As the Obama administration wrestles with how to expand healthcare coverage to the millions of uninsured Americans, some organizations are finding creative ways to help cover employees of small businesses. The programs typically involve collaboration between business owners, nonprofit groups and local hospitals, which offer enrollees a range of medical services at a reduced rate. The plans keep costs down partly by bypassing the extra costs that come with traditional insurance. That can be a big help for small-business employees who can't afford traditional insurance, but for patients with costly chronic diseases or catastrophic illnesses, the coverage would likely be inadequate.
Free pens litter doctors' offices all across New York, part of an often-criticized strategy by drug company sales representatives known as detailers, who traditionally go from waiting room to waiting room giving gifts to entice doctors to prescribe their products. Now in New York City, there is a new kind of detailer: people who are part of a campaign by the city to use pharmaceutical industry marketing savvy to spread the word about healthy practices to doctors in neighborhoods where patients often have the least access to the latest news in healthcare. In the last 10 months, the city has spent nearly $900,000 on half a dozen detailing campaigns, including ones about influenza and pneumococcal vaccine distribution and education, colon and rectal cancer screening and smoking cessation.
Although the illness is difficult to track, health officials estimate that in the United States Clostridium difficile cause 350,000 infections each year in hospitals alone, with tens of thousands more occurring in nursing homes. While the majority of cases are found in healthcare settings, 20% or more may occur in the community. The illness kills an estimated 15,000 to 20,000 people annually. The rate of C. difficile infection among hospital patients doubled from 2001 to 2005, according to an April 2008 report from the CDC.
When it comes to managing pain, long-term care experts say a proactive approach is best—clinicians should anticipate and treat pain before it becomes too intense. However, it seems that many in the long-term care industry have waited for CMS to dial up the pressure before addressing shortcomings in pain management practices.
But the way nursing homes manage pain is about to come under intense scrutiny with the recent release of new pain management guidance and investigative protocols under the survey deficiency tag F309, Quality of Care. Under the new guidance, which CMS released and implemented April 10, surveyors can cite nursing homes that aren't appropriately managing pain with deficiencies.
In the past, nursing facilities were expected to address and manage pain, but nursing homes and surveyors did not have specific guidelines to do so, says Marilyn Mines, RN, BC, RAC-CT, manager of clinical services for FR&R Healthcare Consulting, Inc. in Deerfield, IL.
"Overall, in the industry, it's been felt that pain has been ignored in the geriatric population, and hence, now we have a [survey] protocol that's extremely complex," Mines says.
The new guidance under F309 states that nursing facilities must assess and address pain in all residents, including the cognitively impaired. To comply with F309, nursing facilities need to reexamine how they assess and manage pain in residents, including the use of pain medications, PRN ("as needed") medication regimens, and complimentary and alternative medicine (CAM).
Assessing and treating pain in cognitively impaired residents, who have difficulty communicating pain through statements or commonly-used pain scales, is a major challenge for nursing facilities.
Nursing homes are most likely to underestimate pain in residents with dementia, says Christie Teigland, PhD, director of health informatics and research for the New York Association of Homes and Services for the Aging (NYAHSA) and EQUIP for Quality in Albany, NY.
Even when residents with Alzheimer's disease and dementia have diagnoses known to cause pain, such as arthritis, neuropathies, and joint disease, their pain is reported only about half as often as in cognitively intact residents with similar diagnoses, according to research Teigland presented to the Alzheimer's Association.
Long-term care experts say some other common shortcomings in many nursing facilities' pain management programs include:
Using PRN medications to treat pain when an around-the-clock regimen would be more appropriate
Prescribing PRN medications for cognitively impaired residents who may be unable to communicate pain or ask for medication
Failing to anticipate pain before pain-inducing activities, such as therapy or wound-dressing changes
Dismissing residents' statements of pain based on personal beliefs or attitudes
The good news for nursing facilities may be that the new guidance simply enforces existing clinical practice standards for pain management rather than introducing new standards.
Facilities that address pain with the "nursing process," which involves assessment, problem identification, care planning, implementation, and evaluating outcomes, should be in compliance with F309, says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president of RRS Consulting Services in San Diego.
"Facilities that have been doing this well aren't going to find anything surprising, and they don't have anything to worry about," Shephard says.
Michael Mack, MD, a surgeon on the medical staff of The Heart Hospital Baylor Plano and medical director of cardiovascular surgery for Baylor Health Care System,has been named president-elect of the Society of Thoracic Surgeons. In this role, Mack will provide leadership for the more than 5,600 surgeons, researchers, and allied health professionals worldwide who are members of the Society.
Steve Schelhammer, CEO of Phytel, which develops medical home technology, has joined the Executive Committee of the Patient-Centered Primary Care Collaborative. The PCPCC is a collaboration of employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians, and others that have joined together to develop and advance the patient-centered medical home.