CareManagement April/May 2022

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JOURNAL OF THE COMMISSION FOR CASE MANAGER CERTIFICATION | THE CASE MANAGEMENT SOCIETY OF AMERICA | THE ACADEMY OF CERTIFIED CASE MANAGERS

Vol. 28, No. 2 April/May 2022 INSIDE THIS ISSUE

CONTINUING EDUCATION ARTICLES:

SPECIAL SECTIONS:

11 Pandemic Era Developments for Postacute Care Networks: Part II CE1

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Approvals, warnings and the latest information on clinical trials—timely drug information case managers can use.

Laura Kukral, MBA, LNHA, and Ben Frank, MHA, FACHE Postacute care networks (“networks”) are changing in response to the impacts of COVID-19. These changes include network structures, size, membership, goals, and use of technology. One of the most notable changes is the inclusion of “super skilled nursing facilities (SNFs)” to provide integrated specialty care modeled after hospital-based service line best practices. “Super” SNFs are high-performing SNFs overall and provide one or more types of high acuity specialty care.

16 Getting Back Into Focus: Revisiting Reasons for the Hospital Readmissions Reduction Program CE2 Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN Since 2009, there has been a focus on reducing and preventing hospital readmissions in acute care facilities. Chronic condition management is a major factor in rising health care costs. The extensive costs per hospital admission associated with congestive heart failure and chronic obstructive pulmonary disease is a major financial liability to health care systems, and a significant component of these costs is unplanned avoidable readmissions. Research and the growing evidence base demonstrate that interventions started in the acute facility and carried through the transition to the community for a minimum of 30 days are effective at reducing readmissions.

21 Moral Injury: Health Care Providers and the Pandemic CE3 Janet S. Coulter, MSN, MS, RN, CCM During the pandemic, health care providers have faced many issues that have taken a toll on their physical, emotional, spiritual, and psychological well-being. Unfamiliar and potentially highly distressing work experiences were commonplace. Health care providers were placed in situations where they had to make difficult decisions that sometimes contradicted their values and beliefs. Choosing between professional values and duties and the fundamental priority to protect your family from harm can create internal dissonance. This conflicts with moral beliefs, thus causing a moral injury.

CE Exam

CE

Members: Take exam online or print and mail. Nonmembers: Join ACCM to earn CE credits.

join/renew ACCM online at academyCCM.org

or use the application on page 41

PharmaFacts for Case Managers

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LitScan for Case Managers The latest in medical literature and report abstracts for case managers.

DEPARTMENTS: 2 From the Editor-in-Chief

Becoming an Author: Rise to the Challenge

3 From the Executive Editor

Case Managers and the Great Health Care Resignation: A Call to Action

4 News from CMSA CMSA Hot Topics

5 News from CARF

CARF Standards That May Pose Challenges to Conformance for Case Managers

6 CDMS Spotlight

What Lifelong Learning Means to Me

7 News from CCMC

Diversity, Equity, and Inclusion: Leadership in Case Management

8 Case Manager Insights Impact

9 Legal Update I

Part 3: Updated Pharmaceutical Industry Marketing Code May Help All Providers Understand Current Standards

10 Legal Update II

Return to the Roots of Healthcare: Home Care!

40 How to Contact Us 40 FAQs 41 Membership Application


FR O M TH E E D I TOR -I N -CH I EF

Becoming an Author: Rise to the Challenge

Editor-in-Chief/Executive Vice President Gary S. Wolfe

Gary S. Wolfe, rn, ccm, fcm Editorial Board

Barbara Aubry, rn, cpc, chcqm, faihcq Jennifer E. Voorlas, msg, cmc

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ew of us think about becoming different than writing a report but the an author. As case managers we basic skills are the same. think about how we can support I challenge you to become an author our patients and provide the best and write for publication. There are possible outcomes. We think about how many benefits to becoming an author. to manage our case load. We think about These benefits include: our time management skills and whether • Changing lives we really have enough time to get every• Reaching a wider audience thing done. We also think about our life • Adding credibility to your name and our goals. Our case management • Connecting you to your audience life has been about developing the skills • Increasing your confidence and knowledge to accomplish what we • Getting invitations to speak do. As the professional practice of case • Creating media opportunities management advances, we need authors. • Having a platform Medical knowledge is growing exponenWriting changes people’s lives: your tially. Health care delivery systems are life and all the people who read what you growing more complex. Along with that have written. Writing has the ability to growth is case manmotivate, inspire, agement. How do we change lives, change I challenge you to become an learn and keep up to minds, and improve author. Martin Luther said: “If date with this knowlthe professional edge? We keep up you want to change the world, practice of case manto date through the agement. No one pick up your pen and write.” acquisition of knowlknows everything, edge in a variety of but we learn about formats. Primarily, medical conditions we read and listen. We read journals and and approaches because someone has books, we listen to podcasts, we downshared a story that is applicable to a load research, we search the Web, and we patient. That makes that writing powerful attend conferences and webinars. All of and a life changer. that information has to come from someAs the professional practice of case where, which means someone wrote a management grows and evolves, we need story: some told us what they had learned a firm body of knowledge. We develop and were doing, someone did research, that body of knowledge by documenting and everyone shared their story. You too what we do, why we do it, and how we do can be than someone! it. The what, how, and why is documented Oh, I hear you. I’m not an author. I’m and published. We then lay claim to a a case manager. In reality, you are also professional practice of the case managean author. You write reports all the time. ment body of knowledge. Our body of You probably haven’t thought of yourself knowledge is essential as we grow, eduas an author but that is what you are cate, and train case managers. doing when you write a report. And you When you write and tell a story, you are good at it. Writing for publication is continues on page 38 2 CareManagement April/May 2022

Adele Webb, rn, phd, aacrn, cpnap, faan Executive Editor

Catherine M. Mullahy, rn, bs, ccrn, ccm, fcm Contributing Editor

Elizabeth Hogue, Esq. Copy Editor

Esther Tazartes, MS Art Director and Webmaster

Laura D. Campbell Circulation Manager

Robin Lane Ventura Member Services Coordinator

Kathy Lynch Senior VP Finance & Administration

Jacqueline Abel Publisher, President

Howard Mason, rph, ms Vol. 28, No. 2, April/May 2022. CareManagement (ISSN #1531-037X) is published electronically six times a year, February, April, June, August, October, and December, and its contents are copyrighted by Academy of Certified Case Managers, 2740 SW Martin Downs Blvd. #330, Palm City, FL 34990; Tel: 203-454-1333; Fax: 203-547-7273. Subscription rates: $120 per year for ACCM members; $150 for institutions. Opinions expressed in articles are those of the authors and do not necessarily reflect the opinions of the editors or the publisher or the Academy of Certified Case Managers. One or two copies of articles for personal or internal use may be made at no charge. For copying beyond that number, contact Copyright Clearance Center, Inc. 222 Rosewood Dr., Danvers, MA 01923, Tel: 978-750-8400. CareManagement is indexed in the CINAHL® Database and Cumulative Index to Nursing & Allied Health Literature™ Print Index and in RNdex.™

© Academy of Certified Case Managers, Inc. 2022


FR O M TH E E XECUT I V E ED I T O R

Case Managers and the Great Health Care Resignation: A Call to Action

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hile the calendar says Spring, which should bring sunshine, warmer weather, and happier days, a dark cloud is hanging over many of us who are saddened by the events in Ukraine. It’s often difficult to focus on the positive when so much around us seems unsettled. We question what good could possibly come from that which seems so heartless, tragic, and cruel, and yet there are rays of hope as the best in humanity reaches out to those who have lost everything. The young Ukrainian girl singing the song “Let It Go,” which went viral, was an especially heartwarming moment in this horrific war. The senseless and unprovoked attacks on a country and its people have united citizens in countries around the globe. While the future remains uncertain for the innocent people of Ukraine, their strength and courage remain inspirational and brings out the best in each of us. Trying to create a column with a positive uplifting message for this issue is a bit more challenging than usual. I’m always hopeful that this column would be able to give recognition to the value in what we do every day and encourage us to remember to care for each other as well. Caring for each other has become increasingly important but is sometimes uncomfortable for those of us who care for our patients so naturally. In the past months, much has been published, including in CareManagement and the broader media, about the toll the pandemic has had on frontline workers. Truth be told, however, workplace

violence, racial and cultural injustice, cognitive and technological overload, and staffing issues have been evolving for many years, leading to burnout and challenging the safety and well-being of staff members in practice settings across our country. Suicide among our colleagues continues at an alarming rate, which was addressed in an article titled “Health

Workplace violence, racial and cultural injustice, cognitive and technological overload, and staffing issues have been evolving for many years, leading to burnout and challenging the safety and well-being of staff members in practice settings across our country. Care Provider Suicide: Another Tragic Toll of the Coronavirus Pandemic” by Coulter and Ott in our last issue. The authors of this article urged us to get involved in identifying and improving access to care for this increasingly vulnerable group. Fortunately, our legislators recognized the problem of healthcare workers’ burnout, depression, and rising suicide rates and recently enacted the Dr. Lorna Breen Health Care Provider Protection Act. It requires the Department of Health and Human Services (HHS) to award grants to hospitals, medical professional associations, and other health care entities for programs to promote mental health and resiliency among health care providers. The legislation

Catherine M. Mullahy

also indicates that the HHS may award grants for relevant mental and behavioral health training for health care students, residents, or professionals. The current issue contains an article by Coulter titled “Moral Injury: Health Care Providers and the Pandemic” that addresses this relatively new concept in health care, and this article explores the long-term harm and impact of moral injury. There are several definitions of moral injury, but the one that resonated most with me was “the distressing psychological, behavioral, social, and sometimes spiritual response to acting or witnessing behaviors that go against one’s values and moral beliefs” (Norman et al., 2020). Health care providers who experienced moral injury were often placed in situations that forced them into making difficult decisions and compromised their values, and many of them experienced long-term PTSD. We have witnessed increasing numbers of physicians, nurses, and other health care providers leave the health care industry. In a recent survey, 70% of physicians said they would not recommend the profession to others. A frequently cited American College of Emergency Physicians survey found that 50% of their members were physically assaulted at work, and the Emergency Nurses Association stated that 70% of their members had been hit and kicked on the job. To address these issues, the CEO Coalition was formed (www.ceocoalition.com). Health system leaders from across the country wrote and signed “The Heart of Safety: continues on page 39 April/May 2022 CareManagement 3


NEWS FR OM

CASE MANAGEMENT SOCIETY OF AMERICA

CMSA Hot Topics Melanie A. Prince, MSN, BSN, NE-BC, CCM, FAAN

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s the Case Management Society of America (CMSA) approaches the second quarter of 2022 (already!), we are excited to share a few hot topics that represent the incredible work of CMSA professionals, staff, and volunteers around the country. I wanted to highlight these Hot Topics as a FOMO (Fear of Missing Out) call to all case managers, consumers of case management, employers, health plans, and case management directors and supervisors as well as entrepreneurs and government entities. CMSA launched practical, tangible, relevant solutions for the practice of case management in any setting. Three of these solutions are the CMSA Standards of Practice, CMSA Public Policy Agenda, and the CMSA Fellows Program. The 2016 CMSA Standards of Practice were updated with end users in mind who are tackling important

Melanie A. Prince, MSN, BSN, NE-BC, CCM, FAAN, is president of the Case Management Society of America. Recently retired as an Air Force colonel, Melanie has diverse experience in population health; case, disease, and utilization management; public policy; and trauma/ violence prevention and organizational leadership. Melanie is a certified professional case manager and nurse executive and has master’s degrees in nursing case management and military strategic studies. 4 CareManagement April/May 2022

issues in today’s complex health care environment. We set out to retool and modernize standards that will meet the challenges of not only today but also establish benchmarks for the future of health care. These standards support case managers’ efforts to place the patient/client at the center of care

the lives of patients/clients. As evidenced by a hugely successful Capitol Hill Day in February, CMSA’s voice is loud, influential, and sought-after by policymakers. The CMSA Fellows Program launched in January, and we are eager to reveal the names of these esteemed

CMSA launched practical, tangible, relevant solutions for the practice of case management in any setting. Three of these solutions are the CMSA Standards of Practice, CMSA Public Policy Agenda, and the CMSA Fellows Program. and are in line with a consumer-driven focus on health care delivery. Join or renew your membership with CMSA and secure free access to the 2022 CMSA Standards of Practice as the guiding principles for professional case management in all settings. The 2020–2022 CMSA Public Policy Agenda is one of the most comprehensive plans in decades. In previous years and in concert with other health care institutions and organizations, CMSA was actively involved in policy development around Compact Licensure Agreements and case management Title Protection. The 2020-2022 agenda focuses on mental health, telehealth, and workforce development. These three segments of health care are poised for expansion and transformation. The opportunities and impact for case management in mental health, telehealth, and workforce development have never been more exciting as we continuously strive to improve

case management leaders at the CMSA Annual Conference on June 1-4, 2022, at the Gaylord Palms Resort Hotel in Kissimmee, Florida! These influential case managers have enjoyed phenomenally successful careers in leadership, policy development, management, clinical research, entrepreneurship, and health care quality, to name a few. The 2022 inaugural Class of CMSA Fellows will be recognized for their contributions to case management and charged with advancing the body of knowledge of case management for generations to come. CMSA has a full agenda for the year but these three hot topics are some of the highlights for the spring season. We are proud of the hundreds of volunteers at the state, regional, and national levels who work diligently and passionately to continuously evolve the professional practice of case management and the CMSA strategy. This continues on page 39


NEWS FROM

CARF…THE REHABILITATION ACCREDITATION COMMISSION

CARF Standards That May Pose Challenges to Conformance for Case Managers Terrence Carolan, MSPT

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n CARF-accredited organizations, there are several standards where case managers may find themselves taking the lead on demonstrating conformance for their rehabilitation program. These standards also can pose a challenge to organizations and are frequently cited as recommendations where full conformance wasn’t demonstrated during a CARF survey. This article will focus on a handful of these standards and will clarify how case managers can approach these standards to make them meaningful for their team and their persons served as well help them prepare for any upcoming CARF surveys. The individualized written disclosure statement is intended to be an effort to clearly communicate important details about the plan of care to any person served receiving care from a CARF-accredited rehabilitation program. The standard requires that the rehabilitation program disclose written information to persons served regarding: • The scope of services that will be provided • The intensity of services that will be provided Terrence Carolan, MSPT, is the Managing Director of Medical Rehabilitation in Tucson, Arizona. He is part of the medical rehabilitation team responsible for the training of CARF surveyors and for the development and revision of CARF standards.

In CARF-accredited organizations, there are several standards where case managers may find themselves taking the lead on demonstrating conformance for their rehabilitation program. These standards also can pose a challenge to organizations and are frequently cited as recommendations where full conformance wasn’t demonstrated during a CARF survey. This article will focus on a handful of these standards and will clarify how case managers can approach these standards to make them meaningful for their team and their persons served as well help them prepare for any upcoming CARF surveys.

• Estimated length of stay • Payment • Alternative resources to address additional identified needs The scope of services refers to the types of services that will be provided during a plan of care. This can include, for example, psychology, physical therapy, recreational therapy, or respiratory therapy. The intensity of services can be described in a number of different ways. How many days per week will a patient receive services? How many hours per day will the person served receive services? Estimated length of stay gives inpatient persons served an indication of how long they will remain in the rehabilitation program, and length of stay in an outpatient rehabilitation program can be characterized by the total number of visits over a period of time. Details about payment can help the patient understand how their care is being funded and alternative resources to address additional identified needs can help identify alternate funding

sources or potential referrals to other providers across the continuum of care. This individualized written disclosure statement needs to be written but it does not need to be summarized in one document; there may be multiple written documents that are used to comprise conformance to this CARF standard. The other important factor to consider when determining conformance to this standard is that the individualized written disclosure statement must be individualized. Another CARF standard that case managers may find themselves working to demonstrate conformance to a standard that speaks to the need for rehabilitation programs to determine whether each person served has a system in place to record personal health information to provide to health care providers in case of an emergency. The CARF standard also requires that if the person served has a system or tool in place, the program would assist with updating relevant personal continues on page 38 April/May 2022 CareManagement 5


C DMS SPOTLIG HT

CERTIFICATION OF DISABILITY MANAGEMENT SPECIALISTS COMMISSION

What Lifelong Learning Means to Me Ed Quick, MA, MBA, CDMS

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ifelong learning takes many different approaches, each one as individual as the learners themselves. For some people, it’s part of their DNA; they are always learning something new. Others take a more focused approach based on what they need in order to expand their current knowledge and take the next step along a professional path. Over the course of my career as a certified disability management specialist (CDMS), I have pursued both approaches to further my learning and

such as the International Association of Rehabilitation Professionals (IARP) and the Society for Human Resource Management (SHRM). With the former, I furthered my knowledge of rehabilitation practices; with the latter, I opened my eyes to the demands of a traditional human resources (HR) role. Belonging to these two professional groups led to an important epiphany: rehabilitation expertise, such as return-to-work and stay-at-work programs, could be combined with knowledge of the HR function to sup-

consulting with the Transit Authority in Washington, D.C. I was approached by someone I knew who worked in HR for the Federal National Mortgage Association (Fannie Mae). She had a job opening in her department and encouraged me to apply. I made it to the final round, but another person got the job. When I reached out for feedback, the interviewer explained their concern that, given my background in vocational counseling, executives in the organization might not respond

Lifelong learning takes many different approaches, each one as individual as the learners themselves. For some people, it’s part of their DNA; they are always learning something new. Others take a more focused approach based on what they need in order to expand their current knowledge and take the next step along a professional path. advance my professional development. I started my career in vocational rehabilitation. As I tried to establish myself in the practice, I learned through professional journals, college courses, and membership in groups Ed Quick, MA, MBA, CDMS, is a Commissioner for the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that certifies more than 50,000 professional case managers and disability management specialists. He has more than 30 years of experience in disability and workforce management with Fortune 100 companies and currently works as a global senior benefits manager. 6 CareManagement April/May 2022

port injured employees in returning to work. This dual perspective has helped me as a CDMS, acting as an advocate for injured workers while also helping employers to mitigate the cost and impact of disability and unplanned workforce absences. Expanding my knowledge in both areas has been essential to advancing my career into new areas of workforce management and reducing the frequency and impact of occupational and nonoccupational absences.

