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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Practical and compassionate approaches to providing quality care and safeguarding quality of life
The second edition of Managing the Long-Term Care Facility: Practical Approaches to Providing Quality Care updates the first edition’s discussion of the operational requirements necessary to manage a skilled nursing facility. This book presents sensitive and empathic regulatory compliant methods for the delivery of care that fosters an empowering environment for all stakeholders. Additional new information includes aging in place, trauma-informed care, ethical dilemmas and collaborative decision-making, workforce culture, and surveys, enforcement actions, and appeals. The pedagogical tools include chapter summaries with quiz questions and case studies. Instructors also have access to PowerPoint slides and test banks.
This book is an excellent resource for students and individuals interested in working in long-term care and other health care industries. The updated best practices for clinical and non-clinical roles within the facility and material on resident advocacy and other important topics provide valuable information for the reader. Working professionals can benefit from the emphasis placed on practical approaches to facilitate person-centered and whole person care and a facility’s sustainability.
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Veröffentlichungsjahr: 2025
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Table of Contents
COVER
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT PAGE
DEDICATION
ABOUT THE CONTRIBUTORS
FOREWORD
Reference
PREFACE
ACKNOWLEDGMENTS
ABOUT THE COMPANION WEBSITE
INTRODUCTION
Chapter Overviews
Chapter Features
Instructor Support Materials
Reference
CHAPTER 1: LONG‐TERM CARE CONTINUUM
Introduction
Long‐Term Care Continuum
Senior Housing
Summary
Review Questions
Case Studies
Key Terms
References
Acknowledgment
CHAPTER 2: BIOLOGICAL AND PSYCHOSOCIALASPECTS OF AGING
Introduction
Typical Physical Changes
Common Psychosocial Changes
Stages of Cognitive Change
Unique Illness Presentations
Responses to Medication
Assessment and Care Planning
Comfort Care
Summary
Review Questions
Case Study
Key Terms
References
CHAPTER 3: PERSON‐CENTERED CARE
Introduction
Historical Background of Person‐Centered Care
Transforming the Culture of Long‐Term Care Through Person‐Centered Practices
Transforming the Culture of Long‐Term Care Through Reexamining Key Processes
Transforming the Culture of Long‐Term Care Through Quality Improvement
Summary
Review Questions
Case Study
Case Study Discussion Questions
Key Terms
References
Acknowledgments
CHAPTER 4: TRAUMA‐INFORMED CARE
Introduction
Understanding Psychological Trauma
Trauma‐Informed Long‐Term Care for Residents
Staff Training and Coaching
When There Are Medically Unexplained Symptoms
When There Is Cognitive Impairment and/or Psychiatric Comorbidities
Trauma‐Informed Long‐Term Care for Staff
Trauma‐Informed Long‐Term Care Organizations
Creating a Culture of Trauma‐Informed Care
Summary
Review Questions
Case Study
Key Terms
References
CHAPTER 5: RESIDENT ADVOCATES AND DIVERSITY
Introduction
Quality Assurance and Performance Improvement
Resident Council
Family and Friends
Participation in Family Councils
Advocacy and Dementia Care
Diversity
Advocacy Organizations
National Long‐Term Care Ombudsman Program
National Consumer Voice for Quality Long‐Term Care (Consumer Voice)
The National Long‐Term Care Ombudsman Resource Center
The Center for Medicare Advocacy
Justice in Aging
The National Association of State Long‐Term Care Ombudsman Programs
Paraprofessional Health Care Institute
Service Employees International Union
National Disability Rights Network
California Advocates for Nursing Home Reform and the Long‐Term Care Community Coalition
The Role of Philanthropy
Summary
Review Questions
Case Studies
Key Terms
References
Acknowledgment
CHAPTER 6: PHYSICAL ENVIRONMENT OF LONG‐TERM CARE
Introduction
History of LTC Design in the United States
The Medical Model of Aged Care
Resident‐Centered Care Model
Development of Contemporary LTC Environments
Technology in LTCs
Building Code Requirements
Regulatory Agencies
Occupational Safety and Health Administration
Preventative Maintenance Programs
Infection Control Programs
Emergency Preparedness
Survey Process
Aging in Place
Summary
Review Questions
Case Studies
Key Terms
References
CHAPTER 7: TRANSITIONS OF CARE
Introduction
Communication During Transitions of Care
Bedside Assessments
Impacting Resident Experience
Preadmission Record Review
Interdisciplinary Assessments and Progress Notes
Consultations
Diagnostic Imaging
Laboratory Tests
Evidence of Being Free of Tuberculosis
Readmission Risk Profiling
Preadmission Screening and Resident Review
Admission Orders
Resident Admission Agreement
Transition Processes
Planning Around Social Determinants of Health
Transitions to Community Settings
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgments
CHAPTER 8: RESIDENT‐CENTERED CLINICAL OPERATIONS
Introduction
Clinical Operations
Facility Admission Process
Rehabilitation
Documentation
Summarizing Event Entry
Resident, Patient, and Family Education
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgments
CHAPTER 9: ETHICAL DILEMMAS AND COLLABORATIVE DECISION‐MAKING
Introduction
The Challenges of Implementing Shared Decision‐Making in an LTC Environment
Balancing Business Interests and Ethical Obligations
Practical Solutions to Complicated Problems
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgment
CHAPTER 10: FACILITY‐CENTERED CLINICAL OPERATIONS
Introduction
Daily Operations
24‐Hour Chart Check
24‐Hour Report
Part II Clinical Review
Weekly Operations
Monthly Operations
Quarterly Operations
Challenges with Electronic Medical Records
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgments
CHAPTER 11: TECHNOLOGY AND DATA‐DRIVEN HEALTH CARE
Introduction
Health Information Technology Applications
Advantages of Health Information Technology Use in Long‐Term Care
Disadvantages of Health Information Technology Use in Long‐Term Care
Implementation and Conversion to Health Information Technology
Summary
Review Questions
Case Studies
Key Terms
References
Acknowledgment
CHAPTER 12: RESIDENT ASSESSMENT INSTRUMENT
Introduction
Resident Assessment Instrument
Minimum Data Set
Care Area Assessment
Care Plan
Care Plan Conference
Quality Reporting
Quality Measure Reporting Venues
Summary
Review Questions
Case Studies
Key Terms
References
Acknowledgments
CHAPTER 13: QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) AND QUALITY ASSESSMENT AND ASSURANCE (QAA)
Introduction
QAPI Overview
The QAPI Program
Summary
Review Questions
Case Studies
Key Terms
References
Resources
Acknowledgments
CHAPTER 14: SURVEYS, ENFORCEMENT ACTIONS, AND APPEALS
Introduction
Surveys
Federal Tag
Five‐Star Quality Rating System
CMS Care Compare Website
Special Focus Facilities
COVID‐19’s Impact on Surveys
Enforcement Actions
Civil Money Penalties
Termination from the Medicare Program
Imposition of Temporary Manager
Denial of Payment for All New Admissions
Directed In‐Services
Directed Plan of Correction
Loss of Nurse Aide Training and Competency Program
Informal Dispute Resolution and Independent Informal Dispute Resolution
Is IIDR a Better Choice?
