Caring for Patients with Heart Disease in Skilled Nursing Facilities – the Lessons I Continue to Learn

Nicole OrrThree decades ago, when the discharge based prospective payment system of 1984 gave hospitals an incentive to significantly reduce inpatient length of stay, older adults were being discharged more quickly and in less stable condition, i.e. “quicker and sicker,” and utilization of post-acute care services after hospital discharge for these patients increased. Reimbursement incentives and improvements in technology led to a dynamic change in skilled nursing facilities (SNFs), and the rise of what is often referred to as the “subacute SNF.” Older patients with cardiovascular disease are increasingly discharged to SNFs, and now roughly 1 in 4 older patients hospitalized for heart failure (HF) are discharged to SNF level care for ongoing medical therapy and/or restorative rehabilitation. Patients selected for SNF admission are older, more frail, have higher numbers of comorbidities, and more significant functional and cognitive limitations.

When the Affordable Care Act enacted legislation penalizing hospitals for HF readmissions, I saw an opportunity to develop a practice providing cardiovascular care to vulnerable HF patients admitted to SNFs. The clinical focus on geriatric cardiology, as well as the opportunity to help facilities develop programs and educate their staff about HF management were very compelling. Since starting my practice almost three years ago, not a day has passed without an opportunity for growth and learning.

In my current practice I consult for sixteen SNFs, and I have come to synthesize that the challenges of HF care provision in this setting stem from three broad elements: 1) the patients, who often have advanced disease;  2) the systems, which are not yet optimized for transitional care (hospital to SNF or SNF to home); and 3) the facilities, which lag hospitals in their development of disease management programs and staff education.   Perhaps more importantly, I have grown to understand that the practice of post-acute cardiology requires a unique blend of outpatient and inpatient cardiac care, general cardiology, geriatric medicine, and medical and ancillary care provision (i.e. physical and occupational therapy).

Practicing post-acute cardiology provides a direct window into the clinical and functional challenges patients face after an acute hospitalization, and has been directly illustrative of why older HF patients are at such high risk for readmission. Described by Dr. Krumholz as “post-hospitalization syndrome,” this period recovery is often accompanied by changes in cognitive status or delirium, relatively poor nutritional intake, disturbed sleep patterns, emotional and psychosocial stress, frailty exacerbations, and impaired coordination and deconditioning. It is in this vulnerable period that we ask patients in subacute rehab to recover to their prior level of functioning within 30 days, lest they lose their therapy coverage afforded by their insurance. I have learned all too well that post-acute cardiology care requires striking a fine balance between optimal medical management of an acute cardiac condition, and preserving functional and cognitive ability to enhance recovery. After being disheartened when patients failed to meet their restorative goals because of side effects of intensified cardiovascular medications such as prohibitive orthostasis or fatigue, I learned that optimizing cardiovascular recovery can be incompatible with optimizing functionality and recovery in immediate post-acute care. Knowing which goals of care to prioritize remains a developing medical art.

While the cardiology and post-acute care community has responded to the needs of the growing HF population in SNFs by recently publishing scientific statements and clinical practice guidelines for the care of the SNF HF patient, evidence based recommendations are desperately lacking. I recently published a review discussing some of the challenges and targets for intervention in the care of HF patients in SNFs with colleagues similarly dedicated to the care of these unique individuals. Amidst emerging legislation poised to penalize SNFs for higher than average 30 day readmissions next year, we emphasized in this article that SNFs will increasingly need to invest in the quality of care they deliver. As demands grow, perhaps SNFs will need to allocate their limited resources to subspecialized areas, and those that chose to invest in optimizing HF care might qualify to distinguish themselves as “Heart Failure Ready.” Patients, providers, and hospitals alike could perhaps benefit from this means of guidance in selecting appropriate post-acute facilities to meet their care needs.