Understanding the Employer World

The next major juncture in my learning journey came when I was working as a vocational rehabilitation counselor for a third-party administrator and

as much to me as they would someone with an MBA. With that, I went back to school—10 years after earning my master’s degree in vocational rehabilitation—to pursue an MBA in human resource management and finance. Once I earned my MBA, doors began to open for me on the employer side. It’s an example of how, as a lifelong learner, I have been able to map my knowledge and skills to what the “audience” wanted—namely, current and prospective employers and the people I served. At this stage of my career, I began working for large employers in disability management and absence management. My lifelong learning also changed at this point, with less emphasis on formal continues on page 37


NEWS FR OM

THE COMMISSION FOR CASE MANAGER CERTIFICATION

Diversity, Equity, and Inclusion: Leadership in Case Management MaryBeth Kurland, MPA, CAE, ICE-CCP

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cross the business world at large and, more specifically, within health and human services, a top leadership priority is furthering the goals of diversity, equity, and inclusion (DE&I). Organizations in every industry and sector are examining their practices, from hiring to product and service delivery, through the DE&I lens. For the case management and disability management professions, being on the frontline and working directly with clients, there is arguably an even greater responsibility to adhere to and uphold DE&I principles. At stake is nothing less than contributing to greater access, equity, and justice in providing and delivering care across all populations. As the CEO of the Commission for Case Manager Certification, I believe it is imperative to embrace DE&I in my personal leadership values in support of the Commission’s broader goals. First, the Commission continues to encourage DE&I within the professional case management and disability management communities. The Commission seeks, in principle and MaryBeth Kurland, MPA, CAE, ICECCP, is the CEO of the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies more than 50,000 professional case managers and disability management specialists.

Across the business world at large and, more specifically, within health and human services, a top leadership priority is furthering the goals of diversity, equity, and inclusion (DE&I). For the case management and disability management professions, being on the frontline and working directly with clients, there is arguably an even greater responsibility to adhere to and uphold DE&I principles. At stake is nothing less than contributing to greater access, equity, and justice in providing and delivering care across all populations. practice, to respect, value, celebrate, and lift up the unique attributes of all case managers and disability management specialists. Second, it is crucial that those new to these roles have a greater awareness of the importance of DE&I, particularly as it relates to their responsibility as advocates. Case managers and disability management specialists must rise to the challenge and continue to advocate for individuals and their families/support systems who come from diverse backgrounds, particularly those from minority and traditionally marginalized groups. Such advocacy compels us to transcend our own views, beliefs, and biases in order to understand and advocate for clients and their support systems/families based on their goals. Here we find empathy and empowerment, in furtherance of autonomy and self-determination. In support of DE&I principles, the Commission has adopted both a Diversity, Equity and Inclusion and a Social Justice Statement. I encourage

all case managers and disability management specialists to read and reflect on these statements in hopes it will inspire them to find ways we can advance the cause of justice and equity as individuals and a community.

Commission’s Social Justice Statement

Case management and disability management are rooted in the ideal of service and advocacy for clients regardless of age, appearance, disability, ethnicity, gender, geographic location, nationality, professional level or practice setting, race, religion, sexual orientation, or socioeconomic status. As an organization, the Commission strives to strengthen and empower board-certified case managers and board-certified disability management specialists to exhibit these ideals in their professional lives. We are compelled to champion these ideals in both word and deed and bring continued focus to the principles outlined in the CCM and CDMS continues on page 39 April/May 2022 CareManagement 7


C ASE MANA G E R I N S I GH T S

Impact Connie Sunderhaus RN-BC,CC

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ase managers, nurses, and social workers do not just impact patient’s lives—our patients often have a much greater impact on our lives. During some recent reflections on my career, many patients and situations came to mind. A few touched me in ways they will never know. When I was a young nurse working in home health care, we did everything required on our regular visits to our patients. There were no home health aides or physical therapists on our teams. If patients needed bathing, we did it. If patients needed a level of therapy to improve muscle tone, we guided them in regular range-ofmotion exercises. One patient during that time holds a special place in my heart. She had recently turned 23, a trained classical pianist who had been living in New York City for her career. Things took a wrong turn for her as she learned she had severe multiple sclerosis. In fact, Connie Sunderhaus RN-BC, CC is currently the clinical consultant for CXJ Consulting. She has authored numerous case management articles and is a national speaker on topics of case management, public policy, communication, and patient advocacy. Connie served on the executive committee of the Case Management Society of America, she has chaired several national committees, and she is a past president and board member of the Chicago chapter of CMSA.

8 CareManagement April/May 2022

on her birthday, she came home to tell this horrible diagnosis to her new husband, and it was the same day the husband told her he wanted a divorce. She then moved back to Ohio to live with her parents, and it was during that time that I was assigned to her

Case managers, nurses, and social workers do not just impact patient’s lives—our patients often have a much greater impact on our lives care as a visiting nurse. She could no longer play the piano due to the physical changes to her hands. Walking was no longer an option and she was confined to a wheelchair. Her voice was soft due to the MS changes. We communicated and she shared that she was more disappointed by the actions of the husband than the changes caused by her disease. She and I were the same age. Although I needed to maintain a professional relationship, I recall feeling the same rage as she did about how her life had changed. She has remained in my heart for years. I only hope that I had a small impact on bringing some positivity to our visits, which was one of my goals. Although I left the agency when I became pregnant, I later learned that her parents could no longer manage her care and she was transferred to a care facility. Some things hit close to home and impact our lives and practices as time

goes on. She was my age, newly married as I was, yet our lives had traveled very different paths. In later years as both a nurse and a case manager, I was chastised, even yelled at by physicians and patients. While these things were difficult to experience, I was secure in knowing I was following the appropriate procedure, based on sound principles. For over twenty years I did occasional worker’s compensation case management. On one occasion the patient’s treating physician and I discussed with the patient the need for him to see a pain management specialist, as he was taking multiple medications for pain and wanted a way to discontinue them by finding other ways to decrease and manage his chronic pain. The patient was told the specialists would determine what refills were needed and prescribe anything going forward. At the appointment with the specialist, I waited in reception while the patient had his private appointment. Very shortly after the examination began, the specialist came out to reception and chastised me, saying, “I don’t know why he is here; he just wants me to refill his pain meds. This appointment was a waste of my time.” I listened, then asked if I could come into the room with both him and the patient. I was able to have the patient explain that he was told to bring all his medications with him and didn’t really understand the role of the specialist. The patient said he did continues on page 37


LEGAL UPD A TE I

Part 3: Updated Pharmaceutical Industry Marketing Code May Help All Providers Understand Current Standards Elizabeth Hogue, Esq.

PhRMA,

a trade association whose members are pharmaceutical research and biotechnology companies, recently updated its Code on Interactions with Health Care Professionals. The revised Code took effect on January 1, 2022. Although the Code applies only to members of PhRMA who voluntarily agree to follow it, the Code may help providers to understand current standards regarding acceptable marketing practices.

The Code addresses the issue of use of data related to referrals by marketers. It acknowledges that referral data that does not identify individual patients may be useful. Data may enable providers to: • Convey important information and education to referral sources • Conduct research • Focus marketing activities on referral sources whose patients would most likely benefit from services The Code emphasizes, however, that

providers that use data to facilitate communications with referral sources should use data responsibly. Providers should: • Respect the confidential nature of data • Develop policies that govern use of data • Educate employees and agents about applicable policies and procedures • Designate an internal staff member to handle questions about use of the data continued on page 36

Solutions to Support Hospitals Facing Nursing Shortages • Software to support time savings and efficiency • Help to reduce administrative burdens and address clinician burn-out • Consulting services to optimize clinical workflows

www.mcg.com

April/May 2022 CareManagement 9 Learn More Here


LEGAL UPD A TE I I

Return to the Roots of Healthcare: Home Care! Elizabeth Hogue, Esq.

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he roots of healthcare in the United States are clearly in the care of patients at home. Perhaps the definitive book on home care nursing in this country is No Place Like Home: A History of Nursing and Home Care in the United States authored by Karin Buhler-Wilkerson in 2001. As Ms. Buhler-Wilkerson points out in her book, the care for the sick was part of domestic life in early 19th century America. Physicians and nurses delivered care in patients’ homes, most often with the help of female family members, neighbors and perhaps servants. For those who had no one to care for them, the options for care were scarce. Enter The Ladies Benevolent Society (LBS) of Charleston, South Carolina! The LBS was founded in 1813 during the British blockade of Charleston harbor to address the needs of patients for whom there were few other options. The Society was founded by 125 women who were the wives, sisters and daughters of Charleston’s wealthiest families. The Society was a philanthropic organization only. Members raised needed funds for care of the sick and distributed them, including hiring nurses to care for patients in their homes. A visiting committee conducted the daily work of the Society. Patient load varied with the seasons Elizabeth Hogue, Esquire, is an attorney who represents health care providers. She has published 11 books, hundreds of articles, and has spoken at conferences all over the country. 10 CareManagement April/May 2022

“My view, you know, is that the ultimate destination of all nursing is the nursing of the sick in their own homes… I look to the abolition of all hospitals… But no use to talk about the year 2000.” –Florence Nightingale, June, 1867 and the occurrence of epidemics. In the early years, the Society cared for an average of 290 patients annually. Ms. Buhler-Wilkerson says in her book: “Most important, the LBS supplied the sick poor with nurses, for ‘of what avail are medicines or proper nourishment, unless there be some kind hand to administer them in due season?’” The single most persistent problem for the ladies of the Society was the “vexed question of the chronic patients.” The ladies sometimes found it difficult to stop providing assistance to patients who were no longer acutely ill. One of these patients was described as follows: “Ms. Cowie is an old woman - she has leprosy - and so long, and so greatly has she suffered under it, that her hands are drawn up and deformed. Her eyes are in a state of inflammation - and her body a perfect Skeleton. She is indeed a pitiable object - calling forth compassion of every beholder…our hearts bled when we beheld her.” The financial burden on the Society, especially for the care of chronically ill patients, was substantial. The LBS was solely dependent on

donations to meet expenses. According to Ms. Buhler-Wilkerson, the mission of the LBS became complicated by the unpredictable variables of caring for the sick at home. These variables included family circumstances, chronic disease and poverty. The Society struggled to address these issues. Despite the fact that these variables continue to complicate the provision of care, home care has once again become the “fashion.” An increasing number of treatments such as joint replacements are provided in outpatient settings with the bulk of care rendered in patients’ home post-operatively. It is clear, contrary to Florence Nightingale’s prediction above, that hospitals will always have a role to play in the delivery of healthcare. It is also clear, however, that home care of all types provides an important answer to many dilemmas currently encountered in the healthcare industry and is, therefore, ascendant! CM ©2022 Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author.


CE1

Approved for 1 hour of CCM, CDMS, and nursing education credit Exam expires on October 15, 2022

Pandemic Era Developments for Postacute Care Networks: Part II Laura Kukral, MBA, LNHA, and Ben Frank, MHA, FACHE

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ostacute care networks (“networks”) are changing in response to the impacts of COVID-19. These changes include network structures, size, membership, goals, and use of technology. One of the most notable changes is the inclusion of “super skilled nursing facilities (SNFs)” to provide integrated specialty care modeled after hospital-based service line best practices.

What is a Service Line?

A service line is an organizational and managerial model that follows the patient’s path through the care process to provide and integrate all the services they may need for a medical condition (eg, cardiac care) at a single location or set of locations. Hospital service lines emerged in in the 1990s in response to the demand for integrated care and the need for caregivers to “cut across both institutional and disciplinary boundaries to organize patient care around specific diseases, interventions or populations” (Charns et al., 2001). Before service lines, patients found that hospitals offered a piecemeal system of care with many siloed physicians and departments. Laura Kukral, MBA, LNHA, is a consultant in healthcare strategic planning and innovation. She has 30 years’ experience helping health systems, postacute providers, and community-based organizations with growth and innovation planning. She is currently the President of S-gen Marketing, LLC, and is a go-tomarket and innovations advisor for 3AimPartners, LLC, and SciMedi, LLC. She can be reached at LauraK@s-genmarketing.com. Ben Frank, MHA, FACHE, is Chief Executive Officer at 3AimPartners, LLC, a healthcare consultancy focused on improving patient experience, the health of populations, and cost of care. Ben previously served as the Market President for Chen Medical, System Chief Operating Officer and Chief of Staff for Inova Health System, and System Executive Director of Clinical Operations at the Cleveland Clinic. He can be reached at Ben@3aimpartners.com.

When Johns Hopkins Medicine moved to the model, it was described as a sea change in patient care with the expectation that patients could call a single phone number and enter the system at the right place and into a care path that was more efficient and effective (Blum, 2017). Service lines were established as strategic collaborations between physicians and hospital managers, with physicians designing the clinical process and managers providing day-to-day oversight (Becker’s Hospital Review, 2012). While health systems historically focused on organizing care (and service lines) inside the walls of the hospital, programs such as Medicare’s Value-Based Purchasing Program, Hospital Readmission Reduction Program, and Bundled Payment Care Initiative (BCPI) established incentives for collaboration with providers across the entire continuum of care, notably postacute care providers. Hundreds of hospitals and physician group practices initiated BPCI Model 2 agreements that bundled payments for a Medicare beneficiary’s hospital inpatient stay and all postacute care (CMS, 2022) and gained experience in coordinating care with SNFs. These early collaborations frequently identified preferred providers and created shared care paths. They generally did not result in integrated service lines and strategies because of a variety of obstacles including strategic priorities, organizational culture, and limited understanding of the rules and regulations required at various levels of care as well as disparate data sources, lack of governance and legal structure, and questions about funding, availability of staff and equipment, and costs of care.

Service Lines Across the Continuum of Care

Despite development challenges, specialty programs have a long history in skilled nursing (Marselas, 2021). Notably, the COVID-19 pandemic seems to have created more specialty and service line partnership opportunities for postacute care providers and hospitals, “especially for those who can demonstrate prowess with cardiac, pulmonary, renal failure, sepsis and neurologically impaired patients” (Marselas, 2021). According to PointRight, a data analytics company, the skilled nursing industry experienced a nearly 5x increase in April/May 2022 CareManagement 11


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Postacute care networks are changing in response to the impacts of COVID-19. These changes include network structures, size, membership, goals, and use of technology. One of the most notable changes is the inclusion of “super skilled nursing facilities (SNFs)” to provide integrated specialty care modeled after hospital-based service line best practices.

extensive services including isolation, tracheostomy, and ventilation between fiscal year quarter 4 (FYQ4) 2019 (prepandemic) and FYQ4 2020 (Arellano, 2021). The cause of the dramatic rise is thought to be threefold: 1) the high number of frail elderly diagnosed with COVID-19 and receiving SNF care; 2) a heightened preference for home health over SNFs during the pandemic resulting in SNFs caring for the sickest patients; and, 3) financially attractive reimbursements for medically complex care. Historically, health systems focused on organizing care (and service lines) inside the walls of the hospital and among its physicians. However, payer policies and programs such as Medicare’s Value-Based Purchasing Program and Readmission Reduction Program incentivized hospitals and accountable care organizations to extend their efforts to coordinate care and collaborate with postacute care providers. Although, many of these collaborations engaged specialty physicians and identified preferred providers and care paths, they generally did not result in clinically integrated service lines between hospitals and postacute care providers. The silos still exist. The lack of integration across the continuum impacts patients and providers in several ways. From the patient’s perspective, when they leave the hospital for postacute care a breach can occur in the patient-centered care approach that the service line model intended to address. Patient compliance with the plan of care for rehabilitation, medications, or other services necessary to recover and avoid rehospitalization is at risk as soon as the patient leaves the hospital setting. From the postacute care providers’ perspective, alignment with service line care paths is more difficult when presented as a hodgepodge of orders without the umbrella of knowledge and tools that service line integration offers them. As acuity increases, SNFs face higher staffing demands, training needs, additional compliance requirements, and an increased need for agreed-upon care paths, shared electronic health records, and data. Health system service line integration is increasingly critical if valuebased goals are to be achieved and sustained.