Notices
Formal Legal Appeals
Administrative Law Judge
Departmental Appeals Board
Federal Courts
Surveys Challenged
Survey Reform?
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgments
CHAPTER 15: HUMAN RESOURCES
Introduction
Core Human Resources Functions in Long‐Term Care
Training
Corrective and Disciplinary Action
Workforce Planning
Compensation and Benefits
Legal Rights and Benefits
Union Organization
Americans with Disabilities Act
Recordkeeping and Retention
Summary
Review Questions
Case Studies
Key Terms
References
Acknowledgment
CHAPTER 16: WORKFORCE CULTURE
Introduction
The Long‐Term Care Environment
Inherent Challenges
A Culture of Excellence
Workforce
Strategies
Work–Life Balance
Results
Family Members
Summary
Review Questions
Case Study
Key Terms
References
Acknowledgments
CHAPTER 17: MARKETING AND PUBLIC RELATIONS
Introduction
Assessing Local Demand for Long‐Term Care Services
Public Perceptions and Public Relations
Customers and Their Needs
Competition
Marketing Approaches
Public and Private Oversight of Long‐Term Care Services Providers
Customer Services and Retention
Marketing Plan
Summary
Review Questions
Case Studies
Case Study Review Questions
Key Terms
References
Acknowledgment
CHAPTER 18: FACILITY REIMBURSEMENT
Introduction
Payment Models: Government Programs
Payment Models: Managed Care
Payment Models: Shared Risk
Payment Models: Private Pay
Payment Models: Long‐Term Care Insurance Plans
Payment Models: Supplemental Insurance Plans
Reimbursement Methods
Resident‐Related Items
Summary
Case Study
Review Questions
Key Terms
References
CHAPTER 19: FINANCIAL OPERATIONS
Introduction
Financial Issues and Financial Tools
Budget Development
Revenue Enhancement
Summary
Case Study
Review Questions
Key Terms
References
CHAPTER 20: LEGAL CONSIDERATIONS
Introduction
Legal Responsibilities
Agencies
Principal Areas of Focus
Practical Solutions to Complicated Problems
Summary
Review Questions
Case Study
Key Terms
References
CHAPTER 21: COMPLIANCE AND RISK MANAGEMENT
Introduction
Compliance: LTC Regulatory Oversight
Long‐Term Care Service
Accountability Tools
Primary Risk Areas
Corporate Compliance Program
Risk Management
Summary
Review Questions
Case Studies
Key Terms
REFERENCES
CHAPTER 22: LOOKING AHEAD
Introduction
Long‐Term Care and Public Policy
Landmark US Legislation Relevant to LTC
International LTC Financing Policies
Future Trends of LTC
Summary
Review Questions
Case Study
Key Terms
References
INDEX
END USER LICENSE AGREEMENT
List of Tables
Chapter 6
Table 6.1 Physical Environment Comparison: Models of Care
Table 6.2 Operational Comparison: Models of Care
Chapter 11
Table 11.1 Meaningful Use Requirements
Table 11.2 Applications and Potential Benefits of HIT
Chapter 16
Table 16.1 Direct care worker demographic changes from 2009 to 2019 by gend...
Table 16.2
Demographic data for staff composition in 2021
Table 16.3
Education attainment in 2021
Table 16.4
Number of jobs held at one time
Table 16.5 Largest occupation type in 2021
Chapter 17
Table 17.1 Marketing Challenges for Different Types of Long‐Term Care Servi...
Table 17.2 Words and Terms to Lose and Use
Table 17.3 Nursing Home Myths and Realities
Table 17.4 Marketing Activities for Long‐Term Services
List of Illustrations
Chapter 1
Figure 1.1 The LTC continuum.
Figure 1.2 Our Healthy Together Care Partnership
Figure 1.3 SNF organizational chart.
Chapter 2
Figure 2.1 Healthy Skin–lightly pigmented
Figure 2.2 Stage 1 Pressure Injury
Figure 2.5 Stage 4 Pressure Injury
Chapter 3
Figure 3.1 Core motivational interviewing skills
Chapter 4
Figure 4.1 ACE score prevalence
Figure 4.2 Components of trauma‐informed care in long‐term care
Figure 4.3 Universal, trauma‐specific, and person‐centered precautions
Figure 4.4 Generalists and specialists in trauma‐informed care for long‐term...
Chapter 6
Figure 6.1 Monastic hospital concept floor plan
Figure 6.2 Civil War–era hospital concept floor plan
Figure 6.3 Post–Civil War hospital concept floor plan—Beginning of a traditi...
Figure 6.4 Exploded corridor concept floor plan
Figure 6.5 Divided household concept floor plan
Figure 6.6 Short‐corridor household concept floor plan
Figure 6.7 Hearth household concept floor plan
Figure 6.8 Hybrid household concept floor plan
Chapter 8
Figure 8.1 Sample care plan for pain
Chapter 9
Figure 9.1 The four Cs, a framing tool for ethical analysis of patient right...
