analysis. Setting and Participants: 32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations. Methods: We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for in-dividual resident characteristics that were previously found associated with AEs. Results: We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medi-cations (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47). Conclusions and Implications: AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures. (c) 2021 AMDA -The Society for Post-Acute and Long-Term Care Medicine.

We currently live in the age of medication overload. More than 40% of older adults (>= 65 years old) are prescribed >= 5 medications a day and nearly 20% take >= 10. Although medications can provide a wide variety of benefits, the number of medications prescribed is the largest predictor of drug-drug interactions, nonadherence, and most importantly adverse drug events. Increasingly, patients, caregivers, and health care providers are employing deprescribing efforts as a solution to medication overload. Clinical pharmacists are well positioned to lead and/or contribute to deprescribing efforts. Deprescribing, however, is not commonly and consistently taught within the United States health professional curriculums, and deprescribing infrastructure support is currently limited. The goal of this review is to present a pragmatic approach to pharmacist-driven clinical practice deprescribing implementation.

BACKGROUND/OBJECTIVESAdverse events (AEs) occur frequently in long‐term care (LTC) residents transitioning from the hospital back to an LTC facility. Measuring the association between resident characteristics and AEs can inform AE risk reduction strategies.DESIGNProspective cohort analysis.SETTINGA total of 32 nursing homes from six New England states.PARTICIPANTSA total of 555 LTC residents contributing 762 transitions from the hospital back to LTC.MEASUREMENTSWe measured the association between all AEs and preventable AEs developing in the 45 days following discharge back to LTC and demographic variables, hospital length of stay (LOS), Charlson Comorbidity Index (CCI) (0–1, 2–3, 4–5 and ≥6), dependency in activities of daily living (ADLs) using the Minimum Data Set Long Form Scale (in quintiles 0–12, 13–15, 16, 17–18, and ≥19), and number of regularly scheduled medications (0–9, 10–13, 14–17, and ≥18). To understand the independent association of each resident characteristic with AEs and preventable AEs, we constructed multiple Cox proportional hazards models.RESULTSThere were 283 discharges with one or more AEs and 212 with preventable AEs. Characteristics independently associated with higher risk of an AE included hospital LOS 9 or more days (hazard ratio [HR] = 1.49; 95% confidence interval [CI] = 1.02–2.17); CCI of 4 to 5 (HR = 1.74; 95% CI = 1.13–2.67) or 6 or higher (HR = 1.58; 95% CI = 1.01–2.46); 18 or more regularly scheduled medications (HR = 1.53; 95% CI = 1.07–2.18); and 19 and above on ADL dependency (HR = 1.78; 95% CI = 1.21–2.62). Results from models with preventable AEs were similar to those with all AEs.CONCLUSIONIncreased LOS, higher comorbidity burden, greater dependency in ADLs, and polypharmacy were the resident characteristics most strongly associated with risk of AEs and preventable AEs. We recommend heightened vigilance in the care of LTC residents with these characteristics transitioning back to LTC. We also recommend research to assess strategies to reduce the risk of AEs.