The Super SNF Approach

Hospitals and payers often distinguish service lines as Centers 12 CareManagement April/May 2022

of Excellence when they consistently deliver high value (superior quality, cost, and patient experience). Likewise, “super SNFs” are high performing SNFs overall and provide one or more types of high acuity specialty care. To identify examples, the authors looked for SNFs consistently rated four or five stars overall by the Centers for Medicare & Medicaid (CMS) that had high-skilled care volume and a regional draw area as well as preferred status in payer and health system networks, low readmission rates, and at least one high-performing specialty service. These facilities became a critical resource, particularly during the pandemic, because they provide near hospital-level care facilitating regional inpatient acute capacity and service-line specific outcomes (Kukral & Frank, 2022). One example is Andover Village Skilled Nursing & Rehabilitation (SNR), a five-star rated facility located in rural Ashtabula County, Ohio (Kukral & Frank, 2022) (Figure 1). It meets the author’s criteria for Super SNF status and draws patients from a broad geographic area including Cleveland and Columbus, Ohio as well as Pittsburgh, Pennsylvania. More than half (52.4%) of the facility’s skilled nursing admissions between Q3 2020 and Q2 2021 originated from outside of its home county (Ashtabula, OH). In addition to its referral partnerships with Ohio hospitals, patients were admitted to the facility during the reporting period from eleven hospitals in Pennsylvania and one in New York State. Andover Village Skilled Nursing & Rehabilitation differentiates itself by colocating ventilator services with a freestanding dialysis center operated by DaVita. Its average hierarchical condition category patient risk score is defined as very high at 3.73, its 30-day overall readmission rate based on 2 years of discharges from skilled care is 14.08%, and its most recent year Medicare length of stay is 21 days. The facility’s quality is driven by its respiratory care program which, despite its very high acuity and vent-dialysis program, has a lower 30-day respiratory readmission rate (17.14%) than the Ohio average (18.54%) for SNF patients in the respiratory diagnostic group based on CMS data reported between Q3 2020 and Q2 2021. The average Medicare length of stay for respiratory care patients is 27 days, with a 16-day median length of stay, which is also lower than the Ohio average length of stay for respiratory care (25 days) and the 19-day median length of stay. Other respiratory


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FIGURE 1

Exclusively for ACCM Members

ANDOVER VILLAGE SKILLED NURSING & REHABILITATION: Patient Acuity by Diagnosis-Related Group

Respiratory System Skin Diseases Nervous System Injury & Poisoning Infectious Diseases Genitourinary System Endocrine & Metabolic Digestive System COVID-19 Circulatory System

0

10

20

30

40

Patient Count Low Acuity

Medium Acuity

High Acuity

quality indicators include a ventilator-associated pneumonia rate for the most recently reported period of zero (Ohio Department of Medicaid, 2020). The facility’s acuity (Table 1) is reflective of its ventilator and hemodialysis programs. About 35% of skilled nursing patients are admitted to Andover Village SNR with a respiratory diagnosis, compared with a state average of 10% during the same period (Trella Health, Atlanta, Georgia). Although many SNFs offer high quality overall, superior outcomes for specific diagnosis-related groups (DRGs) are what makes them “super” for patients needing a particular type of care. Readmission rates for DRGs are of interest to network curators because the overall readmission rate does not address underlying variation in SNF performance by DRG (Oruongo et al., 2020). In other words, a high-performing postacute care provider overall may not be high performing in dialysis care, ventilator care, or some other DRG. Research using Medicare claims data and grants supported by multiple organizations including the Health Innovation Program and the UW School of Medicine and Public Health reflect TABLE 1

considerable differences in readmission rates across SNFs by DRG category despite similar overall readmission rates (Oruongo et al, 2020). The investigators suggest that hospital discharge teams be equipped with SNF readmission rate by DRG categories so they can direct patients to facilities with high-quality care specific to their conditions (Oruongo et al., 2020). They go on to add, “policy makers could better identify opportunities for increased value by encouraging specialization and innovation among SNFs” (Oruongo et al., 2020).

The Care Manager’s Role

Care managers may first want to use internal data to evaluate the performance of preferred networks by the types of patients being discharged, the discharge level of care, and the performance of specific network members. They may also want to inventory and evaluate the capabilities and performance of network members for DRGs. According to a Healthcare Financial Management Association article, one reason health systems are well positioned to improve the value of postacute care is because

READMISSION AND LENGTH OF STAY FOR ANDOVER VILLAGE SKILLED NURSING & REHABILITATION VS. STATE OUTCOMES. All Diagnosis

All Respiratory

High Acuity Respiratory

Ventilator > 96 Hours

Facility

State

Facility

State

Facility

State

Facility

State

Readmissions (30-day Medicare fee for service)

14.08%

16.18%

17.14%

18.54%

18.75%

19.44%

Insignificant

33%

Length of stay (average Medicare days)

21

26

27

25

NA

NA

50

35

Note: Data reflect Medicare fee-for-service patients admitted to skilled nursing facilities between Q3 2020 and Q2 2021. April/May 2022 CareManagement 13


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A service line is an organizational and managerial model that follows the patient’s path through the care process to provide and integrate all the services they may need for a medical condition (eg, cardiac care) at a single location or set of locations.

they play a central role in organizing service offerings (Maksimow & Samaris, 2018). The investigators go on to identify four health system activities that are critical to effective network operations including market needs assessment, network evaluation, network design, and alignment options (Maksimow & Samaris, 2018). Given the underlying variation in postacute care performance by DRGs mentioned earlier in this article, we suggest a DRG-based analysis using all four of these steps to identify service line alignment and development opportunities. Care managers are uniquely qualified to contribute to all steps. During the market needs assessment, care managers can be a critical resource to identify: • The strategic framework for the postacute care strategy including the latest problems to be solved • DRG-based opportunities for improvement in readmissions, costs of care, and patient satisfaction, if any • Data sources (both internal and external) including those for DRG-based assessment of post-acute problems and needs

TABLE 2

• Network alignment and service line opportunities to evaluate further • Key considerations for the scope, approach, and methodology to be used by planners to assess and determine the postacute care market strategy • Operational considerations such as past issues with postacute care access by setting and location Service line development opportunities should be explored for high-acuity DRGs such as ventilator care, dialysis, sepsis, neurological rehabilitation, cardiac rehabilitation, behavioral health, and any of the organization’s high-volume service lines. Once needs for DRG-based outcomes improvement are identified, care managers can contribute to the development of specialty programs across the continuum of care by facilitating: • The goals and measures that postacute care specialty programs would be expected to accomplish • Referral pathways for appropriate levels of care and key clinical condition

ROLES AND RESPONSIBILITIES IN INTEGRATED SERVICE LINE DEVELOPMENT

CARE MANAGERS

POSTACUTE CARE PROVIDERS

PLANNING OFFICE/STRATEGY

Problems to be solved

Problems to be solved, projections

Enterprise prioritization

DRG-based improvement opportunities

Specialty care capacity

Projections

Data sources

Data sources

Data sources

Service line opportunities for postacute care alignment

Business case analysis for specialty care development and integration

Business case analysis for specialty care development and integration

Operational considerations

Operational considerations

Consideration of options for build/buy/ partner

Goals a postacute care specialty program should accomplish

Compliance standards

Designation of work plan leadership, accountability, and participants

Referral pathways

Postacute care best practices

Engagement from service line experts

Clinical input

Protocols for placements and communication

Protocols for admission and communication

Status reports

Project management support including medical directorship and training

Implementation: Staffing, equipment, licensure

Project oversight

Identify:

Facilitate:

14 CareManagement April/May 2022


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Care managers may first want to use internal data to evaluate the performance of preferred networks by the types of patients being discharged, the discharge level of care, and the performance of specific network members. They may also want to inventory and evaluate the capabilities and performance of network members for diagnosis-related groups.

• Engagement from service line experts including medical directors, executive directors, hospitalists, SNFists, and telehealth clinicians as well as business analysts and strategists • Protocols for patient placement, communication with postacute care partners, patient communication, and public or other cobranded communication • Project management office oversight for shared work plans across the continuum, resource acquisition, status reports, and obstacle resolution Regardless of where they work (hospital, postacute care, or other level of care), care managers should seek support from their enterprise-level strategy office and/or project management office. The strategy office and project management office functions are responsible for enterprise priorities, timing, and resource allocation. These teams are skilled at forecasting and can help evaluate the return on investment of specialty care integration with postacute care providers. They will consider such things as potential improvement in value (costs/quality/experience), how much time the hospital’s clinical staff will invest in meetings, out-ofpocket costs, legal risks and mitigants, and more. In addition, the strategy office is often tasked with considering a range of options including “build, buy, or partner” that care managers may not be empowered to explore. Likewise, the project management office offers tools and resources to ensure proper governance if a project ensues and can provide work plan leadership and oversight. Care managers should also anticipate significant contributions and leadership from postacute care providers in specialty care program development and integration. Prospective partners most likely have existing specialty care programs and can offer compliance expertise specific to the postacute level of care, best practice guidance, and data about their operations. SNFs have long made specialty care investments based on market needs and can likely bring DRG-based information to the conversation for a regional area including patient need forecasts, costs and reimbursement trends, and DRG-based outcomes like length of stay, readmissions, and Medicare Spending Per Beneficiary. Health systems are pursuing a variety of postacute care, service line, and population health strategies that must be

coordinated and prioritized at the enterprise level. Networks evolve and should reflect market needs. Toward this end, care managers can offer expertise, facilitate relationship building, and encourage flexibility in the design of high-performing postacute care partnerships and service lines that are as effective across the continuum as they are within the hospital ecosystem (Table 2). CE1

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References Arellano, M. 2021. Do Increases in Patient Acuity Present a Problem for SNFs? PointRight. https://pointright.com/increases-in-patient-acuity-aproblem-for-snfs/ Becker’s Hospital Review. 2012 June 14. Structuring Hospital Service Line Management for Success. https://www.beckershospitalreview.com/hospitalkey-specialties/structuring-hospital-service-line-management-for-success. html Becker’s Hospital Review. 2021 April 30. The rise of home-based care: How Jefferson Health is engaging more patients at scale. https://www.youtube.com/ watch?v=uZBnaq0Kb6Y Blum, K. 2017 May 8. Service Lines Put the Patient First. Johns Hopkins Medicine News & Publications. https://www.hopkinsmedicine.org/news/ articles/service-lines-put-the-patient-first Centers for Medicare and Medicaid Services. 2022 January 18 (Last updated on). Bundled Payments for Care Improvement (BCPI) Initiative: General Information. https://innovation.cms.gov/innovationmodels/bundled-payments Charns MP, Wray NP, Byrne MM, Meterko MM, Parker VA, Pucci LG, Fonseca ML, & Wubbenhorst WH. 2001 April. Service Line Management Evaluation Project Final Report. The Management Decision and Research Center, Houston Center for Quality of Care and Utilization Studies. https://www.research.va.gov/resources/pubs/docs/service_line.pdf

continues on page 38 April/May 2022 CareManagement 15


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Getting Back Into Focus: Revisiting Reasons for the Hospital Readmissions Reduction Program Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN

S

ince 2009, there has been a focus on reducing and preventing hospital readmissions in acute care facilities. Potentially preventable readmissions have been related to failed or ineffective discharge planning, especially for patients with chronic high-focus diseases such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Chronic condition management is a major factor in rising health care costs. The extensive costs per hospital admission associated with CHF and COPD (including care, medication, and therapy) represents a major financial liability to health care systems, and a significant component of these costs is unplanned avoidable readmissions. From the perspective of the facility, the factors that are driving the need to reduce readmissions include cost containment, achievement of performance initiatives, penalty avoidance, and improvement of quality indicators and patient experience. National awareness of adverse medical outcomes occurring within care settings continues to rise through quality data reporting, patient satisfaction reports, and a dedication to health care transparency. The expanding evidence base points to comparable problems occurring during the transitions between care settings. There is a key opportunity to develop interventions to improve the quality of patient transitions from acute care to community with a goal of reducing readmissions. Case managers are in an optimal position to develop interventional programs for effective patient transitions. These specially trained health care professionals are adept at developing discharge plans and accessing resources for postacute care. With an eye to the revenue cycle, they can make an impact by helping the facility avoid the potential financial ramifications associated with readmissions by improving patients’ outcomes and by helping patients remain in their own environment which, in turn, improves patient satisfaction.

Historical Information

According to data from the Centers for Medicare & Medicaid Services (CMS), acute hospital readmissions (defined as a 16 CareManagement April/May 2022

readmission within 30 days following postacute discharge) for chronic condition management were associated with $26 billion in Medicare spending in 2011. According to CMS, the population of people diagnosed with chronic medical conditions is predicted to rise to 125 million by the year 2020 (Centers for Medicare & Medicaid Services, 2012). A significant increase in this population will lead to increased spending at a time when the Medicare program itself appears to be in financial trouble. As an example of the impact, the 30-day readmission rates for patients with CHF are reported to be as high as 34% and the cost of managing CHF in the United States is estimated to be at least $10 billion per year. The current COPD population is estimated at 12.7 million diagnosed people, and COPD 30-day readmission rates are reported to be 27% nationwide with associated costs estimated to be $11.9 billion annually in health care dollars and an average annual cost per beneficiary of $9,545 according to Medicare claims data (Centers for Medicare & Medicaid Services, 2017). In a review of 2004 Medicare claims data, Medpac reported that readmissions accounted for almost 10% of all Medicare expenditures; $17.4 million in spending was attributed to unplanned hospital readmissions, of which $12.0 million was traced to what were identified/defined as “preventable readmissions” (Medpac, 2007). Readmission reduction is included in the Patient Protection and Affordable Care Act (PPACA), providing for both penalties and incentives for failure or success in Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN, is the Regional Director of Case Management for Pipeline Health Systems/Chicago Market. She has held positions at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for over 14 years. Her current passion is in the area of improving health literacy. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) for her work in this area.


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According to data from the Centers for Medicare & Medicaid Services (CMS), acute hospital readmissions (defined as a readmission within 30 days following postacute discharge) for chronic condition management were associated with $26 billion in Medicare spending in 2011. According to CMS, the population of people diagnosed with chronic medical conditions is predicted to rise to 125 million by the year 2020. A significant increase in this population will lead to increased spending at a time when the Medicare program itself appears to be in financial trouble. reducing potentially preventable readmissions. Under Section 3025 of the Affordable Care Act, the establishment of the Hospital Readmissions Reduction Program requires CMS to reduce payments to participating hospitals with excess readmissions effective October 1, 2012 (Centers for Medicare & Medicaid, 2015). Quality initiatives such as The Joint Commission on Accreditation of Healthcare Organizations’ and the National Quality Forum’s increased focused on medication reconciliation, the discharge planning process, and examining performance measures for posthospitalization care coordination are examples of endeavors to improve the transitions of care process. Additionally, the Institute of Medicine has advocated for pay for performance measures to motivate health care providers to improve patient care coordination across settings. The result is a focus on transitional care, patient satisfaction, and overall quality of care. The guidelines rolled out by Medicare in 2010 and confirmed by the PPACA in 2012 state readmissions within a 30-day period are reviewed very closely and, in some instances, will not be reimbursed (Centers for Medicare & Medicaid Services, 2012). Facilities with significant readmission rates for certain target diagnoses also run risk of further financial penalties being imposed. Readmission reduction programs have been recommended for implementation and acute care hospitals have been facing yearly penalties based on readmission rates since the 2012 target date discussed in the original Medpac report (Medpac, 2007). The PPACA proposed the methodology for calculating the readmission payment adjustment factor and the process for hospitals to review readmission information and submit corrections as needed. The maximum penalty for 2013 was capped at 1% of total Medicare reimbursement; in 2014 this penalty rose to 2% of total Medicare reimbursement, and in 2015 hospitals can be penalized as much as 3% of their total annual Medicare payment and will also receive reduced payment for each hospital admission/length of stay for the target diagnoses (Centers for Medicare & Medicaid Services, 2015). The initial 2013 penalty is determined by data collected on the identified diagnoses during the initial evaluation period

of July 2010 to June 2013 to determine if the hospital had too many readmissions. This created a baseline for each facility from which improvement/failure to improve would be measured against in subsequent periods via CMS. Timeline of the Hospital Readmissions Reduction Program (HRRP) Evolution In 2012, the HRRP established the definition of readmissions and the initial diagnoses to be followed. These included CHF, acute myocardial infarction, and pneumonia. The 3-year lookback period to establish baseline readmission data was also set. Additional diagnoses were added in 2014: COPD, total hip arthroplasty, and total knee arthroplasty. In 2015, coronary artery bypass graft was added. The year 2016 marked the adoption of the “Extraordinary Circumstances Exemption” that allowed hospitals that experience a significant disaster or other extraordinary circumstance beyond the hospital’s control (hurricane, flood, fire) to request an exemption from the HRRP for a period of time. The 21st Century Cures Act in 2018 directed CMS to assess a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and full Medicaid benefits beginning in FY2019. Starting in FY2019, CMS takes into account the proportion of low-income patients within a hospital because they are more likely to be readmitted due to other socioeconomic factors. Finally, a focus on the impact of social determinants of health on readmissions! The year 2019 also gave us finalized definitions of dual eligible, dual proportion, and the applicable period of dual eligibility. It also created alignment with the Meaningful Measures initiative and, beginning FY2020, the 6 readmission measures were removed from the Hospital Inpatient Quality Reporting Program so that hospitals were not facing penalties twice for the same measure.