The future of HF care in SNFs is a moving target and many changes are sure to come. I suspect that as the SNF patient becomes even more complex, the presence of cardiovascular specialists, now negligible, will grow. From the perspective of a SNF geriatrician, input from specialists with a historical focus on aggressive single disease management may not be aligned with goals of care for the complex SNF patient with multiple comorbidities; SNF specialists will therefore need to heed to geriatric principles of care, the importance of functional as well as clinical outcomes, and an understanding of cardiovascular disease within the context of aging, multimorbidity, and frailty. Amidst the vast unknown, one thing is certain – more research to define the optimal care for the post-acute cardiology patient is desperately needed.

 

By: Nicole Orr, MD

 

Empowering Patients: Innovations from Denver

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Last week I had the privilege of giving Geriatrics Grand Rounds in Denver at the University of Colorado School of Medicine, coupled with a site visit to the Shared Decision Making Core run by Dr. Dan Matlock and Dr. Larry Allen. Their group is doing innovative work in developing decision aids for patients facing a variety of choices, including implantable cardioverter defibrillators, left ventricular assist devices, and colon cancer screening. Their work is available free online (patientdecisionaid.org). Materials are developed by their multidisciplinary team through an iterative process that involves patients and clinicians, in order to develop an easily understandable and user-friendly end-product.

The ultimate goal is to have patients make more informed choices about their care. Myself and other aging specialists have discussed at-length the need for this, and the Denver group is at the forefront of turning this concept into actionable steps. I look forward to their continued work as they develop these aids for other conditions and scale up their efforts across a broad range of healthcare institutions.

By: John Dodson, MD

Photo credit: Bonella Photography by Amy Jenkins

Show me the Evidence! (For Drugs used in Older Adults)

karen-alexanderThe year was 1989, and the FDA publication was “Guideline for the Study of Drugs Likely to be Used in the Elderly.” Fast forward to the present, where 25% of heart failure trials still have an upper age exclusion and 45% of trials have other criteria that disproportionately excludes older adults. In 2014, Congress directed the FDA to prepare an action plan to Section 907 of the Food and Drug Administration Safety and Innovation Act (FDASIA) (Pub L. 112-144) which requires safety and effectiveness to be reported by sex, age, race, and ethnicity. The resulting FDA Snapshots added transparency on age group inclusion but did nothing to increase representation of older adults. Instead of continuing to characterize this geriatric gap for the next 25 years, we need to design and implement mandates, partnerships and incentives to ensure representation of older adults in evidence which forms the basis of their care. The systematic path forward has been paved by other populations with examples of actionable approaches below:

  • Age can be added to Targeted/planned enrollment tables for inclusion of older adults (age ≥75), just like already required for gender/race/ethnicity in NIH trials.
  • An Office of Geriatric Health and Aging can be established within the FDA, just like existing offices for other special populations, Office of Women’s Health, Office of Minority Health, and Office of Pediatric Therapeutics. This office would review early studies for dosing alterations with age, enrollment and data collection plans, and inclusion of older adults in trials relevant to care of older adults.
  • A Geriatric Exclusivity Rule could be passed to grant patent extension for collecting adequate information in older populations, just like the Pediatric Exclusivity Rule (1997) which provides drug manufacturers a 6-month patent extension for conducting studies in children. While requiring an act of Congress, it would protect our elders as we similarly protect our youth. Both have age-associated alterations in physiology hence pharmacokinetics and pharmacodynamics.
  • A Geriatric Value Category could be added to the package insert to provide a uniform risk/benefit rating, just like the Pregnancy Rating Category on labels indicates strength of evidence for safety during pregnancy.
  • Engage Older Adults. Many older adults are eager to connect and contribute to future generations, but need time, education and encouragement to understand participation in clinical trials. Simplified consent forms with large type, added time to consult with family, use of proxy data or remote follow up, and other ideas can be elicited to overcome barriers to participation. Participants in clinical trials have better care and outcomes.
  • Engage Payers. Payers, and specifically Medicare, could provide education about the importance of research participation in subscriber welcome packets, creating a special identifier for those willing to be contacted for participation. Similarly, payers should partner with drug and device manufacturers to identify research priorities for older populations and collaborate in research designs. Those drugs or devices with best evidence in older adults (see Geriatric Value Category above) could get market advantage by payers, a value passed on to older adults with safer care at lower costs.