A year ago, a group of AMDA leaders spent the day on Capitol Hill advocating for policy changes related to post-acute and long-term care (PALTC) telemedicine. A main point of discussion was the need to revise the regulations governing payment for telemedicine visits in a way that would make it more feasible for PALTC clinicians working with facilities to use telemedicine tools to care for residents. Medicare payment for telemedicine physician visits has largely been to support rural nursing homes and limited to no more frequently than monthly regardless of medical necessity. These restrictions have made it very difficult for PALTC clinicians to make the business case to include telemedicine into most clinicians' practice. Telemedicine to date had largely been supported directly by nursing homes that arrange for afterhours and weekend coverage to manage changes of condition with the primary goals of reducing potentially avoidable emergency department visits and hospitalizations. Telemedicine had also been frequently used for certain subspecialties including behavioral health, wound care diagnosis and management. One year later, as a result of rapid policy changes in response to the COVID-19 pandemic, much has changed. Rational changes in regulations guiding telemedicine in nursing homes and the need for thoughtful infection prevention have inspired a new opportunity for innovation and vision for how high-quality care can be accessed in nursing homes. Many factors combine to make nursing homes an ideal venue for telemedicine. The population of patients in nursing homes has steadily increased in complexity, creating the need for timely and skilled acute and chronic care from clinicians with competency in PALTC. In contrast to medical providers working in hospitals, emergency departments, and primary care practices, PALTC clinicians may only be onsite in the nursing facility intermittently and rarely during nights and weekends. This translates into challenges around change of condition assessment and can contribute to misdiagnoses, delays in diagnosis, and overuse of emergency departments. PALTC clinicians and medical directors have believed for many years that their patients would benefit from telemedicine tools to increase access.1Driessen J. Castle N.G. Handler S.M. Perceived benefits, barriers, and drivers of telemedicine from the perspective of skilled nursing facility administrative staff stakeholders.J Appl Gerontol. 2018; 37: 110-120Crossref PubMed Scopus (26) Google Scholar,2Driessen J. Bonhomme A. Chang W. et al.Nursing home provider perceptions of telemedicine for reducing potentially avoidable hospitalizations.J Am Med Dir Assoc. 2016; 17: 519-524Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar A growing abundance of feasibility studies exploring the application of telemedicine in nursing homes has also supported the concept. In early 2019, AMDA's Workgroup on Telemedicine and Technology published a white paper offering guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents.3Gillespie S.M. Moser A.L. Gokula M. et al.Standards for the use of telemedicine for evaluation and management of resident change of condition in the nursing home.J Am Med Dir Assoc. 2019; 20: 115-122Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The paper reviewed the many research studies and published case reports that demonstrate the ability of telemedicine interventions to reduce avoidable emergency department visits and hospitalizations. In this issue of JAMDA, the GeriCare@North example also demonstrates the feasibility of deploying acute geriatric medicine consultation via telemedicine for a variety of routine and symptom-based concerns to nursing home residents in Singapore.4Low J.A. Toh H.J. Chin L.L. et al.The Nuts and Bolts of Utilizing Telemedicine in Nursing Homes—The GeriCare@North Experience.J Am Med Dir Assoc. 2020; 21: 1073-1078Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar The COVID-19 pandemic has highlighted the need to provide timely access to high-quality medical care, especially to nursing home residents with new or worsening respiratory symptoms. The benefits of telemedicine allow for actual or suspected COVID-19–positive residents to be treated in place when their care plan goals support this (ie, goal-concordant care). This concept, called forward triage, can allow for resident assessment in the nursing home using telemedicine to optimize survival and resources, while reducing the risk of community spread and limiting exposure of other health care personnel to COVID-19.5Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for COVID-19.N Engl J Med. 2020; 382: 1679-1681Crossref PubMed Scopus (2029) Google Scholar In their March 2020 response to COVID-19, the US Center for Medicare & Medicaid Services (CMS) has essentially removed the biggest financial barriers to PALTC clinicians providing telemedicine services in the nursing facility. In a sweeping interim final rule issued at the end of March, CMS removed the once-a-month limitation for subsequent care visits (CPT 99307-99310) and added initial visits (CPT codes 99304-06) and discharge services (CPT 99315-16) to the list of Medicare reimbursable telehealth services. Essentially, the agency suspended all face-to-face regulatory visit requirements and allowed them to be completed using telehealth tools. Further, the agency announced that these visits will be paid at the same rate as a face-to-face visit even if completed via telehealth.6Centers for Medicare & Medicaid ServicesPhysicians and other clinicians: CMS flexibilities to fight COVID-19.https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdfDate accessed: June 5, 2020Google Scholar,7Centers for Medicare & Medicaid ServicesLong-term care nursing homes telehealth and telemedicine tool kit.https://www.cms.gov/files/document/covid-19-nursing-home-telehealth-toolkit.pdfDate