Current Readmissions Data

Current readmission data shows that 15.5% of Medicare patients are readmitted within 30 days. Data from 2010 show a Medicare All Cause Readmissions rate of 18.3%, and April/May 2022 CareManagement 17


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The interventions for readmission reduction can be classified into the following major categories: telephonic follow-up calls, discharge planning services, patient education/ teaching, and comprehensive care coordination.

data from 2014 reported readmission rates of 17.3%. The total overall readmission reduction for Medicare All Cause Readmissions for 2010 versus 2019 is 2.8%. Condition-specific Medicare readmissions decreased significantly for heart failure (from 34.0% to 21.9%) and for COPD (from 27.0% to 19.7%). Patient populations with chronic conditions will continue to rise from 133 million in 2020 to a projected 170 million in 2030. Costs of care will also rise accordingly. According to the Institute for Healthcare Improvement (Institute for Healthcare Improvement, 2017), current research has demonstrated that the rate of readmissions can be reduced by improving discharge planning and care coordination between all levels of the care continuum concurrent with providing increased opportunities for patient coaching, education, and support for self-management. Implementation of these interventions from the time of admission through the immediate 30-day postacute period may decrease readmissions and improve quality of care.

Healthcare Theory in Action

Patient coaching and education need to be tailored to the individual patient’s needs. Watson’s Caring Model and Ray’s Theory of Bureaucratic Caring stress that a patient’s individualism must be considered in all aspects of care. Case management uses the ethics of care to develop a patientcentered plan of care across the continuum with a focus on the right care, the right setting, and the right timing as well as patient engagement in the plan. While creating a patient’s discharge plan, the goals of the patient are considered concurrently with their ongoing medical needs. By working holistically and considering the patient’s perspective, a mutually satisfactory discharge plan can be developed with a greater potential for success. Watson’s Caring Theory reminds us that people are not objects and live in context with their surroundings. Watson reminds us that “caring is possible and must be present as much as when curing has failed as when cure is possible” (Nelson-Marten, 1998). In the case of chronic condition management, where a “cure” is not achievable for the patient, it is the duty of nursing to find solutions to provide the best possible outcomes for all stakeholders involved. With the ongoing changes to the healthcare environment, 18 CareManagement April/May 2022

especially when considering reimbursement and access to care, Watson prompts health care leaders to incorporate Caring Theory into active daily practice. Current models in place have co-opted the language of Caring Theory to refer not to the quality of care or holistic healing offered to patients but rather to having the most advanced technology available, recruiting well-known practitioners, and having other services available. Use of the terms “health care consumer,” “provider,” or “health care worker” depersonalizes the intensely personal “business of health care” and shifts the focus from authentic caring to an economic exchange of fees for goods or services (Watson, 2006). Caring should be recognized as a “legitimate economic resource” as studies have demonstrated that patients who experienced caring reported “emotional-spiritual well-being, increase in patient safety, decrease in costs, increase in trust relationships” (Watson, 2006). The Theory of Bureaucratic Caring by M.A. Ray identifies that caring is distinguished by the situation in which it is being applied but is patient-centric no matter the circumstance. In Ray’s theory, the stakeholders integrate a holistic approach to patient care using an interprofessional care team and transform the outcomes; this demonstrates the belief that nurses can challenge and change organizational culture while reinforcing the commitment to caring. This theory has been reviewed and updated several times since it was first published in 1987; the most recent update incorporates the spiritual and ethical origin with other perspectives, including political, economic, and other nontraditional healthcare focus areas. Bureaucratic Caring Theory has been demonstrated to make a positive impact on chronic condition management to achieve high-quality outcomes for this at-risk population. Additionally, Wagner’s Chronic Care Model seeks to “optimize each healthcare team member’s abilities, expertise and willingness to achieve high-quality health outcomes…that are safe, necessary, cost-effective, timely, desired and patient-centered” (Potter and Wilson, 2017). Patients in programs that use this model reported higher satisfaction with the health care team and increased confidence in managing their chronic conditions. Case management applies these theories by coordination of care and postacute care services or resources in alignment with the patient’s needs, provider’s recommendations, and


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benefits available under the patient’s payer plan and network. The Standards of Practice for Case Management direct case managers to be advocates for patients and to contribute to improved health outcomes by fostering case management growth and development, impacting health care policy, and providing evidence-based tools and resources. Professionals in the case manager role assume the role of “advocates who help patients understand their current health status, what they can do about it, and why those treatments are important…by guiding patients and providing cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently” (Case Management Society of America, 2016). Through specific case management interventions, patients benefit from strategies to manage wellness and chronic conditions through a decrease in the fragmentation of the health care system (Brock, 2011). Evidence-Based Practice Interventions to Reduce Readmissions The interventions for readmission reduction can be classified into the following major categories: telephonic follow-up calls, discharge planning services, patient education/teaching, and comprehensive care coordination. Telephonic follow-up models can be grouped into 2 subcategories of single-call and multiple-call formats. Single-call models focus on addressing gaps in education and medication reconciliation. Outcomes from Harris et al. (2016), using a single-call model for a COPD population, demonstrated a decrease in 30-day readmissions from 20.05% preintervention to 11.25% postintervention. Melton et al. (2016) implemented a single post-discharge call intervention that was focused on three topics: review of discharge instructions, medication education, and confirmation of scheduled follow-up appointments. This single event intervention demonstrated a 22% reduction in readmission for the population of 1,994 participants. Multiple-call formats include programs with duration of 30 days to 1 year postdischarge. A study by Copeland et al. (2010) reported significant decreases in readmission rates for CHF patients within 60 days postdischarge; after 1 year, there were no significant differences in the pre- or postintervention populations. Call content included patient education, lifestyle changes, diet, medication, and early identification of symptom exacerbation. Takeda et al. (2012) followed patients for 6 months with a specially trained nurse (RN) to provide education and medication reconciliation and to schedule medical appointments. This program demonstrated a 58% reduction in readmissions for the CHF population. Patient education is a focus of all the interventions reviewed in this proposal. Several of the studies evaluated

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intensive “education only” plans. Blee et al. (2015) used a pharmacist-driven medication education program to increase understanding and compliance with medication usage. Readmissions for COPD were reduced from 21.3% preintervention to 8.6% postintervention. Cavalier and Sickels (2015) developed a checklist for chronic care management education that was focused on patients with CHF and COPD. The checklist drives the patient education throughout the inpatient admission to account for all education required for effective diagnosis management. Use of the checklist reduced readmission from 28.8% to 17.4%. Education has long been seen as a way to empower and engage patients in their self-management. The importance of patient education is underscored by the need to effectively coach patients through self-management strategies. Linden and Butterworth (2014) reported on use of motivation interviewing techniques to increase patient engagement; these techniques were started while the patient was hospitalized and continued periodically through the initial 90 days postdischarge. While this intervention did not produce a statistically significant reduction in 30-day readmission rates, patients reported feeling more educated about their chronic conditions and more engaged in their self-management. Pomerantz et al. (2010) investigated the use of “care coaches” in a telephonic engagement model to improve clinical outcomes. The care coaches were identified as RNs with experience in behavior modification strategies and were supported by an interprofessional care team. Their primary intervention was “to educate and motivate patients to achieve sustained behavior change” (Pomerantz et al., 2010). Through the establishment of one-on-one relationships and a scheduled structured outreach program over a 1-year period that included 3,305 participants, the care coach program demonstrated a decrease in admissions per thousand from 44.91 to 23.66. The study also noted a decrease in the average length of stay and decrease in the use of the emergency department, which were associated with a reduction in cost of care for the population. Comprehensive care coordination models have been shown to demonstrate the most impact on reducing readmissions for the target populations. Six demonstration program studies were reviewed. Each model featured the goal of using a holistic approach to develop collaborative interdisciplinary teams to facilitate patient self-management from the time of admission through a defined postdischarge period and included vital interventions currently absent from the standard discharge process. Assessment and evaluation of the patient’s available social supports and the need to restructure the discharge process to eliminate fragmentation and communication breakdowns were acknowledged as top priorities. Top strategies include the consistent use of April/May 2022 CareManagement 19


CE2

Approved for 1 hour of CCM, CDMS, and nursing education credit

Exclusively for ACCM Members

Case managers are in an optimal position to develop interventional programs for effective patient transitions. These specially trained health care professionals are adept at developing discharge plans and accessing resources for postacute care. With an eye to the revenue cycle, they can make an impact by helping the facility avoid the potential financial ramifications associated with readmissions by improving patients’ outcomes and by helping patients remain in their own environment which, in turn, improves patient satisfaction.

continuous medication reconciliation at each level of care, use of standardized tools and patient education across the care continuum, active coordination of follow-up appointments including making and confirming follow-up appointments before discharge, an effective real-time handoff to the next level of care, and making contact with the patient within 48–72 hours postdischarge to review and reinforce the discharge plan; these strategies increase the communication needed to effect a successful transition. Recognized comprehensive case management programs using these techniques, which include Project BOOST (Better Outcomes for Older Adults through Safe Transitions), Project RED (Re-engineering Discharge), STAAR (State Action on Avoiding Rehospitalization), Naylor’s Transitions of Care Model (TOC), Coleman’s Care Transitions Interventions (CTI), and Hospital to Home (H2H), have all produced documented decreases in readmission rates with use of varied strategies. BOOST reported a 21% reduction, and RED reported readmission rates decreasing from 24% to 16% on average. CTI data demonstrate a 13.8% readmission rate in the control group versus an 8.9% readmission rate in the study group. TOC did not report 30-day readmission rates but did note a reduction in patient days for the target population. The control group used 760 inpatient days versus 270 inpatient days for the study group. Bobay et al. (2015) noted that many of the 32 hospitals surveyed are using one of these identified transitional care models as a base, although they have customized their programs by combining features of other models to address their specific populations and needs.

Conclusion

The use of some type of transitional care has been demonstrated to produce measurable results in readmission reduction while also linking the patient with support and resources in the 30-day postacute hospitalization period. The current state of the discharge process continues to be shown to be ineffective at successfully transitioning patients with chronic conditions back to the community. The current discharge process needs to evolve from physician orders and 20 CareManagement April/May 2022

written discharge instructions accompanied by a stack of indecipherable patient education handouts and recommendations with a suggested follow-up time frame to a true transitional process with active navigation through the immediate postacute care period; the focus should be on process improvement, stakeholder education, and creation of an active interprofessional collaboration to provide the best support and education for each patient. Research and the growing evidence base demonstrate that interventions started in the acute facility and carried through the transition to the community for a minimum of 30 days are effective at reducing readmissions. Case management research is important in providing our patients with a safety net for success! CE II

CE exams may be taken online! Click the link below to take the test online and then immediately print your certificate after successfully completing the test. Members only benefit! This exam expires October 15, 2022.

Take this exam online > Members who prefer to print and mail exams, click here. You must be an ACCM member to take the exam, click here to join ACCM.

References Blee, J., Roux, R., Gautreaux, S., Sherer, J. and Garey, K. (2015). Dispensing inhalers to patients with chronic obstructive pulmonary disease on hospital discharge: effects on prescription filling and readmission. American Journal of Health System Pharmaceuticals, 72 (6), 1204-1208. Bobay, K., Bahr, S. and Weiss, M. (2015). Models of discharge care in Magnet® hospitals. The Journal of Nursing Administration, 45(10), 485-491. Brock, J. (2011). How care coordination affects you. CMSA Today, 1(2), 8. Case Management Society of America. (2016). Standards of practice for case management. CMSA, Little Rock, AR. Cavalier, D. & Sickels, L. (2015). The fundamentals of reducing HF readmissions.

continued on page 36


Approved for 1 hour of CCM, CDMS, and nursing education ethics credit Exam expires on April 15, 2023

Moral Injury: Health Care Providers and the Pandemic Janet S. Coulter, MSN, MS, RN, CCM

W

hat is moral injury? How has it affected health care providers? During the pandemic, health care providers have faced many issues that have taken a toll on their physical, emotional, spiritual, and psychological well-being. Unfamiliar and potentially highly distressing work experiences were commonplace. Health care providers were placed in situations where they had to make difficult decisions that sometimes contradicted their values and beliefs. Sometimes one set of values (example: caring for patients with COVID-19) had to be prioritized over another (example: keeping family members safe from infection), causing an ethical dilemma. Choosing between professional values and duties and the fundamental priority to protect your family from harm can create internal dissonance. This conflicts with moral beliefs, thus causing a moral injury (Watson et al., 2020). Moral injury may happen when health care providers are called to work in extremely difficult circumstances and they witness a great deal more suffering and death than what is normally expected. Moral injury may also develop when a health care provider is caring for someone while experiencing a life-threatening situation themselves. Moral injury can also develop in health care providers when they are present for end-of-life scenarios that are counter to their beliefs about how people should die, such as patients dying without their loved ones present. Moral injury creates psychological disequilibrium, negative feelings, and a deep emotional wound that touches the deepest core of one’s being. Moral injury is a new concept in health care that can have a serious impact on mental health. The concept was first coined by the military when Vietnam veterans returned home in the 1970s. Most research to understand moral injury has been with military service members, veterans, and law enforcement officers. Moral injury has been defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Dean et al., 2019). Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual response to acting

or witnessing behaviors that go against one’s values and moral beliefs (Norman et al., 2020). In the Diagnostic and Statistical Manual of Mental Disorders, moral injury is referred to as secondary trauma. Dean and colleagues state that the difference between burnout and moral injury is that in burnout the root of the problem lies in the broken individual who lacks resilience. In moral injury, the root of the problem is in the broken system that has prioritized profit over healing (Dean et al., 2019).

Clinical situations

A 26-year-old mother of three small children was admitted with a diagnosis of COVID-19. She had several comorbidities including diabetes, hypertension, and asthma. She was rapidly declining with increased oxygen needs. The hospital has a “no visitors” policy, so her husband was not allowed at the bedside. The patient’s deteriorating condition was discussed with her husband. He begged to see his wife. He reported that the family had been quarantined at home for the past 12 days and that his wife did not want him to leave their young children to come to the hospital. He desperately wanted to see his wife. The health care provider knew that the hospital’s visitation policy was to be strictly adhered to. This was the fourth time in 2 days that this health care provider had to tell a family member that they could not visit a critically ill loved one. Janet S. Coulter, MSN, MS, RN, CCM, is a transplant case manager who has also worked as a staff nurse, charge nurse, nurse educator, nurse administrator, case manager, case management team leader, and Director of Case Management for a managed care organization. She has been active in the Southern Ohio Valley Chapter of CMSA and served a fifth term as President. Janet was the 2012-2013 CMSA Chapter Presidents’ Council Representative on the CMSA Board of Directors; has served as a CMSA Board member, Secretary of the CMSA Board of Directors, and a member of the CMSA Executive Committee; and has participated in or chaired several CMSA committees. April/May 2022 CareManagement 21


Approved for 1 hour of CCM, CDMS, and nursing education ethics credit

Exclusively for ACCM Members

Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual response to acting or witnessing behaviors that go against one’s values and moral beliefs.

In this scenario, the health care provider’s moral core and foundational values were being compromised because the health care provider knew the right thing to do but also knew that the situation was impossible and beyond their control. The concepts of nonmaleficence (do no harm) and beneficence (taking positive action to help others) were compromised. The Commission for Case Manager Certification (CCMC) and the Certified Disability Management Specialist (CDMS) Codes of Conduct Principle 2 (respect the rights and inherent dignity of all patients) and Principle 4 (act with integrity and fidelity with patients and others) were not achieved (CCMC, 2015) (CDMS, 2019). This caused internal ethical conflict in the health care provider. The health care provider understood that the grieving families will suffer pain and loss and be deprived of contact with their loved one. The loved one may die without the comfort of their family’s presence at the bedside (Williams et al., 2020). The situation becomes even harder when the patient was a colleague and they recently worked together caring for patients. In the next scenario, the health care provider was placed in a very difficult situation. The health care provider was reassigned to an intensive care unit (ICU) that had reached capacity with COVID-19 patients. The health care provider noticed a familiar name during report and was shocked to discover that a coworker was a patient in the ICU. As the health care provider walked through the ICU toward her assigned patients, the coworker/patient recognizes her and loudly calls out her name. The patient desperately calls out her name again, pleading for her to come to the bedside. The health care provider dons the protective equipment and approaches the patient’s bedside. The patient is very happy to see her coworker. She breathlessly asks the health care worker to call her family and relay a message. The health care provider assured the patient that she would call her family but explains that she must first assess her assigned patients. The coworker/patient states that she understands that but that she really needs to get a message to her family. The health care provider again assured the coworker/patient that she would return and make the phone call. The assigned patients required undivided attention from the health care provider for the first part of the shift. It was several hours before the health care provider was relieved for a break, but she had not forgotten her promise 22 CareManagement April/May 2022

to her coworker/patient. She returned to the coworker/ patient’s bedside. The coworker/patient was very short of breath, anxious, and repeated that she really needed to get a message to her family. The health care provider called the family on her personal cell phone and put the call on FaceTime so that the coworker/patient could see and speak directly to her family. The coworker/patient was able to relay the message directly to her family. After the call, the coworker/patient seemed to relax and was less anxious. The coworker/patient repeatedly told the health care provider how wonderful it was to see her husband and children and to hear their voices. In this scenario, the health care provider put the needs of the coworker/patient above her own needs to rest, eat, drink, and decompress during her break. The case manager demonstrated the ethical concepts of autonomy (respecting the right to self-determine a course of action), beneficence (taking positive action to help others), fidelity (keeping commitments or promises), and nonmaleficence (do no harm). The health care worker’s compassionate and professional values were upheld. The coworker/patient was supported and empowered, and her dignity was respected. The health care provider delivered care to her assigned patients and kept her promise to her coworker/patient. With integrity and fidelity, the health care provider accomplished what she felt was the right thing. CCMC and CDMS Codes of Conduct Principle 1 (place the public interest above their own), Principle 2 (respect the rights and inherent dignity of all patients), Principle 3 (maintain objectivity in patient relationships), and Principle 4 (act with integrity and fidelity with patients and others) were achieved (CCMC, 2015) (CDMS, 2019). Although the situation was distressing, the health care provider focused on what she could control, and she felt a sense of satisfaction and accomplishment from the experience. Health care providers are often confronted with complex ethical dilemmas that are similar to the two clinical situations that were presented above. CCMC and CDMS provide codes of professional conduct. These codes of professional conduct are frameworks for ethical guidelines, principles, and values that steer health care providers’ actions. Selfawareness of professional ethical behaviors, values, and morals governed responses from this health care provider and adherence to the codes of conduct.


