Addressing Quality Improvement and Multicomorbidity in LTC

Long-term care (LTC) staff strive to increase the quality of care they deliver to their patients. However, maintaining an elevated level of care can be a daily struggle for those who work with the geriatric population, who typically have a high prevalence of multicomorbidity and chronic illness in addition to sometimes needing assistance with basic, daily needs such as mobility, hygiene, and meals. Health care professionals are challenged to find person-centered, practical solutions to the complex issues that arise during geriatric care, such as maintaining individuals’ sense of independence and self-worth while also minimizing risks that can result from repetitive care routines. 

The intent of assisted living (AL) has been to promote the dignity and independence of older adult residents. If AL providers are to have a more recognized role in health care, they must embrace the use of quality metrics to guide quality improvement initiatives. Tools that assess structures, processes, and outcomes of care allow AL staff and others to better understand the quality of services provided and can help to indicate where improvement may be indicated. Sheryl Zimmerman, PhD, and colleagues identify five domains as being central to determining quality in the AL setting and conduct a comprehensive review and critique of tools applicable for quality improvement in AL.

Polypharmacy is a significant problem in nursing homes (NHs); it is associated with a myriad of negative clinical consequences such as increased risk of adverse drug reactions, complications created by drug-drug interactions, medication nonadherence, reduced functional capacity, multiple geriatric syndromes, hospitalizations, increased risk of mortality, and greater health care costs. NH residents are particularly vulnerable to polypharmacy due to their multiple comorbidities, highlighting a need for effective intervention to improve medication management in NHs.

Deprescribing—the process of tapering, stopping, or withdrawing medications that are unnecessary or inappropriate—is an effective way to minimize polypharmacy and improve health outcomes. Although deprescribing is an important component of geriatric practice, it is often overlooked due to time pressures on clinicians. Additionally, it is often a challenge for clinicians working in NHs to identify when it is necessary to stop medications and how to do so for each unique case. In order to help clinicians easily and safely engage in deprescribing, as well as identify potential medications that can be discontinued, Linda Liu, DNP, ANP-BC, GNP-BC, ACHPN, and Irene Campbell, MSN, APRN, GNP, provide a step-by-step guide for professionals in the form of a Tip Sheet.

Chronic illnesses and multiple comorbidities can also pose a challenge in the identification and management of depression. Polypharmacy and medication interaction issues must be considered when deciding what medications to prescribe for these patients. Patients with persistent depression who do not respond well to treatment pose a significant challenge to health care providers and NH staff. Subramoniam Madhusoodanan, MD, DLFAPA, and Johanna Landinez, MD, report the case of an 89-year-old patient with a long history of depression and meningiomas of the brain, who was treated with multiple psychotropic medications and psychotherapy with inadequate response eventually leading to suicidal thoughts/plans and psychiatric hospitalization.

The articles in this issue provide tools and evidence-based strategies that LTC professionals can implement into their facilities and daily care regimens in order to achieve their goals of improving the overall personal and medical care experience for their older adult patients.