accessed: June 5, 2020Google Scholar Other codes that are now reimbursable are listed in Table 1.Table 1AMDA–The Society for Post-Acute and Long-Term Care Medicine Guidance for Submitting Claims for Telehealth Services During COVID-19 in the Nursing Home Setting to ReflectAdapted from https://paltc.org/telehealth-paltc (accessed June 5, 2020).COVID-19 Telehealth Waivers•Originating sites (where nursing home residents are located) no longer need to be in rural locations as defined by the Health Resources and Services Administration (HRSA) during any portion of any COVID-19 public health emergency period○Nursing homes can bill Q3014 as an originating site (payment approximately $26 per encounter)•Post-acute and long-term care clinicians do not need to demonstrate prior relationship with the patient, ie, at least 1 encounter in the past 3 years by the same provider or other qualified provider in the same practice (as determined by tax ID)•Changes and clarification to distal site (where the qualified practitioner is located) requirements are as follows:○For practitioner doing the visit:-Use appropriate CPT E&M nursing facility code (99304-99310, 99315/16)-Use appropriate Place of Service (POS) Code: 31, skilled nursing facility; 32, nursing facility-Use modifier 95 to indicate visit done via telehealth-Conduct telehealth visits "as appropriate"-Initial visit (99304-99306) can be completed by physician assistant/nurse practitioner during the public health emergency-Must obtain consent from patient or designated surrogate (can be verbal) for conducting telehealth visits-Can waive any copay associated with the visitCPT, Current Procedural Terminology; E&M, evaluation and management. Open table in a new tab CPT, Current Procedural Terminology; E&M, evaluation and management. Importantly, also removed was the limitation of telemedicine reimbursement for only rural nursing homes. Regulations previously restricted reimbursement to rural nursing homes as originating sites (the location of the patient at the time the service is furnished via a telemedicine). Under the public health emergency waiver, clinicians originating care for residents located in either rural or urban nursing homes can bill for eligible encounters delivered via telemedicine tools. PALTC practitioners at the distant site who may furnish and receive payment for covered telemedicine services, also referred to as distal site practitioners, complete their billing documents with appropriate E&M codes, place of service where the service took place, and modifier 95 indicating a telemedicine visit. Supplemental funding through the Federal Communications Commission was also made available to health care centers seeking to expand their capacity to provide virtual care, further reducing barriers to telemedicine-based care.8United States Health and Human Services Department21st Century Cures Act: Interoperability, information blocking and the ONC Health IT Certification program.https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certificationDate accessed: June 15, 2020Google Scholar Governmental discretion to not enforce penalties for Health Insurance Portability and Accountability Act (HIPAA) violations on health care providers using telemedicine tools in good faith to deliver care during the COVID-19 pandemic has allowed more health care providers to try using telemedicine tools without the burden of complex technology and program initiation costs. However, privacy concerns will likely resurface as we deal with the aftermath of the pandemic. In separate rulemaking just prior to the COVID pandemic, the Office of the National Coordinator (ONC) released a long-awaited interoperability final rule dealing with a plethora of issues including cybersecurity. There will be an ongoing need for the ONC to address concerns about privacy and security as telehealth use expands.9Federal Communications CommissionCOVID-19 telehealth program.https://www.fcc.gov/covid-19-telehealth-programDate accessed: June 5, 2020Google Scholar For now, public health emergency waivers have enabled every PALTC medical provider and facility to try adding telemedicine to their care delivery toolkit. Telemedicine programs are reporting significant growth. Health care's relationship with telemedicine has the opportunity to be forever changed as a result of the COVID-19 global pandemic. During the pandemic, health systems across the United States have exponentially expanded care via telemedicine to nursing home residents. For example, at the University of Rochester, between March and May 2020, telemedicine visits between the medical providers of our geriatrics group that cares for residents of several nursing homes went from being a rare occurrence to the group completing approximately 250 telemedicine visits a week, representing about a third of the practice's nursing home encounters. The Veterans Health Administration, a longstanding leader in adoption of telemedicine in health care, moved to create telemedicine access for nursing home residents in all of their Community Living Centers. As we ride the momentum of change, it is important for us to continue to expand our understanding of how telemedicine tools are best used in care. The interconnected relationship between patient population, the reason for the medical visit, and the modality of telemedicine used needs to be further refined for us to deliver the highest-value care. Many have hypothesized that telemedicine should not replace the face-to-face regulatory care visits and medically necessary visits that form the foundation of primary care in the nursing home. Our experiences in COVID-19 may change our perspective on that question. Can we embrace the disruption of the pandemic and use it to drive other programmatic innovations in post-acute long-term care? As we move beyond the initial COVID-19 storm to a new, improved way of providing care in nursing homes, strategic action is needed to more permanently resolve the issues that may limit our progress (Table 2). The integrated health network of Eastern Ontario has demonstrated the feasibility of using e-consultation for specialty care such as dermatology and infectious disease and identified perceived value with respect to timeliness, quality of care, and cost.10Helmer-Smith M. Fung C. Afkham A. et al.The Feasibility of using eConsult in long-term care homes.J Am Med Dir Assoc. 