Approved for 1 hour of CCM, CDMS, and nursing education ethics credit

Exclusively for ACCM Members

Self-care strategies are challenging for health care providers because they tend to prioritize the needs of others over their own. The health care provider may not take time to care for themselves. This puts the health care provider at high risk for moral injury.

Effects of Moral Injury

Health care providers have been placed in situations that may have violated their moral code, values, and spirituality. In addition, they are physically and emotionally exhausted. Health care fatigue can cause signs of physical distress such as muscle tension, headaches, gastrointestinal upset, and sleep disturbances. Psychological symptoms may include feelings of exhaustion, frustration, guilt, worry, helplessness, anger, shame, fear, and resentment. Psychological symptoms can lead to self-imposed isolation, compulsive behaviors such as overeating or overworking, making mistakes, and decreased sense of empathy or compassion. Health care providers may experience guilt and shame if they felt numb in the face of suffering and death. They may feel powerless and hopeless. This perceived loss of ethical integrity can undermine self-confidence and diminish personal and professional identity. If these consequences of moral distress are underestimated and not addressed in a timely manner, the health care provider may develop posttraumatic stress disorder (PTSD) or experience a moral injury. There is overlap between PTSD and moral injury. Both have core features of guilt, shame, betrayal, and loss of trust. It is possible to have moral injury and not have PTSD. The reaction to moral injury is an inability to self-forgive, engaging in self-sabotaging behaviors, and feeling that they do not deserve to feel better. This can result in long-term emotional scarring, malfunctioning, social isolation, and numbness. If both moral injury and PTSD occur, symptoms of depression are more severe and there is likelihood of suicidal intent. Recent studies from China confirm that health care providers who were in direct contact with COVID-19 patients reported elevated symptoms of depression (50.4%), anxiety (44.6%), insomnia (34%), and distress (71.5%) and that the degree of severity of mental health symptoms was higher in nurses than in other health care workers (Cartolovni et al., 2021). Many health care providers who experience moral injury will not have long-term negative outcomes. They may be able to grow from the experience, redefine their meaning of life, gain new insights, incorporate the experience into growth, and continue helping others.

Interventions

Key interventions include: • Creating and promoting emotional and physical safety • Cultivating calmness • Practicing mindfulness • Fostering connectedness and self-efficacy • Nurturing hope • Focusing on what can be controlled • Becoming more aware of internal self-talk Trauma-focused PTSD treatment may be effective for health care providers in reducing the occurrence of moral injury. One example, prolonged exposure therapy, gives health care providers the opportunity for emotional processing and can help make sense of the trauma. A second example is cognitive processing therapy (CPT). CPT is designed to help patients work through beliefs that generally underlie guilt, shame, and betrayal. CPT also addresses beliefs such as “I am unforgivable.” Both of these treatments can target the core components of moral injury. There are new treatments under investigation that specifically target moral injury. One of those treatments is acceptance and commitment therapy, a 12-session group treatment focusing on helping patients live in accordance with values. Another treatment is adaptive disclosure, a 12-session individual treatment that helps patients process moral injury through imaginary dialogue with a compassionate moral authority by apportioning blame, making amends, and using self-compassion and mindfulness meditations. An additional new treatment is Trauma-Informed Guilt Reduction Therapy. This is a 6-session individual therapy that helps patients identify and evaluate beliefs, identify important values that were violated during the trauma, and make a plan to live in line with those values going forward. Addressing spiritual conflicts is being addressed by a new treatment called Building Spiritual Strength. This is an 8-session group therapy led by a chaplain that addresses concerns about the relationship with a Higher Power as well as challenges with forgiveness. Each of these innovative treatments has trials in progress (Norman et al., 2020).

Self-Care Strategies

Self-care strategies are challenging for health care providers because they tend to prioritize the needs of others over their own. The health care provider may not take time to care for April/May 2022 CareManagement 23


Approved for 1 hour of CCM, CDMS, and nursing education ethics credit

Exclusively for ACCM Members

Trauma-focused treatment for posttraumatic stress disorder may be effective for health care providers in reducing the occurrence of moral injury.

themselves. This puts the health care provider at high risk for moral injury. Self-care strategies include finding satisfaction in what can be accomplished, however small, and being more patient and kinder to themselves. Asking others for assistance and support in making difficult decisions is imperative. Coworker support is very beneficial. Coworkers often have experienced similar feelings and situations, so they may have natural empathy. Coworkers may also need support. If a coworker is showing signs of PTSD or moral injury, reach out to them. Be a good listener. Acknowledge their stress, pressure, and sacrifice. Adopt an ethical mindset. Being proactive can diminish harmful consequences. There is continual need for resources that foster moral repair and resilience. Without these resources, personal guilt may erode professional confidence. Below are examples of mobile applications that can help health care providers cope with these complex feelings. • COVID Coach: A free mobile application designed to help build resilience, manage stress, and increase well-being during the coronavirus (COVID-19) pandemic. • Provider Resilience application by the National Center for Telehealth & Technology (Watson et al., 2020)

Management Support

It is essential for management to promote a supportive culture and establish policies to guide staff through ethically difficult decisions. Keeping morale high, celebrating small and large successes, and removing ethically difficult decisions from frontline workers is critical. Patience, praise, and communicating clear messages of gratitude and support are effective interventions. Reaching out to health care staff and being alert to signs of moral injury are essential. Management and mental health professionals should be available and prepared to discuss moral and ethical challenges and provide support and resources. Rotating staff between high- and low-stress positions and providing a quiet space for decompression and recharging during downtime is necessary amid stressful working conditions.

Summary

It is very important to keep health care providers healthy in both body and mind so that they can care for others. Moral injury among health care providers may occur in a variety of 24 CareManagement April/May 2022

situations (eg, when they must make difficult decisions related to life and death or when they believe they should have been able to save a patient’s life but were not able to do so). Moral injury for health care providers can lead to burnout and even to the decision to leave the profession altogether. During the pandemic, health care providers may have witnessed what they perceived to be unfair acts or policies that could lead to a sense of betrayal and erode professional confidence. They also may feel guilty about possibly infecting people with whom they came in contact with or surviving when others did not. Health care providers experienced substantial personal and professional loss, pain, and injury during the pandemic. For some, the only treatment is forgiveness, compassion, resilience, and moral repair. It is hoped that this article helps to combat the stigma surrounding mental health disorders and treatment and motivates future research, prevention, and intervention related to moral injury. CE III

CE exams may be taken online! Click the link below to take the test online and then immediately print your certificate after successfully completing the test. Members only benefit! This exam expires April 15, 2023.

Take this exam online > Members who prefer to print and mail exams, click here. You must be an ACCM member to take the exam, click here to join ACCM.

References Čartolovni, A., Stolt, M., Scott, P.A., Suhonen, R. (2021) Moral injury in healthcare professionals: A scoping review and discussion. https://doi.org/10.1177/0969733020966776 Commission for Case Manager Certification (CCMC). (2015). Code of Professional Conduct for Case Managers: with Standards, Rules, Procedures and Penalties. https://ccmcertification.org/sites/default/files/ docs/2017/code_of_professional_conduct.pdf Certified Disability Management Specialist (CDMS), The CDMS Code of Professional Conduct, October 2019. Mount Laurel, NJ. https://www.cdms.org/code-conduct

References continued on page 35


PharmaFacts for Case Managers

Vabysmo™ (faricimab-svoa) injection, for intravitreal use INDICATIONS AND USAGE Vabysmo is a vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang-2) inhibitor indicated for the treatment of patients with: • Neovascular (Wet) Age-Related Macular Degeneration (nAMD) • Diabetic Macular Edema (DME) DOSAGE AND ADMINISTRATION General Dosing Information For intravitreal injection. Vabysmo must be administered by a qualified physician. Each vial should only be used for the treatment of a single eye.

Neovascular (Wet) Age-Related Macular Degeneration (nAMD) The recommended dose for Vabysmo is 6 mg (0.05 mL of 120 mg/mL solution) administered by intravitreal injection every 4 weeks (approximately every 28 ± 7 days, monthly) for the first 4 doses, followed by optical coherence tomography and visual acuity evaluations 8 and 12 weeks later to inform whether to give a 6-mg dose via intravitreal injection on one of the following three regimens: 1) Weeks 28 and 44; 2) Weeks 24, 36 and 48; or 3) Weeks 20, 28, 36 and 44. Although additional efficacy was not demonstrated in most patients when Vabysmo was dosed every 4 weeks compared to every 8 weeks, some patients may need every 4 week (monthly) dosing after the first 4 doses. Patients should be assessed regularly. Diabetic Macular Edema (DME) Vabysmo is recommended to be dosed by following one of these two dose regimens: 1) 6 mg (0.05 mL of 120 mg/mL solution) administered by intravitreal injection every 4 weeks (approximately every 28 days ± 7 days, monthly) for at least 4 doses. If after at least 4 doses, resolution of edema based on the central subfield thickness (CST) of the macula as measured by optical coherence tomography is achieved, then the interval of dosing may be modified by extensions of up to 4 week interval increments or reductions of up to 8 week interval increments based on

CST and visual acuity evaluations through week 52; or 2) 6 mg dose of Vabysmo can be administered every 4 weeks for the first 6 doses, followed by 6 mg dose via intravitreal injection at intervals of every 8 weeks (2 months) over the next 28 weeks. Although additional efficacy was not demonstrated in most patients when Vabysmo was dosed every 4 weeks compared to every 8 weeks, some patients may need every 4 week (monthly) dosing after the first 4 doses. Patients should be assessed regularly. DOSAGE FORMS AND STRENGTHS Injection: 120 mg/mL clear to opalescent, colorless to brownish-yellow solution in a single-dose vial. CONTRAINDICATIONS Ocular or Periocular Infections Vabysmo is contraindicated in patients with ocular or periocular infections.

Active Intraocular Inflammation Vabysmo is contraindicated in patients with active intraocular inflammation. Hypersensitivity Vabysmo is contraindicated in patients with known hypersensitivity to faricimab or any of the excipients in Vabysmo. Hypersensitivity reactions may manifest as rash, pruritus, urticaria, erythema, or severe intraocular inflammation. WARNINGS AND PRECAUTIONS Endophthalmitis and Retinal Detachments Intravitreal injections have been associated with endophthalmitis and retinal detachments. Proper aseptic injection techniques must always be used when administering Vabysmo. Patients should be instructed to report any symptoms suggestive of endophthalmitis or retinal detachment without delay, to permit prompt and appropriate management.

Increase in Intraocular Pressure Transient increases in intraocular pressure (IOP) have been seen within 60 minutes of intravitreal injection, including with Vabysmo. IOP and the perfusion of the optic nerve head should be monitored and managed appropriately. April/May 2022 CareManagement 25


PharmaFacts for Case Managers

Thromboembolic Events Although there was a low rate of arterial thromboembolic events (ATEs) observed in the Vabysmo clinical trials, there is a potential risk of ATEs following intravitreal use of VEGF inhibitors. ATEs are defined as nonfatal stroke, nonfatal myocardial infarction, or vascular death (including deaths of unknown cause). The incidence of reported ATEs in the nAMD studies during the first year was 1% (7 out of 664) in patients treated with Vabysmo compared with 1% (6 out of 662) in patients treated with aflibercept. The incidence of reported ATEs in the DME studies during the first year was 2% (25 out of 1,262) in patients treated with Vabysmo compared with 2% (14 out of 625) in patients treated with aflibercept. ADVERSE REACTIONS The following potentially serious adverse reactions are described elsewhere in the labeling: • Hypersensitivity • Endophthalmitis and retinal detachments • Increase in intraocular pressure • Thromboembolic events USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There are no adequate and well-controlled studies of Vabysmo administration in pregnant women. Administration of Vabysmo to pregnant monkeys throughout the period of organogenesis resulted in an increased incidence of abortions at intravenous (IV) doses 158 times the human exposure (based on Cmax) of the maximum recommended human dose. Based on the mechanism of action of VEGF and Ang-2 inhibitors, there is a potential risk to female reproductive capacity, and to embryo-fetal development. Vabysmo should not be used during pregnancy unless the potential benefit to the patient outweighs the potential risk to the fetus. All pregnancies have a background risk of birth defect, loss, and other adverse outcomes. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects is 2%–4% and of miscarriage is 15%-20% of clinically recognized pregnancies.

Lactation Risk Summary There is no information regarding the presence of faricimab in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. Many drugs are 26 CareManagement April/May 2022

transferred in human milk with the potential for absorption and adverse reactions in the breastfed child. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Vabysmo and any potential adverse effects on the breastfed child from Vabysmo.

Females and Males of Reproductive Potential Contraception Females of reproductive potential are advised to use effective contraception prior to the initial dose, during treatment and for at least 3 months following the last dose of Vabysmo. Infertility No studies on the effects of faricimab on human fertility have been conducted and it is not known whether faricimab can affect reproduction capacity. Based on the mechanism of action, treatment with Vabysmo may pose a risk to reproductive capacity.

Pediatric Use The safety and efficacy of Vabysmo in pediatric patients have not been established. Geriatric Use In the four clinical studies, approximately 60% (1,149/1,929) of patients randomized to treatment with Vabysmo were ≥ 65 years of age. No significant differences in efficacy or safety of faricimab were seen with increasing age in these studies. No dose adjustment is required in patients 65 years and above. CLINICAL STUDIES Neovascular (wet) Age-Related Macular Degeneration (nAMD) The safety and efficacy of Vabysmo were assessed in two randomized, multi-center, double-masked, active comparator-controlled, 2-year studies (TENAYA – NCT03823287 and LUCERNE – NCT03823300) in patients with nAMD. A total of 1,329 newly diagnosed, treatment-naive patients were enrolled in these studies, and 664 patients received at least one dose of Vabysmo. Patient ages ranged from 50 to 99 with a mean of 75.9 years. The studies were identically designed two-year studies. Patients were randomized in a 1:1 ratio to one of two treatment arms: 1) aflibercept 2 mg administered fixed every 8 weeks (Q8W) after three initial monthly doses; and Vabysmo 6 mg (0.05 mL of 120 mg/mL solution) administered by intravitreal injection every 4 weeks (approximately every 28 ± 7 days, monthly) for the first 4 doses, followed by optical coherence tomography and visual acuity evaluations 8 and 12 weeks later to determine whether to give a 6 mg (0.05 mL of 120 mg/mL solution) dose via intravitreal injection on one of the following three regimens: 1) Weeks 28 and 44; (also referred to as


PharmaFacts for Case Managers

Q16W dosing); 2) Weeks 24, 36 and 48 (also referred to as Q12W dosing); or 3) Weeks 20, 28, 36 and 44 (also referred to as Q8W dosing). However, the utility of these criteria to guide dosing intervals has not been established. At week 48, after 4 initial monthly doses in the Vabysmo arm, 45% of patients received the Weeks 28 and 44 dosing, 33% of patients received the Weeks 24, 36 and 48 dosing, and the remaining 22% of patients received dosing every 8 weeks. These percentages are reflective of what happened within the conduct of these trials and indicate that some patients did well on two (2) doses spaced 16 weeks apart, or three (3) doses spaced 12 weeks apart, but the percentages may not be generalizable to a broader nAMD population for a variety of reasons. The inclusion/exclusion criteria limited enrollment to a select subset of treatment naive, newly diagnosed nAMD patients and there is no empirical data that a similar magnitude would be observed if eligibility criteria allowed for broader enrollment. The disease activity criteria, which was instrumental in determining dose frequency, is unvalidated. Stricter criteria would have changed how patients were treated resulting in different percentages of subjects in each dose interval cohort. There was not a similarly dosed aflibercept arm for comparison, which makes the percentages difficult to interpret. Both studies demonstrated noninferiority to the comparator control (aflibercept) at the primary endpoint, defined as the mean change from baseline in Best Corrected Visual Acuity (BCVA) when averaged over the week 40, 44, and 48 visits and measured by the Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart. The primary endpoint analysis was a noninferiority comparison for the mean change in BCVA between the aflibercept and the Vabysmo arm. The lower bound of the 95% confidence interval for the mean change in BCVA could not be lower than minus 4 letters to declare noninferiority. In both studies, Vabysmo treated patients had a noninferior mean change from baseline in BCVA compared to patients treated with aflibercept.

Diabetic Macular Edema (DME) The safety and efficacy of Vabysmo were assessed in two randomized, multicenter, double-masked, active comparatorcontrolled 2-year studies (YOSEMITE–NCT03622580 and RHINE–NCT03622593) in patients with DME. A total of 1,891 diabetic patients were enrolled in the two studies with a total of 1,262 patients treated with at least one dose of Vabysmo. Patient ages ranged from 24 to 91 with a mean of 62.2 years. The overall population included both anti-VEGF naive patients (78%) and patients who had been previously treated with a VEGF inhibitor prior to study participation (22%).