 

By: Karen Alexander, MD

 

 

Deprescription: Rethinking Treatment in Older Adults

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The American College of Cardiology, American Geriatrics Society, and National Institute of Aging are convening a conference on pharmacotherapy in older adults with cardiovascular disease. It’s encouraging to see such a diverse group of experts (physicians, nurses, pharmacists, policymakers, patients, funding agencies) working together on this topic. The objectives broadly are to identify gaps in knowledge around the issue of medication prescribing in older adults, and to identify a future research agenda through involving multiple stakeholders in the process.

One of the most interesting talks from Day 1 was on the concept of deprescribing: removing medications that are no longer effective or potentially harmful. This has been a principle within geriatrics for decades, but is only recently gaining traction within the cardiovascular community. As one example within cardiology, a relatively recent trial in JAMA Internal Medicine randomized patients with advanced illness to continuing their statin medication versus discontinuing it. They found no difference in survival after several months; and the “deprescribed” group actually had better quality of life scores and lower medication costs.

For widespread acceptance of the concept within cardiology, deprescribing will need to be studied in a variety of clinical settings – and these studies can be difficult to perform – but there is a crucial need to understand if and when to stop medications in our older patients. And as cardiologists, we may ultimately need to rethink what it means when we say “lifetime” for a particular medication.

By: John Dodson, MD

Dietary recommendations for older adults with heart failure: are they worth their salt?

scott-hummel-2Due to neurohormonal activation and often renal dysfunction, patients with heart failure (HF) are physiologically attuned to retain sodium and fluid. Since worsening symptoms in HF are typically due to fluid congestion, the conventional wisdom has been to reduce dietary salt intake. In observational studies, low sodium intake is associated with fewer hospitalizations for decompensated HF. However, restricting sodium also increases systemic neurohormonal activity, which could be detrimental particularly in patients with HF and reduced ejection fraction. While flawed and challenging to interpret, some randomized trials suggest that sodium restriction actually increases readmission and mortality risk!

What’s more, studies in hypertensive animal models as well as in humans with hypertension imply that the response to sodium is not inherently the same in all patients. “Salt-sensitive” people have greater increases than others in blood pressure, oxidative stress, and inflammation during high sodium intake that may contribute to the development and worsening of HF. This has traditionally been attributed to impaired renal sodium excretion. However, recent work suggests that some ingested sodium is not processed through the kidneys, but stored non-osmotically in the skin and other organs.  The purpose and cardiovascular effects of this storage are not yet known. We and others are studying the endothelial glycocalyx, a thin glycoprotein lining of blood vessels, as a possible link between sodium intake and vascular dysfunction.

With the increasing understanding that frailty, sarcopenia (diminished muscle mass), and metabolic disarray are common and contribute to poor prognosis in older patients with HF, a blanket recommendation to eat less salt could have other unintended consequences. In dietary surveys, older adults with HF who report eating a low-sodium diet frequently have calorie and micronutrient intake deficiencies that could directly contribute to weight loss and impaired mitochondrial function.

At this point, the only certainty is that further research is needed to define the appropriate diet for older patients with HF – and the answer may not be the same for everyone. Ongoing studies (SODIUM-HF; GOURMET-HF) will provide more information over the next few years. Until then, advice for older patients with HF to restrict salt intake is reasonable – provided careful attention is paid to volume management and diuretic dosing to avoid excessive neurohormonal activation. In my practice, I also recommend consultation with a dietitian to make sure that a well-intentioned focus on sodium doesn’t contribute to deficiencies in caloric or other nutrient intake.

By: Scott Hummel, MD