2020; 21: 1166-1170Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Similarly, investigators in the AMDA Telemedicine workgroup conducted a study of the perceived value of subspecialty telemedicine that showed that dermatology, geriatric psychiatry, and infectious disease were the specialties that PALTC practitioners would consult the most if available.11Driessen J. Chang W. Patel P. et al.Nursing home provider perceptions of telemedicine for providing specialty consults.Telemed J E Health. 2018; 24: 510-516Crossref PubMed Scopus (24) Google Scholar Similarly, many have called for reimbursement models to further expand reimbursement for telemonitoring and other telephonic-based care modalities. Now is the time to quantify the cost, quality, and value of these types of clinical services. When we look back, years from now, what will PALTC practitioners have learned about effective care delivery using telemedicine technology? Hopefully, we will see 2020 as the turning point in our understanding of how to build effective, financially stable medical care models, that leverage telemedicine technology effectively to deliver the right care, at the right time, in the right place, to the right patient.Table 2Recommendations for Incorporating Enhanced Telemedicine in Long-Term Care Practice After the COVID-19 PandemicRecommendationActionRegulatory reform•Allow Medicare payments to post-acute and long-term care clinicians for all skilled/nursing facility CPT E&M codes using telehealth•Allow medical necessity to dictate telemedicine visit frequency for subsequent care visits•Allow nursing homes to receive facility fees for all telemedicine encounters regardless of physical location•Expand billable telemedicine services for nursing home residents to include e-consultation and additional remote patient monitoring•Ensure payment parity between face-to-face and telemedicine care in Medicare and third-party payorsEvaluate the impact of telemedicine on nursing home structure, process, and outcomes•Develop and assess the impact of PALTC workforce competencies for both originating and distal site providers who use telemedicine tools on clinical outcomes•Refine and assess the use of telemedicine for forward triage on clinical outcomes•Evaluate how regulatory visits delivered by telemedicine vs face-to-face impact the quality of clinical care and provider or resident satisfactionTechnology•Collaborate with telemedicine service providers to develop cost-effective, low-bandwidth, accessible, and easy-to-use telemedicine technology•Work with cellular service and Internet service providers to deliver high-speed, low-cost Internet access, to support telemedicine and communication technologies in nursing homes•Collaborate with electronic medical record vendors to improve access to and documentation within various information systems during telemedicine visits•Increase the number of easy-to-use, low-cost Health Insurance Portability and Accountability Act (HIPAA) security–compliant telemedicine tools available to post-acute and long-term care providers.CPT, Current Procedural Terminology; E&M, evaluation and management. Open table in a new tab CPT, Current Procedural Terminology; E&M, evaluation and management.

PurposePrior studies suggest that inpatient palliative care services can reduce rehospitalizations. However, medications commonly prescribed by palliative care providers (eg, opioids, benzodiazepines, and antipsychotics) have been independently associated with rehospitalizations. Little is known regarding the role of adverse drug reaction (ADR)-related rehospitalizations within the palliative care population. ObjectiveTo determine the prevalence and explore predictors of ADR-related 30-day rehospitalizations in an inpatient palliative care population. MethodsA retrospective cohort study that included 284 palliative care patients who were readmitted within 30-days of discharge from two academic hospitals in Western Pennsylvania. All unplanned rehospitalizations were assessed for medication causality via the Naranjo algorithm by at least two independent reviewers. ResultsThe mean (SD) age of the cohort was 61 (16) years and included 45% (n = 127) female and 81% Caucasians (n = 229). Of the 254 unplanned rehospitalizations, 11 (4%) were classified as doubtful ADRs, 224 (88%) were classified as possible ADRs, and 19 (7%) were defined as probable or definite ADR-related. Tacrolimus was associated with three probable and one definite ADR-related rehospitalization. Oncologic agents (eg, venetoclax, nivolumab, vincristine, and decitabine, carfilzomib; n = 5), anticoagulants (eg, rivaroxaban, apixaban, and warfarin; n = 4), antimicrobials (eg, cephalexin and vancomycin; n = 2), potassium chloride (n = 2), lorazepam (n = 1), and nicotine replacement (n = 1) were all associated with probable ADRs. Only the number of medication changes during the index admissions was observed as a statistically significant predictor of rehospitalizations in this population (P = .043). ConclusionsPalliative care patients often suffer from potential ADR-related rehospitalizations and the number of medication changes during the index hospital admissions is associated with future potential ADRs. Clinical pharmacists should consider these findings when developing initiatives to reduce rehospitalizations in the inpatient palliative care patient population.