The studies were identically designed 2-year studies. Patients were randomized in a 1:1:1 ratio to one of three treatment regimens: 1) aflibercept Q8W, patients received fixed aflibercept 2 mg administered every 8 weeks (Q8W) after the first five monthly doses; 2) Vabysmo Q8W, patients received fixed Vabysmo 6 mg administered Q8W after the first six monthly doses; and 3) Vabysmo Variable, patients received Vabysmo 6 mg administered every 4 weeks for at least 4 doses and until the central subfield thickness (CST) of the macula measured by optical coherence tomography was less than approximately 325 microns, then the interval of dosing was modified by up to 4 week interval extensions or reductions in up to 8 week interval increments based on CST and visual acuity disease activity criteria at study drug dosing visits. However, the utility of these disease activity criteria to guide dosing intervals has not been established. After 4 initial monthly doses, the patients in the Vabysmo Variable arm could have received between the minimum of three and the maximum of eleven total injections through Week 56 inclusive. At Week 56, 32% of patients had completed at least one Q12W interval followed by one full Q16W interval. Seventeen percent (17%) of patients were treated on Q8W and/or Q4W dosing intervals through Week 56 (7% only on Q4W). Sustainability of the Q16W dosing interval cannot be determined based on year one data alone. These percentages are reflective of what happened within the conduct of these trials, but the percentages are not generalizable to a broader DME population for a variety of reasons. The inclusion/exclusion criteria limited enrollment to a select subset of DME patients and there is no empirical data that a similar magnitude would be observed if eligibility criteria allowed for broader enrollment. The disease activity criteria, which was instrumental in determining dose frequency, is unvalidated. Stricter criteria would have changed how patients were treated resulting in different percentages of subjects in each dose interval cohort. There was not a similarly dosed aflibercept arm for comparison which makes the percentages difficult to interpret. Both studies demonstrated noninferiority to the comparator control (aflibercept) at the primary endpoint, defined as the primary endpoint, defined as the mean change from baseline in BCVA at year 1 (average of the week 48, 52, and 56 visits), measured by the ETDRS Letter Score. The primary endpoint analysis was a noninferiority comparison for the mean change in BCVA between the aflibercept and Vabysmo groups. The lower bound of the 97.5% confidence interval for the mean change in BCVA could not be lower than minus 4 letters to declare noninferiority. In both studies, Vabysmo Q8W and Vabysmo Variable treated patients had a mean change from baseline in BCVA that was noninApril/May 2022 CareManagement 27


PharmaFacts for Case Managers

ferior to the patients treated with aflibercept Q8W. Treatment effects in the subgroup of patients who were anti-VEGF naive prior to study participation were similar to those observed in the overall population. Treatment effects in evaluable subgroups (e.g., by age, gender, race, baseline HbA1c, baseline visual acuity) in each study were generally consistent with the results in the overall population.

(Churg-Strauss syndrome), and hypereosinophilic syndrome (HES) in a prefilled syringe for use in children for severe eosinophilic asthma.

HOW SUPPLIED/STORAGE AND HANDLING How Supplied Vabysmo (faricimab-svoa) injection is supplied as a clear to opalescent, colorless to brownish-yellow 120 mg/mL solution in a single-dose glass vial. Each glass vial contains an overfill amount to allow for administration of a single 0.05 mL dose of solution containing 6 mg of Vabysmo. Each Vabysmo carton (NDC 50242-096-01) contains one glass vial and one sterile 5-micron blunt transfer filter needle (18-gauge x 1½ inch, 1.2 mm x 40 mm).

Xarelto (rivaroxaban), a factor Xa inhibitor used for the treatment and prevention of blood clots that are related to certain conditions involving the heart and blood vessels, has received FDA approval for the use in pediatric patients to prevent and treat blood clots.

Storage and Handling Store Vabysmo in the refrigerator between 2°C to 8°C (36°F to 46°F). Do not freeze. Do not shake. Keep the vial in the original carton to protect from light. Prior to use, the unopened glass vial of Vabysmo may be kept at room temperature, 20°C to 25°C (68°F to 77°F), for up to 24 hours. Ensure that the injection is given immediately after preparation of the dose.

Caplyta (lumateperone), an atypical antipsychotic for the treatment of schizophrenia, has received FDA approval for the treatment of bipolar depression in adults.

PATIENT COUNSELING INFORMATION Advise patients that in the days following Vabysmo administration, patients are at risk of developing endophthalmitis. If the eye becomes red, sensitive to light, painful, or develops a change in vision, advise the patient to seek immediate care from an ophthalmologist. Patients may experience temporary visual disturbances after an intravitreal injection with Vabysmo and the associated eye examinations. Advise patients not to drive or use machinery until visual function has recovered sufficiently. Vabysmo is manufactured by Genentech, Inc.

New Indications

Cabenuva (cabotegravir and rilpivirine) is a long-acting, injectable regimen of the HIV-1 integrase strand transfer inhibitor (INSTI) cabotegravir, and the HIV-1 non-nucleoside reverse transcriptase inhibitor (NNRTI) rilpivirine indicated as a complete regimen for the treatment of HIV-1 infection in adults is now FDA approved for expanding the label for use every two months as the only long acting HIV treatment for HIV-1 treatment in adults. Nucala (mepolizumab) is an interleukin-5 antagonist monoclonal antibody (IgG1 kappa) used for the treatment of severe eosinophilic asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), eosinophilic granulomatosis with polyangiitis 28 CareManagement April/May 2022

Veklury (remdesivir), a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor indicated for the treatment of COVID-19, has received FDA approval for use in nonhospitalized patients at high risk for COVID disease progression.

Oxbryta (voxelotor), an oral HbS (sickle hemoglobin) polymerization inhibitor for the treatment of patients with sickle cell disease (SCD), has received FDA approval for use in children as young as four years of age for sickle cell disease.

Tecentriq (atezolizumab), a programmed death-ligand 1 (PDL1) blocking antibody indicated for use in the treatment of urothelial carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast cancer (TNBC) and small cell lung cancer (SCLC) as well as heptatocellular carcinoma and melanoma, has received FDA approval for adjuvant treatment for people with early non-small cell lung cancer. Biktarvy (bictegravir, emtricitabine and tenofovir alafenamide), a combination of an integrase strand transfer inhibitor (bictegravir) and two HIV-1 nucleoside analog reverse transcriptase inhibitors (emtricitabine and tenofovir alafenamide) used for the treatment of HIV-1 infection, has received FDA approval for treatment of HIV-1 infection in the pediatric population. Repatha (evolocumab), a monoclonal antibody targeting PCSK9 (proprotein convertase subtilisin/kexin type 9) used for the treatment of familial hypercholesterolemia (heterozygous and homozygous) and to reduce the risk of adverse cardiovascular events in adults with established cardiovascular disease (CVD), has been approved by the FDA for the use in pediatric patients age 10 or older for the treatment of heterozygous familial hypercholesterolemia. Jakafi (ruxolitinib), a Janus kinase (JAK) inhibitor used for the treatment of myelofibrosis, polycythemia vera, and graft-versushost disease, has received FDA approval for the treatment of graft-versus-host disease.


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LitScan for Case Managers reviews medical literature and reports abstracts that are of particular interest to case managers in an easy-to-read format. Each abstract includes information to locate the full-text article if there is an interest. This member benefit is designed to assist case managers in keeping current with clinical breakthroughs in a time-effective manner.

Clin Infect Dis. 2022 Feb 15;ciac098. doi: 10.1093/cid/ ciac098. Online ahead of print.

Geographical differences in the self-reported functional impairment of people with HIV and associations with cardiometabolic risk Erlandson KM, Fitch KV, MCallum SA, et al. BACKGROUND: We sought to explore multinational differences in functional status by Global Burden of Disease (GBD) regions in the REPRIEVE cohort. METHODS: REPRIEVE is a prospective, double-blind, randomized, placebo-controlled, multicenter, phase III primary cardiovascular prevention study of pitavastatin calcium vs placebo among PWH ages 40-75 on antiretroviral therapy (ART). GBD super regions were defined using World Health Organization classifications. Participants were categorized by impairment on the Duke Activity Status Instrument (DASI: none, some, moderate, severe. Logistic regression models examined risk factors and GBD regions associated with functional impairment. The association between functional impairment and cardiometabolic risk was also explored. Results: Of 7736 participants, the majority were from high-income countries (n=4065), were male (65%), and had received ART for ≥ 10 years. The median DASI score was 58.2 (IQR 50.2, 58.2); 36% reported at least some impairment. In adjusted analyses, functional impairment was significantly more frequent among participants from Southeast/East Asia. Other factors associated with greater impairment included female sex, Black race, older age, current/former smoking, higher body mass index, use of ART for ≥ 10 years, and select ART regimens; differences were seen in risks across GBD regions. Functional impairment was associated with increased cardiometabolic risk. CONCLUSIONS: Over 1/3 of middle-aged and older PWH in a global cohort across diverse GBD regions demonstrate functional impairments. The associations between DASI and cardiometabolic risk suggest that a measure of functional status may improve risk prediction; these longitudinal associations will be further investigated over REPRIEVE trial follow-up.

BMJ. 2022 Feb 16;376:e068993. doi: 10.1136/bmj-2021-068993. Risks of mental health outcomes in people with covid-19: cohort study Xie Y, Xu E, Al-Aly Z. OBJECTIVE: To estimate the risks of incident mental health disorders in survivors of the acute phase of covid-19. DESIGN: Cohort study. SETTING: US Department of Veterans Affairs. PARTICIPANTS: Cohort comprising 153 848 people who survived the first 30 days of SARS-CoV-2 infection, and two control groups: a contemporary group (n=5 637 840) with no evidence of SARS-CoV-2, and a historical control group (n=5 859 251) that predated the covid-19 pandemic. MAIN OUTCOMES MEASURES: Risks of prespecified incident mental health outcomes, calculated as hazard ratio and absolute risk difference per 1000 people at one year, with corresponding 95% confidence intervals. Predefined covariates and algorithmically selected high dimensional covariates were used to balance the covid-19 and control groups through inverse weighting. RESULTS: The covid-19 group showed an increased risk of incident anxiety disorders (hazard ratio 1.35 (95% confidence interval 1.30 to 1.39); risk difference 11.06 (95% confidence interval 9.64 to 12.53) per 1000 people at one year), depressive disorders (1.39 (1.34 to 1.43); 15.12 (13.38 to 16.91) per 1000 people at one year), stress and adjustment disorders (1.38 (1.34 to 1.43); 13.29 (11.71 to 14.92) per 1000 people at one year), and use of antidepressants (1.55 (1.50 to 1.60); 21.59 (19.63 to 23.60) per 1000 people at one year) and benzodiazepines (1.65 (1.58 to 1.72); 10.46 (9.37 to 11.61) per 1000 people at one year). The risk of incident opioid prescriptions also increased (1.76 (1.71 to 1.81); 35.90 (33.61 to 38.25) per 1000 people at one year), opioid use disorders (1.34 (1.21 to 1.48); 0.96 (0.59 to 1.37) per 1000 people at one year), and other (non-opioid) substance use disorders (1.20 (1.15 to 1.26); 4.34 (3.22 to 5.51) per 1000 people at one year). The covid-19 group also showed an increased risk of incident neurocognitive decline (1.80 (1.72 to 1.89); 10.75 (9.65 to 11.91) per 1000 people at one year) and sleep disorders (1.41 (1.38 to 1.45); 23.80 (21.65 to 26.00) per 1000 people at one year). The risk of any incident mental health April/May 2022 CareManagement 29


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diagnosis or prescription was increased (1.60 (1.55 to 1.66); 64.38 (58.90 to 70.01) per 1000 people at one year). The risks of examined outcomes were increased even among people who were not admitted to hospital and were highest among those who were admitted to hospital during the acute phase of covid-19. Results were consistent with those in the historical control group. The risk of incident mental health disorders was consistently higher in the covid-19 group in comparisons of people with covid-19 not admitted to hospital versus those not admitted to hospital for seasonal influenza, admitted to hospital with covid-19 versus admitted to hospital with seasonal influenza, and admitted to hospital with covid-19 versus admitted to hospital for any other cause. CONCLUSIONS: The findings suggest that people who survive the acute phase of covid-19 are at increased risk of an array of incident mental health disorders. Tackling mental health disorders among survivors of covid-19 should be a priority.

Clin Infect Dis. 2022 Feb 16;ciab1053. doi: 10.1093/cid/ ciab1053. Online ahead of print.

Sexually transmitted infection transmission dynamics during the coronavirus disease 2019 (COVID-19) pandemic among urban gay, bisexual, and other men who have sex with men Schumacher CM, Thornton N, Wagner J, et al. BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) mitigation measures on sexually transmitted infection (STI) transmission and racial disparities remains unknown. Our objectives were to compare sex and drug risk behaviors, access to sexual health services, and STI positivity overall and by race during the COVID-19 pandemic compared with pre-pandemic among urban sexual minority men (MSM). METHODS: Sexually active MSM aged 18–45 years were administered a behavioral survey and STI testing every 3 months. Participants who completed at least 1 during-pandemic (April 2020-December 2020) and 1 pre-pandemic study visit (before 13 March 2020) that occurred less than 6 months apart were included. Regression models were used to compare during- and pre-pandemic visit outcomes. RESULTS: Overall, among 231 MSM, reports of more than 3 sex partners declined(pandemic-1: adjusted prevalence ratio 0.68; 95% confidence interval: .54-.86; pandemic-2: 0.65, .51-.84; pandemic-3: 0.57, .43-.75), substance use decreased (pandemic-1: 0.75, .61-.75; pandemic-2: 0.62, .50-.78; pandemic-3: 0.61, .47-.80), and human immunodeficiency virus/preexposure prophylaxis care engagement (pandemic-1: 1.20, 1.07-1.34; pandemic-2: 1.24, 1.1130 CareManagement April/May 2022

1.39; pandemic-3: 1.30, 1.16-1.47) increased. STI testing decreased (pandemic-1: 0.68, .57-.81; pandemic-2: 0.78, .67-.92), then rebounded (pandemic-3: 1.01, .87-1.18). Neither Chlamydia (pandemic-2: 1.62, .75-3.46; pandemic-3: 1.13, .24-1.27) nor gonorrhea (pandemic-2: 0.87, .46 1.62; pandemic-3: 0.56, .24-1.27) positivity significantly changed during vs pre-pandemic. Trends were mostly similar among Black vs. non-Black MSM. CONCLUSIONS: We observed sustained decreases in STI risk behaviors but minimal change in STI positivity during compared with pre-pandemic. Our findings underscore the need for novel STI prevention strategies that can be delivered without in-person interactions. J Hepatol. 2022 Feb 11;S0168-8278(22)00074-5. doi: 10.1016/j. jhep.2022.01.027. Online ahead of print.

Duration and cost-effectiveness of hepatocellular carcinoma surveillance in hepatitis C patients after viral eradication Mueller PP, Chen Q, Ayer T, et al. BACKGROUND & AIMS: Successful treatment of chronic hepatitis C with oral direct-acting antiviral (DAA) leads to virological cure, however, the subsequent risk of hepatocellular carcinoma (HCC) persists. Our objective was to evaluate the costeffectiveness of biannual surveillance for HCC in patients cured of hepatitis C and the optimal age to stop surveillance. APPROACH: We developed a microsimulation model of the natural history of HCC in hepatitis C individuals with advanced fibrosis or cirrhosis who achieved virological cure with oral DAAs. We used published data on HCC incidence, tumor progression, real-world HCC surveillance adherence, and costs and utilities of different health states. We compared biannual HCC surveillance using ultrasound and alpha-fetoprotein for varying durations of surveillance (from 5 years to lifetime) versus no surveillance. RESULTS: In virologically-cured patients with cirrhosis, the ICER of biannual surveillance remained below $150,000 per additional quality-adjusted life year (QALY) (range: $79,500-$94,800) when surveillance was stopped at age 70, irrespective of the start age (40-65). Compared with no surveillance, surveillance per 1000 cirrhosis patients detected 130 additional HCCs in ‘very early’/ early stage and yielded 51 additional QALYs. In virologically-cured patients with advanced fibrosis, the ICER of biannual surveillance remained below $150,000/QALY (range: $124,600-$129,800) when surveillance was stopped at age 60, irrespective of the start age (40-50). Compared with no surveillance, surveillance per 1000 advanced fibrosis patients detected 24 additional HCCs in ‘very early’/early stage and yielded 12 additional QALYs.


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CONCLUSION: Biannual surveillance for HCC in virologically-cured hepatitis C patients is cost-effective until the age of 70 for cirrhosis patients, and until the age of 60 for patients with stable advanced fibrosis.

Clin Infect Dis. 2022 Feb 18;ciac154. doi: 10.1093/cid/ ciac154. Online ahead of print.