Figure 9.2 Appelbaum’s (2007) approach to assessment of patient capacity.
Figure 9.3 Four core principles of bioethics (Beauchamp & Childress, 2019)....
Figure 9.4 Functional Assessment Staging Test
Figure 9.5 Margot Bentley
Figure 9.6 Nora Harris
Figure 9.7 Letter from Kendal Counsel
Figure 9.8 Triggers for regulatory action
Chapter 13
Figure 13.1 Bowling chart with red (dark gray) and green (light gray) marker...
Figure 13.2 Run chart of complaints data
Figure 13.3 Upward trend
Figure 13.4 Downward trend
Figure 13.5 Run chart, no trend
Figure 13.6 Run chart with a clump of eight indicating special cause
Figure 13.7 Control chart with common cause limits
Figure 13.8 Pareto matrix of falls data
Figure 13.9 Pareto matrix of falls data with Highlights
Chapter 14
Figure 14.1 Scope Severity Grid
Chapter 17
Figure 17.1 Hospital revenue by payer contribution in the US, 2020
Figure 17.2 Sample prospect registration form
Chapter 18
Figure 18.1 Petty cash form
Chapter 19
Figure 19.1 Budget example
Figure 19.2 Gross revenue calculation
Figure 19.3 Profit/loss calculations
Figure 19.4 Maximum annual units of service
Figure 19.5 Physical therapy revenue enhancement model
Figure 19.6 Physical therapy revenue enhancement model 2
Chapter 20
Figure 20.1 Comparison of AKS to Stark
Chapter 21
Figure 21.1 Quality assurance incident reports
Figure 21.2 Incident Investigation
Guide
COVER PAGE
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT PAGE
DEDICATION PAGE
ABOUT THE CONTRIBUTORS
FOREWORD
PREFACE
ACKNOWLEDGMENTS
ABOUT THE COMPANION WEBSITE
INTRODUCTION
BEGIN READING
INDEX
WILEY END USER LICENSE AGREEMENT
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MANAGING THE LONG‐TERM CARE FACILITY
PRACTICAL APPROACHES TO PROVIDING QUALITY CARE
Second Edition
EDITED BY
Rebecca M. Perley
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
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Library of Congress Cataloging‐in‐Publication Data Applied for:
Paperback ISBN: 9781119677161
Cover Design: WileyCover Image: © Cavan/Adobe Stock Photos
DEDICATION
To the current and future health care providers seeking to bring comfort and peace to those in need.
ABOUT THE CONTRIBUTORS
Andrew Lee Alden, M.Arch., is senior associate and senior project designer with AG Architecture in Wauwatosa, Wisconsin. His commitment to designing for an aging population began early, influenced by his extensive family. With over 25 years in architecture, Alden focuses on creating innovative, resident‐centered environments spanning the continuum of care. He supports the future of senior living as an active member of local and national organizations dedicated to improving the lives of older adults. Alden also emphasizes the value of linking research and practice, teaching, conducting post‐occupancy evaluations, publishing articles, and presenting at conferences.
Jeffrey W. Anderzhon, FAIA, is principal of Crepidoma Consulting, specializing in environmental designs for the aging. He holds a BArch degree from Illinois Institute of Technology, where he received the Alumni Professional Achievement Award in 2008. Anderzhon is a member of the American Institute of Architects College of Fellows, past chair for Design for Aging Knowledge Community, and coauthor of Design for Aging, Post‐occupancy Evaluations and Design for Aging, International Case Studies of Building and Program, along with numerous articles on environments for the elderly. He has served on numerous design juries in the United States as well as internationally and is a board of directors member of the Society for the Advancement of Gerontological Environments Federation.
Alex Bardakh, MPP, CAE, PLC, serves as senior director of advocacy and strategic partnerships at AMDA – Post‐Acute and Long‐Term Care Medical Association. He spearheads the organization's public policy agenda through congressional advocacy and engagement with federal agencies. Bardakh graduated from University of Maryland, Baltimore County, with a bachelor’s in political science and psychology and a master's in public and legal policy. He is a recognized industry thought leader and represents the organization in various coalitions and industry partnerships. With extensive experience in specialty society executive leadership, Bardakh focuses on advocacy and strategic growth. He is a certified association executive (CAE), is certified in nonprofit financial management, and holds a Professional Lobbying Certificate.
Michael Carter, OT, is a retired occupational therapist (OT), having built a career in an inpatient rehabilitation hospital. His OT training encouraged a deep interest in accessible housing to maintain independence. Prior to his OT career, he worked in commercial and residential construction. This background experience allowed him to plan meaningful changes to patients living environment. He also worked with the Center for Universal Design at North Carolina State University to bring an OT perspective to architecture students concerning the diversity of human abilities and disabilities. Carter also worked for the University of Southern California as an online instructor with the executive certificate in home modification program.
Carla Cheatham, Rev., PhD, MA, began in psychosocial services with a master’s in psychology, certification in trauma therapy, a doctorate in health and kinesiology, and a master of divinity before working 10 years as a hospice chaplain and grief counselor. Cheatham is a national keynote speaker and consultant focusing on emotionally intelligent and resilient professionals and organizations. She is a member of the National Hospice and Palliative Care Organization’s (NHPCO) Trauma‐Informed Care Task Force, former chair of NHPCO’s ethics advisory council, and assistant professor for University of Maryland’s master of science in palliative care. She publishes books and videos about resilience, posttraumatic growth, ethics, grief, healthy leadership, and other emotional competencies for professionals.
David D. Clarke, MD, is president of the Psychophysiologic Disorders Association (EndChronicPain.org), assistant director at the Center for Ethics, and clinical assistant professor of gastroenterology emeritus at Oregon Health & Science University in Portland. He is board certified in gastroenterology and internal medicine and has treated over 7,000 patients whose symptoms were not explained by organ disease or injury but rather by stress or trauma. His book for patients, They Can’t Find Anything Wrong!, was praised by a president of the American Psychosomatic Society as “truly remarkable.” He has also edited two textbooks on trauma‐informed care.