Objectives This document offers guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. Settings and participants Members of the telemedicine workgroup of AMDA—The Society for Post-Acute Long-Term Medicine-developed this guideline through both telephonic and face-to-face meetings between April 2017 and September 2018. The guideline is based on the currently available research, experience, and expertise of the workgroup's members, including a summary of a recently completed systematic mixed studies literature review to determine evidence for telemedicine to reduce emergency department visits or hospitalizations of nursing home residents. Results Research and experience to date support the use of telemedicine as a tool in change of condition assessment and management as a means of reducing unnecessary emergency department visits and hospitalization. Telemedicine-delivered care should be integrated into the primary care of the resident and delivered by providers with competency in post-acute long-term care. The development and sustainability of telemedicine programs is heavily dependent on financial implications. Quality measures should be defined for telemedicine programs in nursing homes. Conclusions/Implications Telemedicine programs in nursing homes can contribute to the delivery of timely, high quality medical care, which reduces unnecessary hospitalization. Reimbursement for telemedicine-driven care should be based upon medical necessity of visits to care and the maintenance of quality standards. More studies are needed to understand which telemedicine tools and processes are most effective in improving outcomes for nursing home residents.

Potentially avoidable hospitalizations are defined by the Centers for Medicare & Medicaid Services as hospitalizations that could have been avoided because the condition could have been prevented or treated outside of an inpatient hospital setting. Approximately 25% of all hospitalizations are considered potentially avoidable; nearly half of these come from nursing facilities, and they cost CMS approximately $8 billion annually. To address this common and costly problem, the CMS Innovation Center and the CMS Medicare-Medicaid Coordination Office initially partnered with seven organizations that currently support nearly 250 nursing facilities across the United States. This program was rolled out in two phases (phase one: 2012–2016; phase two: 2016–2020) to implement a range of evidence-based clinical and educational interventions for eligible long-stay residents who are enrolled in traditional Medicare fee-for-service or are dual eligible (enrolled in both the Medicare and Medicaid programs). The RAVEN Initiative (Reduce AVoidable hospitalizations using Evidence-based interventions for Nursing) for facilities located in Pennsylvania was funded in 2012, and it is the only CMS Innovation Award that has a telemedicine component to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. The RAVEN Initiative … is the only CMS Innovation Award that has a telemedicine component to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. Telemedicine is defined as the use of telecommunication and information technologies to provide clinical health care at a distance. Telemedicine has been shown to reduce avoidable emergency department (ED) visits and hospitalization of nursing facility residents. Telemedicine can be used to assess and manage a variety of medical conditions, including the six most common conditions associated with potentially avoidable hospitalizations: congestive heart failure, chronic obstructive pulmonary disorder/asthma, dehydration/electrolyte abnormalities, pneumonia, skin ulcers/cellulitis, and urinary tract infections. In the RAVEN model, nurse practitioners provide both daytime and after-hours (nights and weekends) telemedicine consults for managing any changes associated with the aforementioned six most common conditions. These six medical conditions have qualifying criteria for facility-based payment under phase two of the initiative. Payment is issued to a partner-facility under Medicare Part B after evaluation by a physician, nurse practitioner, or physician assistant either face to face or by telemedicine for a qualifying medical condition by the end of the second day after the change in condition is noted, irrespective of the geographic location of facility (i.e., it does not need to be a rural Health Resources & Services Administration facility). During phase one of the RAVEN initiative, there were an average of 5.0 telemedicine and 71.7 telephonic consults per month from September 2014 to November 2016. Since phase two began, there have been an average of 9.3 telemedicine and 45.0 telephonic consults per month from November 2016 to February 2018. This suggests that the facility-based payment associated with phase two in November 2016 has led to a significant increase in telemedicine use among RAVEN-partnered nursing facilities. In addition to increasing the use of telemedicine, we have seen consistent self-reported avoidance of EDs and hospitalization among more than 60% of RAVEN telemedicine providers, and our findings are reflected in the Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Final Report (Waltham, MA: RTI International, 2017; https://goo.gl/uDn5nC), research that was contracted by CMS. Independent data from our research, supported by AMDA – the Society for Post-Acute and Long-Term Care Medicine, has shown the value of telemedicine for managing potentially avoidable hospitalizations of nursing facility