Where Washington is Concerned, AGS Aims High for the Year Ahead

Late last year, the Centers for Medicare and Medicaid Services (CMS) proposed its most comprehensive revision of regulations covering long-term care facilities since 1991. “Reform of Requirements for Long-Term Care (LTC) Facilities” includes proposals on facility responsibilities, comprehensive person-centered care planning, and quality assurance and performance improvement. On the winds of earlier successes to champion important policy transformations, the American Geriatrics Society (AGS) is again leading the way toward great change in policies regarding LTC through the work of an interprofessional panel convened by the Society to offer insights on CMS proposals and ways to improve LTC.

One key concern in the CMS proposal for LTC has been a new requirement for an in-person evaluation of residents by a physician, physician assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital. In its letter to CMS, the AGS expressed concern that this might delay emergency or urgent care and, thus, cause more harm than good. Not all situations are appropriate for prior in-person evaluation when a resident is transferred to a hospital, the AGS noted. If a resident is clearly septic and does not have an advance directive declining hospitalization, for example, healthcare providers should have the option of transferring the resident to a hospital without delays that could be caused by unnecessary assessments. Additionally, a range of factors may impact how quickly a healthcare professional can be made available for conducting an in-person evaluation from one care context to the next. Rural areas often rely on providers who are not centrally located to LTC facilities, for example, and there is no existing evidence that this type of a requirement either improves resident health or decreases costs.

Still, reducing unnecessary hospital transfers remains a high priority for CMS, Medicare beneficiaries, and the AGS collectively. AGS experts suggested several possible solutions that could increase care quality without adding to the complexity of the healthcare system. The AGS supports already ongoing efforts to fund intervention trials that provide facilities with evidence-based approaches for decreasing unnecessary transfers, for example. In addition, with efforts to monitor unplanned hospital admissions already underway, the AGS predicted that facilities will be motivated to develop approaches to improve performance, which may include quality assurance and performance improvements focused on standardized tools to evaluate change in condition. Overall, the AGS recommended that the selection and implementation of approaches to avoid inappropriate transfers be left to facilities within the bounds of good clinical practice.

Other recommendations proffered by the AGS touch both the breadth and scope of proposed revisions to LTC regulations.

Resident Rights. Recognizing the importance of offering older adults access to a range of credentialed healthcare professionals, the AGS recommended clarifying language in the CMS proposal to note that credentialing requirements could be satisfied using either existing internal processes or the services of an outside credentialing organization. 

Facility Responsibilities. The AGS recommended that, in addition to being subject to clinically necessary or reasonable restrictions, open visitation rights also should be subject to a requirement that they not infringe on the privacy of other residents.

Freedom from Abuse, Neglect, and Exploitation. The AGS suggested expanding current employment prohibitions to include licensed professionals facing disciplinary action for abuse, neglect, or mistreatment of any elderly individual, not just a resident of a LTC facility as originally proposed.

Transitions of Care. The AGS agreed with CMS proposals underscoring the importance of effective communication between providers during care transitions. However, the AGS noted a lack of clarity on the overall scope of new care transition requirements, particularly with regard to whether new requirements apply “only to non-urgent, planned situations” or also to “emergency and urgent transfers…[such as when] a patient needs immediate surgery or evaluation…”

Finalized LTC regulations are expected later in 2016 and should feature prominently in discussions at the 2016 AGS Annual Scientific Meeting (May 19–21; Long Beach, CA), a premier educational event and a seminal reference point on policy updates for the year ahead. Registration is now open at: https://www.americangeriatrics.org.