Deborah K. Cruze, JD, MA, currently serves as bioethics director for Kaiser Permanente Riverside Service area. Throughout her 20+ years in bioethics, she has been a frequent presenter and author of topics at the intersection of law and bioethics. Additionally, Cruze has served as adjunct faculty for several colleges and universities, teaching bioethics, law, and business management courses. She holds a bachelor of science in English and political science (summa cum laude) from Northern Arizona University, a juris doctorate from Arizona State University, and master of arts in Bioethics from Midwestern University, where she was awarded the Outstanding Achievement Award in Bioethics. She completed a post‐doc clinical ethics fellowship at the University of Texas M.D. Anderson Cancer Center. A member of the Arizona Bar, she previously served the legal profession as assistant attorney general and city court judge.
Cindy Donovan BN, MSHA, served remarkably as the long‐time chief executive officer of Loch Lomond Villa in Saint John, New Brunswick (NB). She implemented many positive changes, achieved unprecedented quality improvements, and growth for the organization. Donovan introduced a person‐centered care model, which has transformed long‐term care in NB. Nurse practitioners now work in NB nursing homes, a provincial Radiography on Wheels brings services to patients, and the program Cycling without Age offers residents trishaw rides throughout communities. She also received the Queens Jubilee Medal and the Planetree Visionary Leadership Award for person‐centered care.
Susan M. Duncan, RN, inclusive design specialist, brings more than 40 years of consulting and experience in virtually all facets of accessible and inclusive design. In 1978, she established an interior design consulting firm dedicated to supporting the unique goals and needs of residential, public, and private sector clients. Duncan combined her decades of cross‐disability experiences with teaching. She developed and taught a required course on universal design in housing for Seattle Pacific University in Washington. Duncan was an instructor for the online international Executive Certificate in Home Modification program at the University of Southern California Andrus Gerontology Center.
Alain P. Durocher, PhD, has been working full time in medical bioethics since 2010 and taught philosophy, religious studies, and ethics at Dillard University in New Orleans, Louisiana, for eight years. He completed his PhD at the Graduate Theological Union in Berkeley, California, and a master’s and two bachelor’s degrees from the Université de Montréal, Canada. Durocher is currently the medical bioethics director for Kaiser Permanente, Downey Service Area; codirector of the medical bioethics program for Kaiser Permanente Southern California; and lecturer for the Health Care Management Department at California State University, Long Beach, teaching courses mainly related to health care ethics.
E. Erlyana, MD, PhD, is professor in the Department of Health Care Management at California State University, Long Beach. She worked as a physician for more than seven years before joining the Department in 2009. She received her MD from the University of Atmajaya, Indonesia, and earned her PhD in public administration (with a concentration in health service administration) from the University of Southern California, Los Angeles. Her research interests include access to care for underserved populations, social determinants of health care utilization, disparities in health, and comparative health systems.
Barbara Ganzel, PhD, LCSW, has more than 25 years of experience studying the impact of psychological trauma on brain, body, and behavior as a research neuroscientist, hospice‐trained social worker, and trauma therapist. She has been the principal investigator of a neuroimaging research laboratory at Cornell University, director of the Ithaca College Gerontology Institute, and was a founding member of the National Hospice and Palliative Care Organization’s (NHPCO) Trauma‐Informed Care Workgroup. She has published in Psychological Review, Journal of the American Medical Association, American Journal of Psychiatry, The Gerontologist, NeuroImage, Psychology and Aging, and the Journal of Traumatic Stress, among others.
Robyn Grant, MSW, served as director of public policy and advocacy at the National Consumer Voice for Quality Long‐Term Care, where she was responsible for the development and implementation of the public policy agenda. Grant has a master’s in social work with a specialization in aging. Before joining Consumer Voice, she was the long‐term care policy director at United Senior Action, an Indiana senior advocacy organization, a consultant with the National Long‐Term Care Ombudsman Resource Center, and a member of the Consumer Voice Board of Directors. Grant was the Indiana State Long‐Term Care Ombudsman for eight years and president of the National Association of State Long‐Term Care Ombudsman Programs for two terms. She retired in July 2022.
Melvin Hector, MD, FAAFP, CMD, CAQ in Geriatrics, CMD, is a family physician with fellowship training in geriatrics and over four decades of experience. His work in Tucson, Arizona, continues in the care and management of geriatric patients as clinical associate professor in the Department of Geriatrics, General Internal Medicine, and Palliative Care at the University of Arizona.
Paige Hector, LMSW, is a consultant and nationally recognized speaker with over 25 years’ experience in post‐acute and long‐term care settings. She excels at transforming complex issues into strategies for immediate application with diverse topics for the interdisciplinary team, person‐centered trauma informed care, Nonviolent Communication, and sustainable process improvement. Hector serves on the editorial advisory board for Caring for the Ages, the publication for the Post‐Acute and Long‐Term Care Medical Association (PALTMed). Hector is actively involved in the PALTMed Education Committee and the Diversity, Equity, and Inclusion Workgroup. Hector is a Nonviolent Communication Certification Candidate with the Center for Nonviolent Communication.
David N. Hoffman, JD, is a health care lawyer and clinical ethicist in New York, where he is assistant professor of professional practice in bioethics in the Columbia University bioethics master’s and certificate program. He is also clinical assistant professor at the Albert Einstein College of Medicine. Hoffman serves as chief compliance officer and general counsel for Claxton Hepburn Medical Center and as clinical ethics consultant to the VNS Health Hospice program ethics committee. Hoffman has provided counsel to hospitals, medical facilities, and individual practitioners in governance, mergers, affiliations, medical litigation, bioethical decision making, and regulatory matters. He has also served on and advises ethics committees and institutional review boards.
Alan C. Horowitz, JD, is Of Counsel at Arnall Golden Gregory and successfully represents nursing facilities in matters involving the Centers for Medicare and Medicaid Services (CMS). Previously, Horowitz represented CMS as assistant regional counsel at the United States Department of Health and Human Services’ Office of the General Counsel. Additionally, he served as the director of clinical and legal affairs for the Institute for Safe Medication Practices and was acting director of ECRI Institute’s National Center for Independent Medical Review. Horowitz has written over 75 articles regarding health law and has been a frequent presenter at national and state forums regarding health law.
