Adverse Events in Nursing Homes – Reflections on the February OIG report

April 18th, 2014 by Rod Baird

We’d would like to invite you to read a blog post from Rod Baird summarizing his thoughts on Adverse Events and ePrescribing in Skilled Nursing Homes in light of the recently released OIG Report.

The OIG says: Patients in SNF’s experience frequent Adverse Events, Medications are the leading cause. What’s the solution? More CMS regulations, or do we work together to reduce harm? This blog post offers a constructive suggestion to improve LTPAC medication safety. Link to February 2014 Report

Attending a meeting like AMDA’s 2014 Convention, always creates a subtle anxiety; do I attend the next lecture, or talk to a colleague I haven’t seen for 2 years?

I was particularly thankful I made it to one of the programs I’d bookmarked weeks in advance – Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. This was the propitiously timed lecture, it was March 1st, just days before the OIG released the above mentioned report to the public. The report was based on a sample of 653 medical records of randomly selected Medicare patients from more than 600 facilities. Reviewers Drs. James Lett and Lee Adler, and Project Leader Jeremy Moore, presented a concise summary of the report’s findings. At least 22% of the patients studied during the single Month, August 2011, had an Adverse Event during their stay (35 days or less and 15.5 days ALOS).

Yes, the adverse event rate for newly admitted patients in the sample, during the study month, was greater than 1 in 5. The most frequent causes of these events were issues with Medications and their side effects. An additional 11% of the patients in the sample experienced events that resulted in temporary harm.

The report was both depressing, and gratifying. Depressing because so much avoidable harm continues to occur; gratifying because the report validates the significance of an issue many of us have worked on for several years – improving LTPAC prescribing and medication management. That effort is happening at the NCPDP LTPAC ePrescribing Work Group (WG 14). NCPDP is the abbreviation for the National Council of Prescription Drug Programs, an accredited standard setting organization. The NCPDP 10.6 Script ePrescribing message is incorporated into the ONC certification standards for Ambulatory EHR use. It is mandated for all LTPAC electronic messages containing prescription information in the fall of 2014.

During the month of March, I’ve followed the position statements, press releases, and blogs of our industry’s leading organizations, quality alliances, and public advocacy groups. Links to these statements are as follows:

Advancing Excellence, AMDA, ASCP, Center for Medicare Advocacy, LeadingAge, and Propublica

Needless to say, no one is pleased with the frequency of errors documented in the report. The range of solutions was limited; more education, more enforcement, or more engagement. The strategy advanced by Cheryl Phillips, MD, LeadingAge’s Sr.VP for Public Policy was the most promising – advocating for facilities themselves to adopt a “culture of quality and safety.” That is the heart of the QAPI (Quality Assessment & Performance Improvement) strategy being advanced through the CMS regulatory process.

None of the proposals were a solution to the most frequent adverse events – problems related to medications. What I continue to be astonished by is lack of interest in a proven quality improvement tool that works – ePrescribing. Ambulatory medical practices and hospitals employ ePrescribing as a standard part of patient care.

ePrescribing isn’t the end, just an effective tool. I believe physicians, facilities, and LTC pharmacies jointly using this tool is the only logical starting point for a strategy to reduce actual harm.

The OIG report focused on the SNF as the location for improvement/correction. In the course of the entire 65 page report, there was no mention of the role played by the attending physician, or consulting/dispensing pharmacist. That is typical. In March, 2013 the ONC published an Issues Brief on Health IT in LTPAC. The attending physician was never mentioned.

Nursing Home Care, and medication management, is a team activity. Every resident is the patient of at least 3 providers – the facility, attending physician, and consulting pharmacist. Each provider has a distinct, but complimentary role – that is why the CMS Conditions of Participation require the presence of each service as part of the definition of SNF care.

How do we engage all the members of that team to improve the quality of medication management?

Increase regulation/punishment of the SNF?

Use one or more proprietary solutions – each focused on the technology of a particular vendor. These solutions require the use of custom HL-7 interfaces, don’t satisfy EHR certification requirements, and only connect two parties at one time.

Use the NCPDP 10.6 Script standard – a requirement for all 2014 ONC Certified EHRs, and mandated for LTC in the fall of 2014. The NCPDP model uses standard messages that connect with any and all participants in the Patient’s care team.

You be the judge. Anyone interested in learning more about the NCPDP, and their standard setting work is eligible to enroll in the effort.

Rod Baird

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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