Risk Management Challenges in Long-Term Care

Risk management is important in any healthcare setting, but the more complex the patient population, the more challenges this poses. With long-term care (LTC) facilities housing people who have severe physical and/or cognitive impairments, multiple comorbidities, and on numerous medications, risks abound. Some of these risks are relatively easy to identify, such as the risk of fractures in a person with osteoporosis or of pressure ulcers in residents who are bedridden, whereas other risks may not become apparent until a patient experiences an unusual adverse effect. In this issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC), we examine some of the risk management challenges faced by LTC providers.   

In “Antithrombotic Therapy for Atrial Fibrillation: An Update on Safety, Evidence-Based Treatment Decisions, and the New Oral Anticoagulants”, William Smucker, MD, provides a comprehensive review of antithrombotic therapy, an area that has seen considerable drug development over the past few years as several new drugs have come onto the market in an effort to replace warfarin. As Dr. Smucker notes, although these new anti-coagulants are marketed as having better safety profiles than warfarin and as eliminating the need to monitor patients’ international normalized ratios, the trials that were conducted to evaluate these agents excluded the type of patients and conditions that are commonly found in LTC settings. Therefore, their safety profile and propensity to cause drug-drug interactions in vulnerable patients on multiple medications remain unknown. As a result, these agents may not be any safer for LTC residents than warfarin, which has been on the market for almost 60 years and with which clinicians subsequently have considerable experience. The newer agents are also considerably more expensive than warfarin, which may make them cost-prohibitive to LTC patients. Nevertheless, as Dr. Smucker suggests, if a newer anticoagulant is deemed to be preferable to warfarin for an LTC resident, a risk management strategy that includes regular clinical and laboratory monitoring and close follow-up would be warranted to prevent adverse events. In addition, LTC providers should not use these agents off-label.

In “Neuroleptic Malignant Syndrome in an Older Woman With Schizophrenia”, Julie Pullen, MS, and Charlotta Eaton, MD, report the case of a newly admitted LTC resident who developed neuroleptic malignant syndrome (NMS) shortly after being prescribed an antibiotic to treat a urinary tract infection. It appears that the newly prescribed antibiotic interacted with the neuroleptic that the patient had been taking for a decade. Although NMS is rare, this case report highlights the need to stay mindful of potential drug-drug interactions when adding any new agent to a patient’s medication regimen. It also shows that LTC residents may have unusual presentations when any adverse effects occur, including a rare syndrome like NMS. The patient in the author’s case report did not develop a fever or have elevated creatine phosphokinase levels, which are generally considered to be hallmarks of NMS. Although some adverse effects cannot be anticipated because of the complexity of a patient’s clinical picture, risk management requires that every effort be made to consider as many risks as possible and to make every effort to prevent them and ensure they are caught before they become debilitating or life-threatening. One resource LTC providers should use to mitigate the risk of adverse drug reactions is the American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which is accessible at www.americangeriatrics.org

In “Moving Into 2013: Major Issues Facing Long-Term Care Providers”, Richard G. Stefanacci, DO, reviews some of the major 2012 healthcare-policy trends, the impact these policies are having on healthcare today, and what the ramifications will be on the future of US healthcare. One major change Dr. Stefanacci reviews is the expansion of measurable outcomes through accountable care organizations and clinically integrated organizations. With the shift from fee-for-service, volume-based reimbursement to pay-for-performance reimbursement, LTC providers will be held accountable for more outcomes than ever before. This will increase the pressure to prevent adverse events, particularly those requiring hospitalization or hospital readmission, and to implement even greater risk management measures. ALTC would like to know your thoughts about this reimbursement shift and whether your facility is implementing more stringent risk mitigation strategies. You can send your thoughts on this topic to our associate editor, Allison Musante, at amusante@hmpcommunications.com, or take our poll online at www.annalsoflongtermcare.com.

Thank you for reading!