Abby Swanson Kazley, PhD, currently serves as program director in the master of science in health informatics program at the Medical University of South Carolina. Her research examines the relationships between hospital health information technology use and cost, quality, and efficiency by examining electronic medical record and computerized provider order entry use and telemedicine. An award‐winning teacher, Kazley has expertise in the area of management and strategic management and teaches courses in the master of health administration and master of health informatics programs. Kazley earned a PhD in health services organization and research from Virginia Commonwealth University in 2006 and has published more than 60 peer‐reviewed research articles.
Jim Kinsey, FPCC, PLCC, CDP, has an extensive background in facilitating change with health care organizations across the continuum of care. With a focus on person‐centered care, equity, and honoring individuals' preferences, Kinsey has been part of transforming health care organizations of all sizes around the globe. A skilled facilitator, he can engage participants in a journey that makes them deeply feel the importance of their work. Kinsey is also a skilled content development professional, designing workshops, individual presentations, and educational materials that engage staff around person‐centered care, health care equity, diversity, and belonging.
Ronke Komolafe, DBH, MBA, excels in the convergence of mental and physical health care, emphasizing regulatory affairs, operations, and policy innovation. With an incisive focus on social determinants of health, she has been pivotal in shaping and implementing health policies that foster integrated care models. Her career is marked by significant contributions to operational excellence and the crafting of regulatory frameworks that enhance service delivery. Komolafe's work not only aligns with but also advances best practices and legislative guidelines, ensuring comprehensive, equitable health solutions in complex care environments. Komolafe earned her doctorate in behavioral health from Arizona State University.
Nancy Kusmaul, PhD, MSW, is an associate professor in the baccalaureate social work program at the University of Maryland, Baltimore County. She earned her PhD from the University at Buffalo and her MSW from the University of Michigan. She was a nursing home social worker for a decade. Her research explores organizational culture, trauma‐informed care, and the impact of trauma on workers and care recipients. She is a fellow of the Gerontological Society of America fellow and was a 2019–2020 Health and Aging Policy Fellow. She has done podcasts on aging, trauma, and nursing homes on various platforms.
Christopher Laxton is an association professional with over 40 years’ experience in long‐term care, policy, and leadership. Laxton was executive director of AMDA – Post‐Acute and Long‐Term Care Medical Association from 2013 until his retirement in May 2023. He is now an independent consultant in aging. Laxton volunteers as vice chair of the Center for Excellence in Assisted Living, now CEAL@UNC, a program of the University of North Carolina; the Moving Forward Coalition; the Advancing Excellence in Long‐Term Care Collaborative; and the Board of Overseers for the American Health Care Association’s Baldrige‐based National Quality Award. He lives in Portland, Oregon.
Adrienne Lindsey, DBH, MA, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center in San Antonio. Lindsey serves as director of the Center for Substance Use Training and Telementoring. She holds a master’s in psychology from Northwest University and a doctoral degree in integrated behavioral health from Arizona State University. Her areas of expertise include motivational interviewing; screening, brief intervention, and referral to treatment (SBIRT); and integrated care. Lindsey has over 15 years of experience training providers in motivational interviewing and other patient‐centered care modalities.
Ken Merchant is a workforce development and education consultant who works with the long‐term health care industry. From 1999 to 2005, he ran the education arm of the California Association of Health Facilities, developing training programs and managing over $12 million in workforce training programs. From 2011 to 2017 he was chief operating officer of the College of Medical Arts, a chain of private postsecondary schools that specialized in training nursing home workers. He is a graduate of the University of California, Davis, is an Army veteran, and served on the California Board of Vocational Nursing and Psychiatric Technicians.
Robert J. Miller, PhD, has over 33 years experience in health care systems development and administration in the private and public sectors. He joined Arizona Emergency Medical Systems in 1981. While there, he implemented the state’s first standardized emergency department patient record system facilitating data collection for categorizing hospitals’ emergency capabilities. Dr. Miller served in a variety of C‐level and consulting positions, including the Agency for International Development in Costa Rica. He received his PhD from Arizona State University in biological anthropology and currently serves as adjunct faculty in the Department of Social and Cultural Sciences at Mesa Community College.
Sarah Moser, RA, EDAC, is a licensed architect who, after nine years of practicing health care design and medical planning, transitioned into the role of training and coaching strategist at Page, a 1,400‐person interdisciplinary design firm. Moser is focused on coaching project and pursuit teams and facilitating human skills, emotional intelligence, leadership, and team effectiveness training sessions. She is an EQ‐i 2.0 certified practitioner and a volunteer facilitator with Ripple Intent, a nonprofit organization dedicated to making work better for the architecture, engineering, and construction community through self‐awareness and interpersonal connection.
Arif Nazir, MD, currently serves as chief medical officer for Abode Care Partners, a large provider of primary care services to frail and older people across various settings. As past president for AMDA – Post‐Acute and Long‐Term Care Medical Association and cochair of AMDA’s Drive to Deprescribe initiative, he has positively influenced systems of care for skilled nursing facilities in the country. Nazir’s work led him to win the Distinguished William Dodd Award for AMDA in 2023. As a health care leader and an implementation champion, he continues his efforts on finding practical solutions for serious care gaps.
Rebecca M. Perley, DBH, MSHCA, LNHA, earned her doctorate in behavioral health at Arizona State University. She is assistant professor at California State University, Long Beach, and a licensed California nursing home administrator. Her work experience includes collaboration with residents, families, and health care staff to achieve improved care delivery in skilled nursing facilities. Perley’s lecture topics and research interests include ways that trauma‐ informed care improves whole‐person care and how care delivery, regulatory oversight, behavioral health, and continuous quality improvement can assist in achieving the Quadruple Aim goals and a person’s ability to age in place.
