The Effects of Regulatory Changes on the Provision of Long-Term Care

The US Centers for Medicare and Medicaid Services (CMS) continues to update their regulatory policies regarding the provision of care in long-term care (LTC) facilities, in order to improve the quality and value of care provided to older adult residents of these facilities. It can be challenging for care providers in LTC setting to stay informed of these developments and to know how changing regulations affect their daily interactions with older adults in their care. The articles in this issue of Annals of Long-Term Care: Clinical Care and Aging^® each highlight a particular regulatory issue affecting the care of older adults and prescribe solutions to the challenges that may be presented by these regulations.

Behavioral and psychological symptoms of dementia (BPSD) are very common as the disease progresses, impacting 80% of LTC facility residents. BPSD can be even more challenging to manage than the characteristic cognitive decline associated with dementia. They often lead to increased caregiver burden, early nursing home placement, hospitalizations, and excess morbidity and mortality. Effective BPSD management is often challenging and requires frequent symptom reassessments and treatment adjustments as the disease progresses. Currently, no pharmacologic therapies are approved by the US Food and Drug Administration for the treatment of dementia-related behaviors. CMS has implemented several initiatives to reduce the inappropriate use of antipsychotic medications, especially in older adults, for whom they can cause dangerous side effects and an increased risk of death. However, the prevalence of antipsychotic use for BPSD in US LTC facilities remains high, despite findings that they provide modest, if any, benefit compared with placebo in the treatment of behavioral symptoms. Angela G. Catic, MD, describes the behaviors and features of BPSD, the process of evaluating LTC residents with these symptoms, and the many available nonpharmacologic treatment options for BPSD in this population. Knowledge of these approaches is essential for LTC providers and staff so that they can be implemented in the place of pharmacologic treatments when possible.

Chronic pain affects about 100 million American adults and is associated with costs of up to $635 billion each year in the United States. Studies have shown that older adults are more vulnerable to severe or persistent pain and that the ability to tolerate severe pain decreases with age. Despite a recent emphasis on recognizing the importance of treating pain, regulatory barriers have increasingly limited access to pain medications. In particular, the treatment of pain in the LTC setting has become far more challenging for health care providers. In addition, the difficulty of navigating the guidelines of the Drug Enforcement Administration and other health organizations has raised serious concerns among health care providers about regulatory issues and legal risks, creating additional barriers to providing appropriate pain management. Richard Stefanacci, DO, MGH, MBA, AGSF, CMD, reviews these regulations and provides suggestions for processes that can be put in place so that LTC providers can continue to effectively manage the pain of residents in their care. 

Healthcare policy makers have been attempting to link payments for multiple services that patients receive during an episode of care for more than 20 years. In January 2015, the bundled payments model received a large boost with the announcement by the Department of Health and Human Services that 50% of Medicare payments will be tied to quality or value through alternative payment models, such as bundled payments, by the end of 2018. One means by which transitional care interventions can ensure sustainability is to leverage the non-medical workers who provide long-term supports and services (LTSS) to help the aging population maintain function and address nonmedical health determinants in the community. Andrey Ostrovsky, MD, and coauthors provide a history of how bundles have evolved over time and suggests that the incorporation of LTSS into bundles represents the next step in this evolution. Although most transitional care interventions fail to tap into the nonmedical workforce, there are emerging technology-enabled care transition models using LTSS staff that minimize program cost while significantly improving outcomes.

Staying abreast of recent developments in policies and regulations surrounding the provision of care to older adults living in LTC settings can enable administrators and staff to ensure that they are not only meeting the necessary legal requirements but also providing the highest quality of care at the greatest value to their residents.