residents (J Am Med Dir Assn 2016;17:519–524;Telemed J E Health, Jan. 2, 2018; [doi:10.1089/tmj.2017.0076]). I have worked closely with UPMC Enterprises, the commercial arm of University of Pittsburgh Medical Center (UPMC), to determine whether there was an opportunity to commercialize concepts, products, and processes developed as part of the RAVEN project. The goal was to take a concept that had a narrow focus (i.e., long-stay residents as part of a CMS Innovation Award) and create a generalizable and scalable telemedicine solution that could serve the broader post-acute and long-term care market. During the collaboration, UPMC Enterprises supplied the capital to develop the company as well as the business and market acumen necessary to take a grant-funded concept to a viable commercial project. To this end, UPMC Enterprises provided a variety of talent, including an Entrepreneur in Residence (an entrepreneur who has specific experience related to the product to be developed), a product developer, a project manager, and a team of software developers. UPMC Enterprises also created a space for the team to collaborate and, ultimately, to develop their initial commercially viable product. Without these “incubator” functions along with a generous capital investment, Curavi Health, which offers telemedicine solutions, would not have been formed, and the ability to help many nursing facility residents would have been lost. As of January 2018, Curavi Health has more than 40 nursing facilities under contract in three states, and offers acute change of condition management, specialty consults (e.g., geriatric psychiatry), EKG services with a one-hour turnaround time by a cardiologist over-read, and management of the CMS Innovation Award (as RAVEN Supported by Curavi). Curavi Health either provides a clinician network (i.e., fellowship-trained geriatricians or certified registered nurse practitioners with nursing facility experience) or provides the technology platform to allow local nursing facility providers to manage the care of their own residents. The path to commercialization has not always been an easy one. The RAVEN CMS Innovation Award has allowed Curavi to develop hardware and software that is optimized for medically fragile, older adults in an institutional setting. Curavi facilitates resident assessments using an integrated stethoscope, otoscope, examination/wound camera, and a 12-lead EKG. Curavi has worked hard to address nursing facility adoption with an eye to the fact that nursing facilities, which have been the primary customer, are highly value-conscious and operate with low margins. Providing a range of product options such as the “bring your own provider” model and varying hours of operation has allowed Curavi to customize the solution to align with a facility’s needs and budget. Many nursing facilities also have insufficient Wi-Fi connectivity, and Curavi has overcome this problem by investing in a solution that optimizes low-bandwidth environments and by partnering with all major cellular service providers to provide an on-cart cellular router solution to bypass Wi-Fi altogether. Finally, Curavi strives to increase utilization and value for our clients by investing in ongoing facility training, continually improving the nurse user experience, and adding additional services. Innovation is needed in the nursing facility environment. Without it, residents will not have access to the right care at the right time in the right setting. Telemedicine has the potential, when coupled with appropriate facility- and provider-based payment changes, to lead to substantial improvements to access while reducing the need for care in alternate settings such as specialists’ offices, EDs, and hospitals. To help promote and support the development of innovation, the Society formed the Innovations Platform Advisory Council (I-PAC). At the 2018 Annual Conference, I-PAC is sponsoring the Society’s first-ever “Shark Tank” Competition to highlight how innovators are tackling PA/LTC issues. The four companies that were invited to compete are CareBand, Mentia, Patient Patterns, and TriageTrace. The competition showcases these companies, highlighting new systems, devices, and technologies with the goal of improving PA/LTC processes and outcomes. The winners will receive recognition in the Society’s publications (Caring for the Ages and JAMDA) and on the Society’s social media accounts. They will also receive consulting from an expert panel of physicians and advanced practice providers, free Society membership, and opportunities to exhibit free the following year in the Innovation Tech Pavilion and judge the next year’s competition. We hope that others realize the importance of innovation as well as acknowledge the commitment that the Society has made to helping early-stage entrepreneurs invest in the PA/LTC setting. This column is sponsored by AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Innovation and Implementation Workgroup. Dr. Nazir is the chief medical officer for Signature HealthCare and president for SHC Medical Partners. He is treasurer for the Society, chair of the Society’s Innovation and Implementation Workgroup, and editor of this column. Dr. Handler, this column’s author, is chief medical and innovation officer of Curavi Health, Inc. Dr. Handler also serves as the chief medical informatics officer for UPMC Community and Provider Services Division, and is the codirector and medical director for telemedicine and health information for the RAVEN CMS Innovation Award.