Suzanne Richards, RN, MPH, MBA, FACHE, is currently a health care consultant along with owning and operating home care companies and care coordination call centers in California and Nevada along with an ambulatory surgery center in California. Prior to becoming an entrepreneur, Richards worked over 30 years in hospital executive management in various roles as chief executive officer and chief clinical officer for hospitals. She holds many certifications and fellowships in health care. Richards is an instructor at California State University, Long Beach, for the master’s program in health care management. She is an accomplished health care executive with a diverse background in management and direct patient care.
Martin Smalbrugge, PhD, MD, earned his earned his PhD in elderly care medicine at the VU University Medical Center (UMC) in Amsterdam and his MD at State University Utrecht. He is professor of medicine and head of the Department of Medicine for Older People at Amsterdam UMC. His research focuses on neuropsychological symptoms of dementia, end‐of‐life care, quality of care for patients with dementia, and infections in long‐term care. He serves as associate editor of Journal of the American Medical Directors Association.
Karl Steinberg, MD CMD HMDC HEC‐C, has been a California nursing home and hospice medical director since 1995. He is a past president of AMDA – Post‐Acute and Long‐Term Care Medical Association, the California Association of Long‐Term Care Medicine (CALTCM), and the National POLST Collaborative; delegate to the American Medical Association's House of Delegates; and chair of the California Medical Association's Council on Ethical, Legal, and Judicial Affairs. Steinberg got his bachelor's from Harvard College and his MD from The Ohio State University, then did his family medicine residency at University of California, San Diego. He is board certified in family medicine and in hospice and palliative medicine and has certifications as a health care ethics consultant (HEC‐C) and as a nursing home (CMD) and hospice (HMDC) medical director. Steinberg also is an associate editor of JAMDA ‐ The Journal of Post‐Acute and Long‐Term Care Medicine and hosts two podcasts for AMDA: JAMDA‐on‐the‐Go and Caring‐on‐the‐Go.
Lovella D. Sullivan, MBA, earned her degree in marketing from South University and is currently a health care leader in managed care with more than 1.5 million members in Southern California. She owns Marketing Solutions, a marketing consulting agency, and has more than 25 years in marketing, 17 of which are in health care. Her experience includes more than 27 years in leadership and team development. Sullivan also serves on multiple boards such as the March of Dimes and the Leukemia and Lymphoma Society and has served as guest lecturer for several management course professors at the California State University, Long Beach.
Sonja M. Talley, MA, SHRM‐SCP/SPHR, is a certified human resources (HR) professional with over 30 years HR experience, including 20 in executive leadership. She is the principal owner of CORE HR Solutions, LLC, and provides consulting services across all areas of HR. Talley serves on the Arizona Society for Human Resources Management State Council as strategic alliance director and is president of Arizona Industry Liaison Group. She advocates for employee wellness through her work with Ignite Yoga Foundation, serving healthcare, veterans, and Title I schools in Arizona. Talley’s education includes a BA in business administration and MA in human resources management. Her doctoral studies (ABD) provide insight into generational work value differences based on national culture.
Joel VanEaton, BSN, RN, RAC‐CT, RAC‐CTA, MT, MTA, is executive vice president of the Post Acute Care (PAC) Regulatory Affairs and Education for Broad River Rehab. He began his career in long‐term care as a minimum data set (MDS) coordinator and worked for many years as director of clinical reimbursement and the resident assessment instrument for a group of nursing facilities across the southeast. VanEaton contributes monthly to McKnight’s LTC News. He also serves on the American Association of Post‐Acute Care Nursing (AAPACN) Expert Advisory Panel and as president of the AAPACN Education Foundation board. VanEaton is an AAPACN certified advanced master teacher and presents regularly on state and federal regulation, the MDS, and clinical reimbursement.
Nancy Wexler, DBH, MPH, is program officer at the John A. Hartford Foundation. She has more than 16 years of experience in developing and managing integrated care delivery and population health models aimed at improving the quality, value, and experience of care. Prior to joining the foundation, Wexler served as director of innovation and collaborative care for Banner University Health Plans, where she developed care programs for older adults with complex needs and created alternative payment models and payer–provider partnerships. She is also faculty associate at Arizona State’s College of Health Solutions doctoral program in integrated care.
Barbara White, DrPH, RN, is emerita associate professor of nursing at California State University Long Beach with specialization as an adult/gerontological nurse practitioner; previous director of the gerontology program that offers a minor, certificate, and master of science degree; and former director of the Osher Lifelong Learning Institute on campus. She has also been a director of nursing in a long‐term care setting. White has a doctorate in public health with a focus on health promotion/disease prevention. She coauthored two textbooks: The Nurse Practitioner in Long Term Care: Guidelines for Clinical Practice and Critical Care Assessment Handbook, which includes geriatric care considerations.
Cory W. Woods, DNP, MHA, MSN, RN, is chief population health, payer strategy, and clinical programming officer for Rockport Healthcare Services. Over the past decade, Woods has supported the clinical transformation and care delivery redesign within the skilled nursing industry. As an accomplished clinician, he has also supported clinical teams across the country through clinical specialty program development focused on providing a patient‐centered, outcome‐driven approach to high‐quality care in an evidence‐based way. Woods earned his doctorate in nursing practice from Capella University in Minneapolis, Minnesota, and continues to mentor future nursing students to achieve clinical success and professional growth.
Ann Wyatt, MSW, currently works to promote and implement palliative care practices for people living with advanced dementia. With support from the Ella Lyman Cabot Trust, she recently visited programs and researchers involved in palliative care for this population in Scotland, the Netherlands, Sweden, and Finland. She has an MSW, has been a nursing home administrator, and helped found the National Citizens’ Coalition for Nursing Home Reform (now The National Consumer Voice), the Village Nursing Home, Inc., and Music and Memory, Inc. (the iPod project). She is a current board member of the Coalition for the Institutionalized Age and Disabled (CIAD), Isabella Center in the MJHS Health System, and Music & Memory.