Screening for Chagas disease should be included in entry-to-care testing for at-risk people with HIV living in the United States Clark EH, Marquez C, Whitman JD, et al. Chagas disease screening of at-risk populations is essential to identify infected individuals and facilitate timely treatment before end-organ damage occurs. Co-infected people with HIV (PWH) are at risk for dangerous sequelae, specifically Trypanosoma cruzi reactivation disease. Recently published national recommendations indicate that at-risk PWH, particularly those from endemic areas or born to women from endemic areas, should be screened via a sensitive anti-T. cruzi IgG assay. However, immunocompromised patients with negative serologic results may warrant further investigation. Reactivation should be suspected in at-risk, untreated PWH with low CD4 cell counts presenting with acute neurologic or cardiac symptoms; these patients should be promptly evaluated and treated. One pragmatic solution to improve Chagas disease screening among PWH and thereby reduce T. cruzi-related morbidity and mortality is to incorporate Chagas disease screening into the panel of tests routinely performed during the entry-to-care evaluation for at-risk PWH.

J Heart Lung Transplant. 2021 Oct;40(10):1181-1190. doi: 10.1016/j.healun.2021.06.018. Epub 2021 Jul 10. The modified US heart allocation system improves transplant rates and decreases status upgrade utilization for patients with hypertrophic cardiomyopathy Fowler CC, Helmers MR, Smood B, et al. BACKGROUND: On October 18, 2018, the US heart allocation policy was restructured to improve transplant waitlist outcomes. Previously, hypertrophic cardiomyopathy (HCM) patients experienced significant waitlist mortality and functional decline, often requiring status exemptions to be transplanted. This study aims to examine changes in waitlist mortality and transplant rates of HCM patients in the new system. METHODS: Retrospective analysis was performed of the

United Network for Organ Sharing Transplant Database for all isolated adult single-organ first-time heart transplant patients with HCM listed between October 17, 2013 and September 4, 2020. Patients were divided by listing date into eras based on allocation system. Era 1 spanned October 17, 2013 to October 17, 2018 and Era 2 spanned October 18 2018 to September 4, 2020. RESULTS: During the study period, 436 and 212 HCM patients were listed in Eras 1 and 2, respectively. Across eras, no differences in gender, ethnicity, BMI or functional status were noted (p>0.05). LVAD utilization remained low (Era 1: 3.7% vs Era 2: 3.3%, p = 0.297). Status upgrades decreased from 49.1% to 31.6% across eras (p = 0.001). There was no statistically significant difference in waitlist mortality across eras (p = 0.332). Transplant rates were improved in Era 2 (p = 0.005). Waitlist time among transplanted patients decreased in Era 2 from 97.1 to 63.9 days (p<0.001). There was no difference in one-year survival post-transplant (p = 0.602). CONCLUSIONS: The new allocation system has significantly increased transplant rates, shortened waitlist times, and decreased status upgrade utilization for HCM patients. Moreover, waitlist mortality remained unchanged in the new system.

J Heart Lung Transplant. 2022 Jan 15;S1053-2498(22)000158. doi: 10.1016/j.healun.2022.01.010. Online ahead of print.

Clinical outcomes of heart transplantation using hepatitis C-viremic donors: a systematic review with meta-analysis Villegas-Galaviz J, Anderson E, Guglin M. BACKGROUND: Heart transplantation (HTx) from hepatitis C virus (HCV)-viremic donors to nonviremic recipients decreases mortality and costs. Consequently, many transplant centers have reported their results using this strategy. Hence, there is a need for an outcome analysis. METHODS: We performed a systematic review with metaanalysis. In August 2020, we searched PubMed and EMBASE for publications containing data of nonviremic recipients who underwent HTx from HCV-viremic donors once direct-acting antiviral (DAA) therapy had become available (≥2014). Results: We identified 398 publications, 13 of which met inclusion criteria, and analyzed the outcomes of 195 recipients. The HCV-transmission rate was >97% but, the cure rate was 100% with DAA therapy. The 6 and 12-month survival were 95.6% and 92.9%, respectively. Of 10 deaths reported, none were associated with HCV infection. The acute cellular rejection (ACR) rate was 31.1%. The overall DAA failure rate was 1.1%, defined as the need to alter the initial DAA therapy due to failure to cure HCV. However, the DAA failure rate April/May 2022 CareManagement 31


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was 0% when the DAA therapy was started within the first 2 weeks post-HTx. No statistically significant differences in HCV cure rates, survivals, ACR rates, and DAA failure rates were observed when outcomes were stratified by therapeutic approach type (i.e., a prophylactic approach in which DAA was given to the recipient before confirming HCV-transmission vs a reactive approach, in which DAA was given to the recipient only after an HCVtransmission was confirmed). CONCLUSIONS: Excellent clinical outcomes have been observed in nonviremic recipients of HTx from HCV-viremic donors since DAA had become available.

Ann Surg. 2022 Feb 1;275(2):259-270. doi: 10.1097/

Stroke. 2022 Feb;53(2):523-531. doi: 10.1161/

Racially conscious cancer screening guidelines: a path towards culturally competent science

TROKEAHA.121.035488. Epub 2021 Sep 30.

Cerebral small vessel disease and depression among intracrebral hemorrhage survivors Castello JP, Pasi M, Kubiszewski P, et al. BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) is an acute manifestation of cerebral small vessel disease (CSVD), usually cerebral amyloid angiopathy or hypertensive arteriopathy. CSVD-related imaging findings are associated with increased depression incidence in the general population. Neuroimaging may, therefore, provide insight on depression risk among ICH survivors. We sought to determine whether CSVD CT and magnetic resonance imaging markers are associated with depression risk (before and after ICH), depression remission, and effectiveness of antidepressant treatment. METHODS: We analyzed data from the single-center longitudinal ICH study conducted at Massachusetts General Hospital. Participants underwent CT and magnetic resonance imaging and were followed longitudinally. We extracted information for neuroimaging markers of CSVD subtype and severity. Outcomes of interest included pre-ICH depression, new-onset depression after ICH, resolution of depressive symptoms, and response to antidepressant treatment. RESULTS: We followed 612 ICH survivors for a median of 47.2 months. Multiple CSVD-related markers were associated with depression risk. Survivors of cerebral amyloid angiopathy-related lobar ICH were more likely to be diagnosed with depression before ICH (odds ratio, 1.68 [95% CI, 1.14-2.48]) and after ICH (sub-hazard ratio, 1.52 [95% CI, 1.12-2.07]), less likely to achieve remission of depressive symptoms (sub-hazard ratio, 0.69 [95% CI, 0.51-0.94]), and to benefit from antidepressant therapy (P=0.041). Cerebral amyloid angiopathy disease burden on magnetic resonance imaging was associated with depression incidence and treatment resistance (interaction P=0.037), whereas hypertensive arteriopathy disease burden 32 CareManagement April/May 2022

was only associated with depression incidence after ICH. CONCLUSIONS: CSVD severity is associated with depression diagnosis, both before and after ICH. Cerebral amyloid angiopathy-related ICH survivors are more likely to experience depression (both before and after ICH) than patients diagnosed with hypertensive arteriopathy-related ICH, and more likely to report persistent depressive symptoms and display resistance to antidepressant treatment.

SLA.0000000000003983.

Perez NP, Baez YA, Stapleton SM, et al. OBJECTIVE: To review the racial composition of the study populations that the current USPSTF screening guidelines for lung, breast, and colorectal cancer are based on, and the effects of their application across non-white individuals. SUMMARY OF BACKGROUND DATA: USPSTF guidelines commonly become the basis for establishing standards of care, yet providers are often unaware of the racial composition of the study populations they are based on. METHODS: We accessed the USPSTF screening guidelines for lung, breast, and colorectal cancer via their website, and reviewed all referenced publications for randomized controlled trials (RCTs), focusing on the racial composition of their study populations. We then used PubMed to identify publications addressing the generalizability of such guidelines across non-white individuals. Lastly, we reviewed all guidelines published by non-USPSTF organizations to identify the availability of race-specific recommendations. RESULTS: Most RCTs used as basis for the current USPSTF guidelines either did not report race, or enrolled cohorts that were not representative of the U.S. population. Several studies were identified demonstrating the broad application of such guidelines across non-white individuals can lead to underdiagnosis and higher levels of advanced disease. Nearly all guideline-issuing bodies fail to provide race-specific recommendations, despite often acknowledging increased disease burden among non-whites. CONCLUSION: Concerted efforts to overcome limitations in the generalizability of RCTs are required to provide screening guidelines that are truly applicable to non-white populations. Broader policy changes to improve the pipeline for minority populations into science and medicine are needed to address the ongoing lack of diversity in these fields. continues on page 34


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Pediatr Nephrol. 2022 Feb 15. doi: 10.1007/s00467-022-05479-

4. Online ahead of print.

Agreement between attended home and ambulatory blood pressure measurements in adolescents with chronic kidney disease Glenn TW, Eaton CK, Psoter KJ, et al. BACKGROUND: This study aimed to compare attended home blood pressure (BP) measurements (HBPM) with ambulatory BP monitor (ABPM) readings and examine if level of agreement between measurement modalities differs overall and by subgroup. METHODS: This was a secondary analysis of data from a 2-year, multicenter observational study of children 11-19 years (mean 15, SD = 2.7) with chronic kidney disease. Participants had 3 standardized resting oscillometric home BPs taken by staff followed by 24-h ABPM within 2 weeks of home BP. BP indices (measured BP/95%ile BP) were calculated for mean triplicate attended HBPM and mean ABPM measurements. Paired HBPM and ABPM measurements taken during any of 5 study visits were compared using linear regression with robust standard errors. Generalized estimating equation-based logistic regression determined sensitivity, specificity, negative, and positive predictive values with ABPM as the gold standard. Analyses were conducted for the group overall and by subgroup. RESULTS: A total of 103 participants contributed 251 paired measurements. Indexed systolic BP did not differ between HBPM and daytime APBM (mean difference -0.002; 95% CI: -0.006, 0.003); the difference in indexed diastolic BP was minimal (mean difference - 0.033; 95% CI: - 0.040, - 0.025). Overall agreement between HBPM and 24-h ABPM in identifying abnormal BP was high (81.8%). HBPM had higher sensitivity (87.5%) than specificity (77.4%) and greater negative (89.8%) than positive (73.3%) predictive value, and findings were consistent in subgroups. CONCLUSIONS: Attended HBPM may be reasonable for monitoring BP when ABPM is unavailable. The greater accessibility and feasibility of attended HBPM may potentially help improve BP control among at-risk youth. A higher resolution version of the Graphical abstract is available as Supplementary information.

Ren Fail. 2022 Dec;44(1):217-223. doi: 10.1080/0886022X.2022.2032151. Hyperkalemia in chronic peritoneal dialysis patients Elliott AB, Soliman KMM, Ullian ME. BACKGROUND: Chronic peritoneal dialysis (PD) patients often 34 CareManagement April/May 2022

develop hypokalemia but less commonly hyperkalemia. METHODS: We explored incidence and mechanisms of hyperkalemia in 779 serum samples from 33 patients on PD for 1-59 months. Normal serum potassium concentration was defined as 3.5-5.1 meq/l. RESULTS: Mean monthly serum potassium concentrations were normal (except for 1 month), but we observed hypokalemia (<3.5 meq/l) in 5% and hyperkalemia (>5.1 meq/l) in 14% of 779 serum samples. Incidence of hyperkalemia did not change over time on PD: Year 1 (15%), Year 2 (11%), Year 3 (19%), Years 4-5 (22%). Hyperkalemia was mostly modest but occasionally extreme [5.2-5.4 meq/l (55%), 5.5-5.7 meq/l (21%), 5.8-6.0 meq/l (10%), >6.0 meq/l (14%)]. Of 31 patients (2 excluded due to brief PD time), 39% displayed hyperkalemia only, 23% displayed hypokalemia only, and the remainder (38%) displayed both or neither. Comparing hypokalemia-only with hyperkalemia-only patients, we found no difference in potassium chloride therapy, medications interrupting the renin-angiotensin system, small-molecule transport status, and renal urea clearance. We compared biochemical parameters from the hypokalemic and hyperkalemic serum samples and observed lower bicarbonate concentrations, higher creatinine concentrations, and higher urea nitrogen concentrations in the hyperkalemic samples (p < 0.001 for each), without difference in glucose concentrations. CONCLUSION: We observed hyperkalemia 3 times as frequently as hypokalemia in our PD population. High-potassium diet, PD noncompliance, increased muscle mass, potassium shifts, and/or the daytime period without PD might contribute to hyperkalemia.

Ann Surg. 2022 Feb 1;275(2):e299-e306. doi: 10.1097/ SLA.0000000000004702.

Effects of community-based exercise prehabilitation for patients scheduled for colorectal surgery with high risk for postoperative complications: results of a randomized clinical trial Berkel AEM, Bongers BC, Kotte H, et al. OBJECTIVE: To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in highrisk patients scheduled for elective colorectal resection for (pre) malignancy. SUMMARY BACKGROUND DATA: Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications.


F O R

C A S E

M A N A G E R S

METHODS: This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold <11 mL/kg/min at the baseline cardiopulmonary exercise test was the final inclusion criterion. Inclusion was based on a power analysis. Patients in the prehabilitation group participated in a personalized 3-week (3 sessions per week, nine sessions in total) supervised exercise program given in community physical therapy practices before colorectal resection. Patients in the reference group received usual care. The primary outcome was the number of patients with one or more complications within 30 days of surgery, graded according to the Clavien-Dindo classification. Data were analyzed on an intention-to-treat basis. RESULTS: Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024). CONCLUSIONS: Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.

METHOD: All Norwegian citizens born between January 1, 1925, and December 31, 1959, were followed up from January 1, 1990, to December 31, 2014. The total sample included 1,852,113 individuals, of which 6548 were registered with schizophrenia. We estimated hazard ratios (HR) for all-cause and CVD mortality with Cox models, in addition to life years lost. Educational attainment for index persons and their parents were included in the models. RESULTS: In the general population individuals with low educational attainment had higher risk of all-cause (HR: 1.48 [95% CI: 1.47-1.49]) and CVD (HR: 1.59 [95% CI: 1.57-1.61]) mortality. In individuals with schizophrenia these estimates were substantially lower (all-cause: HR: 1.13 [95% CI: 1.05-1.21] and CVD: HR: 1.12 [95% CI: 0.98-1.27]). Low educational attainment accounted for 3.28 (3.21-3.35) life years lost in males and 2.48 (2.42-2.55) years in females in the general population, but was not significantly associated with life years lost in individuals with schizophrenia. Results were similar for parental educational attainment. CONCLUSIONS: Our results indicate that while individuals with schizophrenia in general have lower educational attainment and higher mortality rates compared with the general population, the association between educational attainment and mortality is smaller in schizophrenia subjects than in the general population.

Moral Injury: Health Care Providers and the Pandemic Acta Psychiatr Scand. 2022 Feb 13. doi: 10.1111/acps.13407. Online ahead of print.

continued from page 24

Educational attainment and mortality in schizophrenia

Dean, W., Talbot, S., & Dean, A. (2019). Reframing clinician distress: moral injury not burnout. Federal practitioner: for the health care professionals of the VA, DoD, and PHS, 36(9), 400–402. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/

Tesli M, Degerud E, Plana-Ripoll O, et al. BACKGROUND: Individuals suffering from schizophrenia have a reduced life expectancy with cardiovascular disease (CVD) as a major contributor. Low educational attainment is associated with schizophrenia, as well as with all-cause and CVD mortality. However, it is unknown to what extent low educational attainment can explain the increased mortality in individuals with schizophrenia. AIM: Here, we quantify associations between educational attainment and all-cause and CVD mortality in individuals with schizophrenia, and compare them with the corresponding associations in the general population.

Norman, S. & Maguen, S. (2020) Moral injury. Retrieved from The U.S. Department of Veteran Affairs. PTSD: National Center for PTSD website: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp Watson, P., Norman, S., Maguen, S., & Hamblen, J. (2020) Moral injury in health care workers. Retrieved from The U.S. Department of Veteran Affairs. PTSD: National Center for PTSD website: https://www.ptsd. va.gov/professional/treat/cooccurring/moral_injury_hcw.asp Williams, R.D., Brundage, J.A. & Williams, E.B. (2020). Moral injury in times of COVID-19. J Health Serv Psychol 46, 65–69. https://doi.org/10.1007/s42843-020-00011-4

April/May 2022 CareManagement 35


CE2

Approved for 1 hour of CCM, CDMS, and nursing education credit

Getting Back Into Focus: Revisiting Reasons for the Hospital Readmissions Reduction Program continued from page 20 Centers for Medicare & Medicaid Services. (2012). Hospital Readmission Reduction Program. Retrieved October 1, 2015, from Centers for Medicare & Medicaid Services: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/AcuteInpatientPPS/Readmissions-ReductionProgram Centers for Medicare & Medicaid Services. (2013). IPPS Readmissions Update for 2013. Retrieved October 1, 2015, from Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/Archived-Supplemental-Data-Files/ FY2013-IPPS-Final-Rule-HRRP-Supplemental-Data-File Centers for Medicare and Medicaid Services. (2015). Hospital Readmissions Reduction Program, Fiscal Year 2015 Fact Sheet. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Value-Based-Programs/HRRP/HRRP-2015-Fact-Sheet-.pdf Centers for Medicare & Medicaid Services. (2017). Conditions patients must meet to qualify for coverage of home health services. Medicare Benefit Policy Manual, Section 30.1.1. https://www.cms.gov/ RegulationsandGuidance/Guidance/Manuals/downloads. Copeland, A., Berg, D., Johnson, M. and Bauer, J. (2010). An inervention for VA patients with congestive heart failure. The American Journal of Managed Care, 16(2), 156-165. Harris, S., Lang, B., Percy, R. & Patronas, C. (2016). Reducing 30-day readmissions for chronic obstructive pulmonary disease. MEDSURG Nursing, 25(6), 403-422.

