From The President
Dear Members,
It was very encouraging to see so many of you at the AMDA national symposium in Salt Lake City, Utah. Next year the travel will not be as onerous since the meeting will be held right here in Charlotte, NC. This is a great opportunity to bring your administrator and director of nursing to the meeting and plan time to brainstorm about putting new information and skills into action within the nursing homes of NC that you serve. (see more below about this event)
The AMDA House of Delegates was hard at work in Salt Lake City. One white paper was approved that highlighted the importance of every nursing facility having an ethics committee that can help when end of life issues need to be discussed. Two resolutions were approved. One highlighted the importance of standardize flow of critical information between acute and long-term care sites and resolved that AMDA work with the AMA and others to improve and standardize these procedures and policies in an effort to enhance care transitions. The other resolution reiterated AMDA’s opposition to the CMS 3-day hospitalization requirement for skilled nursing rehabilitation eligibility and urged CMS to allow observation bed status and emergency room observation time to count toward meeting the 3-day inpatient stay requirement. These resolutions and the white paper are available on the AMDA website (amda.com) under ‘governance’.
We now have a full compliment of NC chapter board members. Randy Long, MD from Lexington, NC was elected as representative for the central region. Steve Ferguson is representing the eastern region and Eileen Caquias-Gonzalez, MD is representing the western region. Jamehl Demons, MD is our past president, Gwen Buhr, MD is the current vice President, and Jose Gonzales is our secretary/treasurer. If you are interested in serving the organization in some specific capacity please let one of us know.
We are looking forward to an outstanding NC/SC MDA symposium in Charlotte, NC October 3-4, 2008. Many of the speakers have already been chosen and the schedule will soon be finalized. We are considering a new hotel site for this exciting symposium so save the date and watch for further details to come
We are gearing up for the AMDA National Symposium in Charlotte, NC March 5-8, 2009. At the North Carolina State Chapter meeting in Salt Lake City each member agreed to contact two other medical directors or attending physicians in their region who are not currently members of the organization to especially let them know about the upcoming AMDA National Symposium that will be held in Charlotte, NC within the year. This is an exciting opportunity that will not come our way again for a long time. March , 2009 are the dates for next AMDA National Symposium. We would like to see the medical director, director of nursing, administrator and consulting pharmacist from each of the over 400 NC facilities respresented. Continuing education credits are available for each of these professions and the AMDA provides a registration discount for attendance of more than 2 people from a single facility.
The NC chapter is serving our state and our members. I was invited to speak at the NC Health Care Facilities Association January meeting in Greensboro, NC. It was good to have the attention of a committed group of nursing home administrators for a full 90 minutes and to share a productive conversation about improving medical care in nursing facilities for our oldest and frailest citizens. Dr. Buhr, Dr. Demons and I are sharing the responsibility of discussing medical direction with administrators-in-training. This professional development and licensing preparation course is required for anyone seeking a license to serve as a nursing home administrator in North Carolina. This course is conducted by the North Carolina State Board of Examiners for Nursing Home Administrators (NCBENHA) in partnership with the School of Public Health, at the University of North Carolina at Chapel Hill. We are willing and able to serve NC in other ways and to partner with other organizations that promote excellent long-term care services. We rely upon our members in large part to bring opportunities to our attention.
Sincerely,
Heidi K. White, MD, CMD
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Featured Article
Nutrition in Assisted Living
By Gwen Buhr, MD, MHS
Assisted living (AL) blossomed in the past 15 years, so that now there are almost half as many assisted living beds as there are nursing home (NH) beds in the U.S. Providing optimal nutrition to the AL population is a serious concern, though one that may not be adequately met. In a presentation at the annual symposium of the American Medical Directors Association at the end of March, this issue was discussed by Connie Bales, PhD, RD, Gwendolen Buhr, MD, and Heidi White, MD. Dr. Bales is an Associate Professor in the Division of Geriatrics at Duke University Medical Center, a registered dietician, and an expert on geriatric nutrition. Drs. Buhr and White are medical directors at continuing care retirement communities and faculty in the geriatrics division at Duke.
Dr. Buhr began by reviewing the characteristics of AL and implications for nutritional health of AL patients. AL care differs from nursing home (NH) care in its emphasis on maintaining privacy, independence, and a homelike environment, while providing assistance with at least 2 activities of daily living. At the same time, there are many similarities in AL and NH residents, namely similar medical conditions, the same number of medications on average, and comparable prevalence of depression, anxiety and psychosis. In spite of the serious clinical concerns of AL residents most AL corporations follow a hotel model, rather than a healthcare model. While the risk of poor nutritional health is well-documented for NH residents, the same is not true for AL residents. Nevertheless, several characteristics of the AL populations strongly suggest that malnutrition is a concern; these include declining functional status, depressive symptoms, polypharmacy, and multiple chronic illnesses. It is regrettable that in this light, AL residents are less likely than NH residents to be assessed for eating and drinking difficulties, less likely to receive treatment for eating difficulties, and less likely to receive physical assistance. Dr. Buhr concluded by advocating for nutritional monitoring among AL patients, and emphasizing that this is the responsibility of the primary care provider since few other professionals are readily available in the AL environments.
Dr. Bales reviewed an 11 state sample of nutrition-related regulations for AL facilities. Surprisingly, no states had requirements for nutritional assessment. She then discussed risk factors for poor nutritional health which included the following: (1) poor appetite and low food, nutrient intakes, (2) restrictive therapeutic diets, (3) dysphagia and other conditions requiring texture modifications, and (4) eating dependency. Unfortunately, AL care is often not sufficient to counteract these medical concerns and support good nutrition. For instance in AL, there is little medical supervision, no regular nutritional surveillance or dietitian consults, and personalized assistance with meals is not routinely provided. Dr. Bales then proceeded to discuss screening tools that may be useful for identifying malnutrition among AL patients. While clinical indicators of under-nutrition comprise a vague list of symptoms, serial measurement of body weight or body mass index (BMI) is probably the single most important strategy for the evaluation of nutritional status in the frail elderly. The elderly are at risk of under-nutrition if they have lost 5% of usual weight in 30 days or 10% of usual weight in 6 months, or if the BMI is less than 22.
Dr. White finished the session with a case discussion, from which she reached conclusions regarding the AL environment and implications for nutrition. In several respects AL supports good nutrition for its residents; these include appealingly presented meals, flexible dining schedules, social interaction that could help counteract depression or isolation, and a homelike environment that enhances the overall quality of life. However negative aspects of AL care are also present that undermine nutrition; these include the lack of close medical and nutritional supervision, frequent inability to accommodate special dietary needs, unreliable support for those with eating dependency, very limited ability to accommodate use of tube feeding, and prevalent dysphagia that may go unnoticed and untreated. |
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