FOREWORD
Why is post‐acute and long‐term care (PALTC) so important? The late Vice President Hubert Humphrey once said, “The moral test of a society is how it treats those in the dawn of life—its children; those in the twilight—the elderly; and those in the shadow of life—the sick, the needy and the handicapped.” At its core, this is the true measure of success for PALTC. Our work is a calling we can respond to thoughtfully, and this book will be a helpful guide in that. Our seniors, residents, and patients in PALTC deserve no less, and to respond well in these dynamic times is a legacy we can be most proud of
Leaders in PALTC will welcome the publication of this second edition of Managing the Long‐Term Care Facility: Practical Approaches to Providing Quality Care. Not only does this updated and expanded resource provide a useful guide for PALTC leadership and operations; it is also a comprehensive overview of modern nursing home operations.
While those who work in this field are aware of the dynamic nature of PALTC, this second edition, when compared with the first, demonstrates how much the field has changed and grown in complexity over a relatively short period of time. This is broadly reflective of trends in PALTC generally, both at the macro and the micro level. For example, this second edition has a much heavier focus on person‐centered care and acknowledges the growing population of people living with dementia, along with the need for much more robust and consistent advance care planning and end‐of‐life goal setting. There is a new chapter on trauma‐informed care and, importantly, a much‐needed new chapter focused on transitions of care. Additionally, there is a new chapter on strategies human resources can utilize to create a culture of excellence in patient care. This edition features an expanded focus on health information technology, not simply electronic health record (EHR) systems but also telehealth, artificial intelligence, assistive devices, medication dispensing systems, and the growing use and prevalence of mobile devices in PALTC. There is an expanded focus on the survey process, and a much deeper dive into quality assurance and performance improvement (QAPI).
Given the growing number of seniors seeking health care today and into the future, some key challenges will have to be addressed sooner rather than later. In particular, are adequate resources available to take care of older, sicker patients, who may be expected to live longer and with more acute health care needs than previous generations? Also, how are we to make PALTC an attractive career choice for frontline staff and the entire clinical team? What leadership and clinical competencies are needed to empower our team members to practice up to their full scope, to better manage patients in these facilities? These are just some of the vexing questions that need to be answered soon to have a sustainable path forward for provision of quality care in PALTC.
Still to be determined, but worth paying close attention to, is the growing role of innovation and technology in PALTC. Smart incorporation of innovations is a must to ensure that we are not adding to the health care team’s burnout and frustration. How will care processes, workflow, financial, and risk management be affected by the increasing use of big data sets and artificial intelligence in patient assessment, diagnosis, and treatment? How can we deploy robotic innovations in ways that minimize the burden of workload for the staff, freeing them up for spending more time with the residents and patients?
Speaking of innovation, the mushrooming penetration and specialization of telehealth and remote patient monitoring services will continue to be disruptive. Projected to surpass $25 billion by 2025, administrators will have to adapt, and strategically implement, effective telehealth and tech‐enabled models (Committee for a Responsible Federal Budget, 2022). New value‐based and care‐coordination mandates by Centers for Medicare and Medicaid Services (CMS) challenge PALTC providers to design outside‐the‐box collaborative care models, including telehealth.
Regardless of possible solutions, it is clear from even a casual observation of these changes that PALTC is now one of the most complex and challenging healthcare settings in the United States and the world. Consider these top‐line characteristics of our setting:
Our dedicated practitioners and frontline staff care for a medically complex, frail, and most often older patient population that requires clinicians to understand the care requirements of multimorbidity and polypharmacy, clear end‐of‐life goal setting, and to be assertively engaged in good transitions of care across the wide spectrum
1
of health care settings.
These care requirements alone mean that PALTC clinicians urgently require specialized training if they are to manage their patients well in their nursing homes and other care communities and prevent avoidable hospital admissions. This training is not part of the regular physician or nursing curricula, yet many practitioners and even medical directors come into our setting without any PALTC specific preparation.
The nursing home regulatory framework is highly burdensome, punitive, and backward‐looking. The federal nursing home regulations have not kept pace with the ongoing changes in PALTC and now represent a clear and present obstacle to innovation. Nonetheless, full compliance with the Nursing Home Requirements of Participation, and the community’s resulting five‐star score on Nursing Home Compare, the government‐run nursing home rating system, is critical to success—indeed, to simply remaining in operation.
Staying with PALTC regulatory requirements, home care has its own separate and distinct regulatory structure, and assisted living is not regulated at the federal level, whereas inpatient rehabilitation facilities (IRFs) and long‐term acute care hospitals (LTACHs) are regulated as hospitals. This dizzying array of different and sometimes conflicting regulatory frameworks are well outside the grasp of most patients, families, and sometimes the medical teams, and they add to the challenges of helping consumers understand their care choices and the consequences of those choices.
The pandemic added more visibility into the glaring gaps that exists to meet the increasingly intense health care needs of residents and patients, and the infrastructure, capabilities, and capacity of most nursing homes. Clinical teams in skilled nursing take care of hospital‐level patients and residents but lack the equipment, labs, pharmacy, and consultants, commonplace in hospitals, including IRFs and LTACHs. The National Academies of Sciences, Engineering, and Medicine has put forth refreshing ideas and recommendations that aim to address these gaps, but it remains to be seen how successful the efforts of the Moving Forward Nursing Home Quality Coalition will be in implementing them.
Staffing our PALTC facilities with a well‐trained frontline workforce is an ongoing challenge. Attracting personnel to PALTC is no easy task, given that the work is mentally and physically challenging, often thankless, and does not pay well. Those drawn to PALTC are often mission driven, with a heart for the frail and seniors; yet even with the most engaged and dedicated team members, we see increasing burnout of staff due to regulatory mandates overshadowing meaningful staff–patient interactions.
Last but not least, financing and reimbursement in PALTC is variable and generally inadequate, and payment mechanisms are constantly in flux as CMS experiments with more and different ways to save costs and improve care processes and outcomes, thus increasing the value of the care provided.
2
Successful PALTC leaders must continually monitor reimbursement flows, case mix, and census and find creative ways to make up shortfalls when they occur through such means as philanthropy, grants, and other nontraditional but important revenue streams.
Hence the need for this book. As with many challenging environments, skillful, strong, and consistent leadership is an all‐important component of success, and to both the uninitiated and the experienced leader, this guide will prove to be invaluable.