Potentially inappropriate medications in nursing home (NH) residents carries significant burden and costs to residents and health-systems alike. The goal of this study was to survey a nationally representative sample of NH providers to describe current utilization of deprescribing, and perception and desired components of a deprescribing program in NH residents to reduce potentially inappropriate medications.

OBJECTIVE:Potentially inappropriate medications carry significant burden and costs to nursing facility residents and health systems. The goal of this study was to survey nursing facility providers from across the United States to describe the current utilization of deprescribing, and perceptions and desired components of a deprescribing program, in nursing facilities to reduce potentially inappropriate medications.DESIGN/SETTING/PARTICIPANTS/MEASUREMENT:We surveyed health care providers who attended the 2017 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference-in Phoenix, Arizona. Returned surveys were entered into an electronic database from paper copies. Survey responses were summarized using descriptive statistics.RESULTS:Of the 1,431 conference attendees, 637 surveys were returned for a 45% response rate. Most respondents were physicians (n = 563, 88%). Respondents indicated a strong agreement with the potential for deprescribing to reduce cost to residents and nursing administration time and burden, while disagreeing that deprescribing may be depersonalizing. Respondents indicated clear preference for deprescribing programs to target medications that are no longer indicated and are "high risk," and that such programs should include discussions with the resident. Respondents also agreed that deprescribing programs are successful if the resident, or the resident's family and/or caregivers, reports an improvement in quality of life.CONCLUSION:Among respondents there was a high degree of confidence in the potential impact of deprescribing initiatives, as well as a broad consensus of desired components. This information may increase consultant pharmacist engagement and drive future proactive deprescribing initiatives.

As the US population ages, recognizing and providing care for those with geriatric syndromes will become ever more important. However, with most trainees learning in hospitals, the opportunities for discovering practical ways of implementing geriatric skills—such as assessment of delirium or identifying community services for dementia patients, usually learned in the outpatient setting—are limited. Presently, short-form, easily accessible resources teaching the mechanics of geriatric care are not available. In order to ensure housestaff are exposed to geriatric principles and increase their comfort with the same, we polled internal medicine and orthopedic surgery housestaff on specific geriatric topics and designed a geriatric-focused podcast as a learning supplement.

OBJECTIVE:To conduct a systematic literature review to determine what telemedicine services are provided by pharmacists and the impact of these services in the nursing facility setting.DATA SOURCES:MEDLINE®, Scopus®, and Embase® databases.STUDY SELECTION:The terms "telemedicine" or "telehealth" were combined by "and" with the terms "pharmacist" or "pharmacy" to identify pharmacists' use of telemedicine. Also, "telepharmacy" was added as a search term. The initial search yielded 322 results. These abstracts were reviewed by two individuals independently, for selection of articles that discussed telemedicine and involvement of a pharmacist, either as the primary user of the service or as part of an interprofessional health care team. Those abstracts discussing the pharmacist service for purpose of dispensing or product preparation were excluded.DATA EXTRACTION:A description of pharmacists' services provided and the impact on resident care.DATA SYNTHESIS:Only three manuscripts met inclusion criteria. One was a narrative proposition of the benefits of using telemedicine by senior care pharmacists. Two published original research studies indirectly assessed the pharmacists' use of telemedicine in the nursing facility through an anticoagulation program and an osteoporosis management service. Both services demonstrated improvement in patient care.CONCLUSION:There is a general paucity of practice-related research to demonstrate potential benefits of pharmacists' services incorporating telemedicine. Telemedicine may be a resource-efficient approach to enhance pharmacist services in the nursing facility and improve resident care.