Part 3: Updated Pharmaceutical Industry Marketing Code May Help All Providers Understand Current Standards continued from page 9 • Identify appropriate disciplinary actions for misuse of data In addition, providers should withhold referral data from marketers at the request of referral sources. The Code also addresses the issue of independent decision-making. According to the Code, no grants, scholarships, subsidies, support, consulting contracts, or educational or practice-related items should be offered or provided to referral sources in exchange for referrals or a commitment to make referrals. Nothing should be offered or provided in a manner or on a condition that may 36 CareManagement April/May 2022

Exclusively for ACCM Members

Institute for Healthcare Improvement Readmissions. (2017). Readmissions. Retrieved from the Institute for Healthcare Improvement. http://www.ihi.org/Topics/Readmissions/Pages/default.aspx Linden, A. & Butterworth, S. (2014). A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial. American Journal of Managed Care, 20(10), 783-792. Medpac (2007). Report to Congress: promoting greater efficiency in Medicare. Retrieved Sep 10, 2015, from Medicare Payment Advisory Commission http://medpac.gov/-documents-/reports. Melton, L., Foreman, C., Scott, E., McGinnis, M. & Cousins, M. (2012). Prioritized post discharge telephonic outreach reduces hospital readmissions for select high-risk patients. American Journal of Managed Care, 18(12), 838-844. Nelson-Marten, P. (1998). Caring theory: a framework for advance practice nursing. Advanced Practice Nursing Quarterly, 4(1), 70-78. Pomerantz, J., Toney, S. & Hill. Z. (2010). Care coaching: an alternative approach to managing comorbid depression. Professional Case Management, 15 (3), 137-42. Potter, M. & Wilson, C. (2017). Applying bureaucratic caring theory and the chronic case model to improve staff and patient self-efficacy. Nursing Administration, 41(4), 310-320.282. Takeda, A., Taylor, S., Taylor, R., Khan, F. and Underwood, M. (2012). Clinical service organization for heart failure. Cochrane Database of Systematic Reviews, 9, CD002752. doi:10.1002/14651858.CD002752. pub3 Watson, J. (2006). Caring theory as an ethical guide to administrative and clinical practices. Nursing Administration, 30(1), 48-55.

interfere with the independence of referral sources. Finally, the Code recognizes that marketers and coordinators/liaisons play an important role. They often serve as the primary point of contact between providers and referral sources. Consequently, marketers and coordinators/liaisons must act with the highest degree of professionalism and integrity. Providers must ensure that all of their representatives who interact with referral sources receive training about applicable laws, regulations and industry codes of practice that govern interactions with health care professionals. Marketers and coordinators/liaisons should receive updated or additional training as needed. Companies should also

evaluate their representatives periodically to ensure that they comply with relevant policies and standards of conduct. Providers should take appropriate disciplinary action when representatives fail to comply. Although the Code described above applies only to members of PhRMA who voluntarily agree to adhere to it, to the extent that the Code represents standards for marketing in the healthcare industry, it is helpful for all providers to know about it. CM ©2022 Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author.


What Lifelong Learning Means to Me continued from page 6 education and more on learning that comes from continuing education, networking, and working closely with peers. As I met more people and understood their backgrounds and expertise, it helped me identify gaps in my own knowledge. Although I hav more than 30 years in my career, there are still new areas I want to explore to expand my understanding. Among them is diversity, equity, and inclusion (DE&I), with a certificate program from Cornell University offered by my employer. My decision to embark on this latest course of study came after awareness sessions with my employer, which

Impact continued from page 8 not want to continue taking so many pills. This gave the specialist a better understanding of the patient and an opportunity to explain his role in the patient’s care. This case impacted me by demonstrating the important role of the case manager as the bridge to improve communication and achieve the real goals of care. It happened that I was present and managing the care in that instance, but what happens when there is no case manager? What could have occurred if I had not been there? Since he had a case manager, this young worker was able to transition off the pain medications more quickly, and I helped to prevent multiple, unnecessary physician appointments for him to achieve his goal. This was another instance where I felt impacted by this exchange and it helped make me a better case manager. In more recent years in my role as a case manager consultant, I frequently deliver educational presentations for case management audiences.

opened my eyes to what I did not know but thought I knew both personally and professionally. While I have always considered myself aligned with the goals and principles of DE&I, I see it as imperative to continue building my knowledge and skills in this area to support my corporate position and my role as chair of the Commission’s subcommittee on diversity and inclusion. No matter where my life and work take me next, I know that learning will be part of it. Even a purely personal pursuit can expand my lifelong learning as I allow my curiosity and interests to lead me to what I want to explore. I’m constantly evaluating my knowledge and experiences so that my journey as a lifelong learner remains dynamic and interesting. CM When receiving reviews, it helps me focus on the presentation—should it be modified? Was my delivery satisfactory? etc. And it is nice to read those “atta boy” notes that the program was considered very good. However, the greatest impact comes from those audience members who stick around at the end to ask questions. Those are the ones that touch me the most. Not so much that I did my job, but that I connected with those individuals in a more personal way. There is no way to adequately describe that other than to say, again my job touched me more than it touched the audience. Many writers have tried to describe the impact we receive from our patients, colleagues, and audiences. All I can say is that I have been fortunate enough to have been touched beyond any expectation. CM

Home of

Reprinted by permission from “Case Management: Elevate, Educate, Empower” by Colleen Morley and Eric Bergman, Editors, CMSA Chicago, Westchester, Il 2021.

April/May 2022 CareManagement 37


CE1

CARF Standards That May Pose Challenges to Conformance for Case Managers continued from page 5 health information. Anyone who has used a large pharmacy chain throughout the pandemic has experienced this type of a product that provides a platform that allows for personal health information to be shared both to the person served and also to other health care providers. Where these products can fall short of assisting with demonstrating conformance to the CARF standard is that they may not allow the patient to add, delete, or edit information to them, and certain health care providers may also lack the ability to make these same modifications. If the person served does not have a system or tool in place, it’s the responsibility of the rehabilitation program to provide education on the importance of having such a system or tool to the person served and the family or support system. The rehabilitation program would also need to assist the person served to develop a system or tool to record personal health information. The system or tool may be called many things (eg, a portable profile, medical passport, patient care notebook, shared care plan, smartcard, or healthcare folder). Offering the person served a choice of formats may improve the actual use of the system or tool. The format facilitates ease of access and ready availability in case of an emergency. These efforts will assist persons served in managing their personal health information in an efficient and meaningful way. If you are interested in receiving more information about CARF accreditation in your setting or to identify IPR programs in your area, contact Terry Carolan at tcarolan@ carf.org. CM

38 CareManagement April/May 2022

Becoming an Author: Rise to the Challenge continued from page 2

Pandemic Era Developments for Postacute Care Networks: Part II continued from page 15

are sharing your knowledge and experience with the wider world. In some cases, you are sharing research findings, but more frequently you are sharing experiences that have helped your patients achieve improved outcomes. That information is worth sharing! You may be sharing an opinion about an issue in case management. You may be presenting a point of view that can advance the professional practice of case management. The ideas, topics, and stories for you to tell are only limited by your imagination! Topics might include a particular health condition, improving the case management process, how to do a better assessment, time management, discharge planning, working with the whole health care team, patient education, social support, overcoming barriers to access, maximizing resources, and ethics. The list of potential topics is really endless! I challenge you to become an author. Martin Luther said: “If you want to change the world, pick up your pen and write.” I paraphrase by saying, if you want to change the professional practice of case management, pick up your pen and write. Authors are needed. Catherine M. Mullahy, RN, BS, CRRN, CCM, FCM, Executive Editor, and I are excited to work with you in telling your story. Please be in touch. Think about what story you have to tell! Happy writing!

Gary S. Wolfe, RN, CCM, FCM, Editor-in-Chief gwolfe@academyccm.org ACCM: Improving Case Management Practice through Education

Hegyi J, Kukral L, & Brewer T. 2016 August/ September. Evaluating the Selection Process of Post-Acute Preferred Provider Relationships. CareManagement. Vol 22, No 4. https://issuu. com/academyccm/docs/cm_aug_sep_2016_ af01e8179978ae?e=23788880/38131818 Kukral L, Frank B. 2022 February/ March. Pandemic Era Developments for Postacute Care Networks: Part I. CareManagement, Vol. 28, No. 1. https:// issuu.com/academyccm/docs/cm_feb_ mar_2022?fr=sZWIxOTQ2NTc4MDU Maksimow A, Samaris D. 2018 May 8. Optimizing a Health System’s Post-Acute Care Network. Healthcare Financial Management Association. https://www.hfma.org/topics/ hfm/2018/may/60603.html Marselas, K. 2021 September 1. Skilled nursing specialties are very much alive–and thriving– after COVID-19. https://www. mcknights.com/print-news/skilled-nursingspecialties-are-very-much-alive-and-thrivingafter-covid-19/ Ohio Department of Medicaid. 2020. Ventilator Program–Ventilator-Associated Pneumonia Rates Calendar Year 2020. https://medicaid.ohio.gov/static/ Providers/ProviderTypes/LongTermCare/ NursingFacility/Calendar-Year-2020.pdf Oruongo J, Ronk K, Alagoz O, Jaffery J, & Smith M. 2020 March 3. Skilled Nursing Facility Differences in Readmission Rates by the Diagnosis-Related Group Category of the Initial Hospitalization. JAMDA The Journal of Post-Acute and Long-Term Care Medicine. https://www.jamda.com/article/S15258610(20)30194-8/fulltext#relatedArticles Raths, D. 2020 August 12. Pennsylvania ACO’s Post-Acute Strategy Reinforces Best Practices. Healthcare Innovation. https:// www.hcinnovationgroup.com/policyvalue-based-care/accountable-careorganizations-acos/article/21149907/ pennsylvania-acos-postacute-care-strategyreinforces-best-practices


Case Managers and the Great Health Care Resignation: A Call to Action

Diversity, Equity, and Inclusion: Leadership in Case Management

continued from page 3

continued from page 7

Protecting our Healthcare Workforce— Declaration of Principles.” The declaration contains three key principles: 1. Safeguard Psychological and Emotional Safety; 2. Ensure Physical Safety; and 3. Promote Health Justice. The coalition membership is continuing to expand, as is its message. The issues that have been encountered by far too many health care professionals over the years have resulted in the movement “End the Trauma, Stop Health Care’s Great Resignation and Protect Care Teams Now!” This is an urgent matter, and each case manager can be a catalyst for change in his/her organization. While some of the problems are systemic, others can be addressed by incremental changes. I would like to suggest the “top 5 things” to plant this Spring to help your career grow. Why not consider the following? 1. Attend a professional conference (eg, CMSA is back to a live meeting in Orlando on June 1–4, 2022 https://cmsa.societyconference.com/ v2/). 2. Partake in continuing education opportunities (no cost or low cost); 3. Mentor younger professionals; 4. Take care of yourself by eating healthy, exercising, and accessing mental health services; and 5. Make time for family, friends, and activities you love. 6. Consider contributing an article to CareManagement! Wishing you a beautiful Spring and fulfillment in case management as you make a difference…one patient at a time!

professional codes of conduct, which expressly obligates our certificants to: • Place the public interest above our own at all times • Respect the rights and inherent dignity of others • Always maintain objectivity in our relationships with clients • Act with integrity, dignity, and fidelity with clients and others. These principles are not aspirational. Board-certified case managers and board-certified disability management specialists proactively accept responsibility for their behavior and embrace these principles in practice. Further, the Commission pledges to: • Condemn discrimination because of age, appearance, disability, ethnicity, gender, geographic location, nationality, professional level or practice setting, race, religion, sexual orientation, or socioeconomic status • Celebrate and lift up the unique attributes of all case managers and disability management specialists • Value and seek diversity, equity, and inclusion within the case management and disability management professions • Promote an inclusive environment that encourages involvement, innovation, and expanded access to leadership opportunities that maximize engagement across all groups within the framework of the certification criteria • Leverage the unique characteristics, perspectives and contributions of a diverse case management and disability management population, including, but not limited to, age, appearance, disability, ethnicity, gender, geographic location, nationality, professional level or practice setting, race, religion, sexual orientation, and socioeconomic status

Catherine M. Mullahy, RN, BS, CRRN, CCM, FCM, Executive Editor cmullahy@academyccm.org

• Highlight diversity to collectively and effectively provide for opportunities to improve the health and welfare for clients who receive case management and disability management interventions • Advocate for efforts to end systemic racism and inequity, thereby affirming the inherent dignity and value of every individual. In closing, the case management and disability management professions must not only continue to embrace DE&I in practice but also fulfill this vision and rallying cry, compelling us all to become our best selves. Through the actions we take and the example we make, we can all help advance a society that is more diverse, equitable, and inclusive. CM

CMSA Hot Topics continued from page 4 strategy is designed to enable the association to support and enhance case managers’ ability to achieve patient goals, improve outcomes, and enrich the patient care experience. Stay tuned and monitor email, social media, publications, and the CMSA website to continue the conversation on CMSA Hot Topics! CM

Readers:

Have an idea for an article? Send your suggestions for editorial topics to: Catherine Mullahy, cmullahy@ academyccm.org.

Authors:

Consider contributing an article to CareManagement. Please send manuscripts or inquiries to: cmullahy@academyccm.org.

April/May 2022 CareManagement 39


HOW TO CONTACT US

REFER A COLLEAGUE TO ACCM Help your colleagues maintain their certification by referring them to ACCM for their continuing education needs. They can join ACCM at www.academyCCM.org/join or by mailing or faxing the Membership Application on the next page to ACCM. Why join ACCM? Here are the answers to the most commonly asked questions about ACCM Membership: Q: Does membership in ACCM afford me enough CE credits to maintain my CCM certification? A: If you submit all of the CE home study programs offered in CareManagement, you will accumulate 90 CE credits every 5 years. Q: D oes membership in ACCM afford me enough ethics CE credits to maintain my CCM certification? A: If you submit all of the CE home study programs for ethics credits offered in CareManagement, you will accumulate at least 10 ethics CE credits every 5 years. Q: Are CE exams available online? A: Yes, ACCM members may mail exams or take them online. When taking the exam online, you must print your certificate after successfully completing the test. This is a members only benefit. If mailing the exam is preferred, print the exam from the PDF of the issue, complete it, and mail to the address on the exam form. : Where can I get my membership certificate? Q A: Print your membership certificate instantly from the website or click here. Your membership is good for 1 year based on the time you join or renew. Q: How long does it take to process CE exams? A: Online exams are processed instantly. Mailed exams are normally processed within 4 to 6 weeks. Q: Do CE programs expire? A: Continuing education programs expire in approximately 90 days. Continuing education programs that offer ethics CE credit expire in 1 year. Q: Is your Website secure for dues payment? A: ACCM uses the services of PayPal, the nation’s premier payment processing organization. No financial information is ever transmitted to ACCM. application on next page

join/renew ACCM online at www.academyCCM.org 40 CareManagement April/May 2022

Editor-in-Chief/Executive Vice President: GARY S. WOLFE, RN, CCM, FCM 541-505-6380 email: gwolfe@academyccm.org Executive Editor: Catherine M. Mullahy, RN, BS, CRRN, CCM, FCM, 631-673-0406 email: cmullahy@academyccm.org Publisher/President: Howard Mason, RPH, MS, 203-454-1333, ext. 1; e-mail: hmason@academyccm.org Art Director: Laura D. Campbell e-mail: lcampbell@academyccm.org Copy Editor: Esther Tazartes e-mail: justice@dslextreme.com Subscriptions: 203-454-1333 Website: academyCCM.org

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Academy of Certified Case Managers

Executive Vice President: Gary S. Wolfe, RN, CCM, FCM 541-505-6380 email: gwolfe@academyccm.org Member Services: 203-454-1333, ext. 3 e-mail: hmason@academyccm.org Phone: 203-454-1333; fax: 203-547-7273 Website: academyCCM.org Vol. 28, No. 1, April/May 2022. CareManagement (ISSN #1531-037X) is published electronically six times a year, February, April, June, August, October, and December, and its contents are copyrighted by Academy of Certified Case Managers, Inc., 2740 SW Martin Downs Blvd. #330, Palm City, FL 34990; Tel: 203-454-1333; Fax: 203-547-7273.


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HEALTH CARE CASE MANAGEMENT

GET CERTIFIED.

STAY CERTIFIED.

DEVELOP OTHERS.

Ready to demonstrate your value? When you become a CCM®, you join the top tier of the nation’s case managers. It’s a commitment to professional excellence, elevating your career and influencing others.

The CCM is the oldest, largest and most widely recognized case manager credential. Those three letters behind your name signal the best in health care case management.

Employers recognize proven expertise. Among employers of board-certified case managers: ●●50% require certification ●●62% help pay for the exam ●●45% help pay for recertification Join the ranks of more than 45,000 case managers holding the only cross-setting, cross-discipline case manager credential for health care and related fields that’s accredited by the National Commission for Certifying Agencies.

You’re on your way to great things.

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GET CERTIFIED. STAY CERTIFIED. DEVELOP OTHERS. Commission for Case Manager Certification | 1120 Route 73, Suite 200 | Mount Laurel, NJ 08054 ccmchq@ccmcertification.org | www.ccmcertification.org | 856-380-6836


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