In closing, we see PALTC today as one of our most important health care and societal forums—a stage on which society will act out the interplay of our values as a country; our attitudes toward those who are older and frail; the strength and resilience of our governmental, business, and organizational systems; and the sustainability of our societal bonds, social safety net, and leadership in the world.
What will the future bring for post‐acute and long‐term care? While nursing homes will always have a place in the health care industry, the global demographic shift to a rapidly growing 85‐and‐older population tells us that we cannot rely on nursing homes alone. Instead, new models of health care delivery are emerging and will continue to evolve, be tested, and brought to scale. Those of us committed to this setting of care have an exciting opportunity to actively participate in the development of these new models. We have an opportunity to provide leadership in a setting of care that desperately needs it. Post‐acute and long‐term care may never be sexy, but it will, now and into the future, represent a calling to solve complex care challenges with compassion, integrity, creativity, and insight.
For those new to PALTC or new to leadership in PALTC, we hope this book becomes an invaluable guide and companion in your journey. In the end, to choose to work in PALTC is a calling—a vocation—much more than a job. Just as this book may guide you, may that calling sustain you and your colleagues for many years to come.
Reference
Committee for a Responsible Federal Budget. (2022, April 21).
Fiscal considerations for the future of telehealth
.
https://www.crfb.org/papers/fiscal‐considerations‐future‐telehealth
Notes
1
The use of the term
continuum
in PALTC is somewhat misleading, implying a smooth integration of all settings across acute, post‐acute, and long‐term care and even a seamless, stepwise progression of a senior through ever higher levels of care as their needs increase. Such scenarios are, sadly, far from the reality experienced by seniors today, where they ricochet between the hospital to the skilled nursing facility (SNF), to independent or community‐based living, back to the hospital or SNF, perhaps to assisted living or some other supportive setting, before finally ending their journey in a hospice program, which could be home based, institutional, or delivered in a long‐term care community. These transitions are rarely well‐managed; they often lack clear communication of the individual's end‐of‐life goals and often lead to significant care deficits or the application of unnecessary and unwanted interventions that cause even more adverse consequences for the patient.
2
The shift from volume‐based, fee‐for‐service reimbursement to value‐based payment mechanisms is indeed a noble goal of the Department of Health & Human Services (DHHS) and CMS. Unfortunately, it risks further constricting the resources available to care for residents and patients, as the complex care needs of the PALTC population makes this setting very costly and, using traditional definitions, with generally poor outcomes. Value‐based payment methodologies will need to reflect the unique nature of this population to be successful.
PREFACE
The goal in producing the first edition of Managing the Long‐Term Care Facility: Practical Approaches to Providing Quality Care was to provide additional clinical and operational information needed by skilled nursing facility administrators and ancillary health care providers to improve the delivery of care and health outcomes for residents. I began to consider a second edition because of the many changes taking place in the long‐term care environment such as the COVID‐19 pandemic, regulatory updates, and the impact of implementing the Quadruple Aim goals which are improving health outcomes, patient satisfaction, employee well‐being, and decreasing health care costs.
To bring about the second edition, I again sought industry experts across the country in the fields of skilled nursing and the broader long‐term care continuum. All the first edition chapters were updated. The foreword along with the following new chapters were added and are named Person‐Centered Care, Trauma‐Informed Care; Transitions of Care; Resident Assessment Instrument; Quality Assurance and Performance Improvement and Quality Assessment and Assurance; Surveys, Enforcement Actions, and Appeals; and Workforce Culture. The second edition can be of value to all stakeholders in the long‐term care continuum.
ACKNOWLEDGMENTS
I thank the contributors who have been my partners in the compilation of this book. Their dedication to accuracy and thoroughness has made this project a one‐of‐a‐kind resource. Working with so many dedicated professionals was a rewarding and valuable opportunity for me.
A special thanks goes to those contributors who worked diligently on the first and second editions. Those contributors are Andrew Alden, M.Arch., Jeffrey Anderzhon, FAIA, Erlyana Erlyana, MD, PhD, Paige Hector, LMSW, Abby Swanson Kazley, PhD, Jim Kinsey, FPCC, PLCC, CDP, Kenneth Merchant, Robert Miller, PhD, Sarah C. Moser, EDAC, Sonja Talley, MA, SHRM‐SCP/SPHR, Barbara White, DrPH, RN, and Ann Wyatt, MSW.
The contributors who joined our team for the second edition were Alex Bardakh, MPP, CAE, PLC, Michael Carter, OT, Carla Cheatham, Rev., PhD, MA, David Clarke, MD, Deborah K. Cruze, JD, MA, Cindy Donovan, BN, MSHA, Susan Duncan, RN, Alain P. Durocher, PhD, Barbara Ganzel, PhD, LCSW, Robyn Grant, MSW, Melvin Hector, MD, FAAFP, CMD, CAQ in Geriatrics, CMD, David Hoffman, JD, Alan C. Horowitz, JD, Ronke Komolafe, DBH, MBA, Nancy Kusmaul, PhD, MSW, Christopher Laxton, Adrienne Lindsey, DBH, MA, Arif Nazir, MD, Suzanne Richards, RN, MPH, MBA, FACHE, Martin Smalbrugge, PhD, MD, Karl Steinberg, MD, CMD, HMDC, HEC‐C, Lovella Sullivan, MBA, Joel VanEaton, BSN, RN, RAC‐CT, RAC‐CTA, MT, MTA, Nancy Wexler, DBH, MPH, and Cory Woods, DNP, MHA, MSN, RN.
A special acknowledgment goes to Paige Hector, LMSW, who was an invaluable source of informed, insightful, and practical advice. Also, Jim Kinsey, FPCC, PLCC, CDP, is appreciated as a great source of information and for his willingness to cheerfully support the book whenever asked.
In addition, thank you to the Wiley team for supporting this second edition.
ABOUT THE COMPANION WEBSITE
Managing the Long‐Term Care Facility: Practical Approaches to Providing Quality Care is accompanied by a companion website
www.wiley.com/go/practicalapproachestoprovidingqualitycare2E
The website includes:
