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Advisory Council January 2020 Meeting Presentation: Clinical Subcommittee Update

Monday, January 27, 2020

Printer Friendly Version in PDF Format (9 PDF pages)




Centers for Medicare & Medicaid Services

National Partnership to Improve Dementia Care in Nursing Homes: Update

  • Decrease of 39 percent to a national prevalence of 14.6 percent in Quarter 4 2018
  • CMS acknowledges that circumstances exist where clinical indications for the use of antipsychotic medications are present, and does not expect that the national prevalence of antipsychotic medication use will decrease to zero
SOURCE: CMS Quality Measure, based on MDS 3.0 data. For more information, see the MDS 3.0 Quality Measures Users Manual.

(Strategy 2.D)

National Partnership to Improve Dementia Care in Nursing Homes: Late Adopter Update

  • Data specific to the progress of the late adopters
  • Decrease of 7.1 percent to a national prevalence, among late adopters, of 19.9 percent in Quarter 4 2018
SOURCE: CMS Quality Measure, based on MDS 3.0 data. For more information, see the MDS 3.0 Quality Measures Users Manual.

(Strategy 2.D)

CMS Strengthens Oversight of Nursing Home Inspections to Keep Residents Safe

  • In October CMS announced changes to the nursing home safety inspection process called the State Performance Standards System, which includes new performance measures and stricter monitoring to ensure inspections are done in a fair, accurate, and timely manner to support resident safety, and ensuring that enforcement actions -- like civil money penalties -- are applied consistently
  • Changes include increased monitoring to assure State Survey Agencies (SSAs) are conducting surveys timely, new performance measures related to citation rates and timeliness, holding SSAs accountable for correctly handling "immediate jeopardy" cases by examining timeliness and accuracy of notification, increasing flexibility for state-specific measures so resources can be targeted to poor-performing SSAs, and better access for SSAs to CMS data to streamline reporting

Information at:
(Strategy 2.F)


Indian Health Srevice

Caregiver Support -- REACH into Indian Country Initiative Update

  • Integrating PHN dementia training and training on REACH-based intervention into the Rural Interdisiplinary Team Training (RITT) provided by the VA Greater Los Angeles
    • Pilot test with the San Carlos Apache Tribe this month.
    • Engagement of the IHS Public Health Nursing program

Toward Generational Improvement in Native Elder Health. Finke, B. & Winchester, B. Curr Geri Rep (2019) 8: 265

  • High Leverage Strategies:
    1. Reduce the risk of fall-related injuries through implementation of routine screening for fall risk, multi-disciplinary assessment, and targeted interventions for both the individual elder and their environment to reduce fall risk
    2. Ensure access to evidence-based caregiver support for elders with dementia and frailty in every tribal and Urban Indian community provided through the tribal aging network, public and community health nursing programs, and community health representatives
    3. Develop decision support tools and training resources for the diagnosis, assessment, and management of Alzheimer's disease and related dementias
    4. Integrate care management into primary care services, targeted to elders and younger adults with frailty, dementia, complex comorbidities, and in transitions of care
    5. Routinely offer an annual comprehensive exam for elders. This can start with older cohorts of elders and move younger as resources allow


Agency for Healthcare Research and Quality

AHRQ/NIDDK E-care Plan Project

  • Develop e-Care Plan for People with Multiple Chronic Conditions
    • Building on existing work (current e-care plans disease or setting specific) to develop a shared interoperable e-care plan
    • Currently identifying data elements through technical expert panels; developing clinical information models, a SMART on FHIR e-care plan app and accompanying implementation guide
  • Pilot Test e-care Plan in Clinical Practice
    • Health system/practices to provide user input to developers
    • Test and evaluate in primary care and ambulatory practices in large health system
  • Rapidly evolving field
    • Please share new work with team
  • Project website:

AHRQ Opioids and Older Adults Initiative

  • Prevention, Diagnosis, and Management of Opioids, Opioids Misuse, and Opioid Use Disorder in Older Adults (Technical Brief)
    • Aim: To map the published evidence around risk factors and interventions to improve management of opioids in older adults
  • Identifying and Testing Strategies for Management of Opioid Use and Misuse in Older Adults in Primary Care Practices (Pilot Project)
    • Aim: To describe how opioids are currently managed in the older adult population and to identify promising interventions to improve outcomes
  • Improving the management of opioids and opioid use disorder in older adults (R18)
    • Aim: To develop, implement, evaluate, and disseminate strategies to improve the management of opioid use and opioid use disorder (OUD) in older adults
    • Applications due February 20, 2020


Dept. Veterans Affairs Updates

Marianne Shaughnessy, PhD, CRNP
Susan G. Cooley, PhD

VHA Directive 1140.12 Dementia System of Care (Oct 2019)

  • First Veterans Health Administration (VHA) directive devoted entirely to a system of care for Veterans with dementia within VHA.
  • VHA Dementia System of Care defined as an integrated service delivery network that provides primary & specialty care to Veterans with dementia.
  • Policy: It is VHA policy that all VA medical facilities provide comprehensive, coordinated, person-centered care for Veterans with dementia & their caregivers.
  • Available on Veterans Health Administration (VHA) Publications Internet site

REACH-VA Caregiver Support Intervention Updates

  • National Program to Continue Providing REACH VA to Caregivers of Veterans - Funded by VA Caregiver Support Program
  • Caregiver Staff at each VA facility to be trained to provide REACH VA Individual & Telephone Support Group Interventions to Caregivers of Veterans
    • Part of expansion of Program of General Caregiver Support Services (PGCSS), through P.L. 115-18, VA MISSION Act
    • Funded by VA Caregiver Support Program
  • REACH Hope - Caregivers of Veterans with Dementia and TBI
    • National Randomized Controlled Trial to examine effectiveness of intervention combining REACH VA individual intervention with DoD app Virtual Hope Box to improve caregiver well-being & management of Veteran concerns & safety
    • Collaboration between Caregiver Center, Memphis VAMC, & Virginia Commonwealth University
    • Funded by Department of Defense Congressionally Directed Medical Research Program (CDMRP), 2020-2023

VA Office of Rural Health Geriatrics/Extended Care & Dementia-Related Projects Funded for FY2020

  • Home Based Primary Care expands home-based Patient Aligned Care Team services to rural areas within a VA medical center or VA health care system service area.
  • Medical Foster Home provides an alternative to nursing home for Veterans who need daily personal assistance, are no longer able to live independently, and do not have an available family caregiver.
  • Gerofit provides physical activity therapy to elderly rural Veterans using telehealth technology.
  • National Teleneurology Program provides neurological care to rural Veterans using telehealth.
  • National Telestroke Program provides emergent telehealth care by qualified stroke neurologists to Veterans with stroke symptoms at VA medical centers that do not have stroke neurologists on site.
  • Remote Home-Based Deliver of Cardiac Rehabilitation uses telehealth to eliminate the need for rural Veterans to travel multiple times a week to a rehabilitation facility, and enables patients to tailor the location and schedule of their rehabilitation sessions for their home
  • Adoption of VA Video Connect to Support Rural Caregivers: Caregiver Support Coordinators will adopt VVC for conducting required 90-day monitoring assessments and utilize this modality for other types of visits with rural Veterans and caregivers
  • VA Video Connect (VVC) for Rural PACT Case Managers: This project will enhance the ability of rural PACT case managers to effectively manage rural Veterans healthcare and improve outcomes by using VVC to coordinate and manage rural Veteran healthcare
  • Late Life PTSD Educational Program for VHA and non-VHA Rural Health Providers: This project will develop an evaluation and educational program building on the "Empower Community Hospices Initiative" which targets non-VA hospice staff providing care for Veterans.
  • Improving Access to Geriatric Care in Rural Areas/Geriatric Research, Education, and Clinical Center (GRECC) Connect: National dissemination project to support providers caring for rural Veterans with geriatric syndromes, significantly those with dementia
  • Geriatric Scholars: National dissemination program to address needs of rural Veterans by educating and supporting innovation of rural providers concerning geriatric needs including dementia.

VA Geriatric Scholars FY2020 Plans Initiated Dementia Education and Resources

  • Geriatric Scholars Program to integrate geriatrics into primary care practices, core course in geriatric medicine and gerontology:
    • Boston, February 28-March 30, 2020 -- Palo Alto, April 27-May 1, 2020
    • Los Angeles, September 8-12, 2020 -- New York, September 21-25, 2020
  • Geriatric Scholars Program Clinical Practicum with focus on dementia at the following GRECCs:
    • Little-Rock GRECC, Palo Alto GRECC, Puget Sound GRECC-- Dates to be announced
    • Madison GRECC, May-August, 2020; San Antonio GRECC, August 27-28, 2020
  • Geriatric Scholars Program Advance Scholar courses:
    • American Geriatrics Society (AGS)/Long Beach, May 7-9, 2020
    • Leadership and Management/Los Angeles, August 2-3, 2020
  • Geriatric Scholars Program Rural Interdisciplinary Team Training in care of older Veterans with focus on recognition of dementia in primary care clinics
    • Funded for 20 on-site training for all clinic staff at VA clinics (led by Bronx GRECC)
    • Funded for at least 6 at Indian Health Service clinics (led by GLA GRECC)
  • Geriatric Scholars Program Webinars
    • 4-part series on issues for caregiver spouse of a Veteran with dementia (led by Palo Alto GRECC)
    • 4-part series to supplement VA Rural Interdisciplinary Team Training (RITT) (led by Bronx GRECC)
  • New curriculum and enduring educational materials
    • Non-pharmacological interventions for challenging behaviors in dementia -- to supplement IHS-RITT (led by GLA GRECC)
    • Medication pocket guide for VA general psychiatrists (led by GLA GRECC)
    • Web-based interactive learning program on dementia (led by Madison GRECC)
  • GRECC Connect Webinars for VA Staff with specific focus on cognitive impairment, dementia:
    • The 3Ds: Delirium, Dementia and Depression (Thomas Caprio) January 17, 2020


Veterans Health Administration

STAR-VA: Updates on Program Implementation and Outcomes


STAR-VA intervention and training program

  • STAR-VA[1] is a person-centered, inter-disciplinary, behavioral approach to managing challenging behaviors among CLC[2] residents with dementia
  • A CLC Mental Health (MH) Professional ("Behavioral Coordinator") and Registered Nurse ("Nurse Champion") work with entire team, including direct care staff
  • Four core components
    1. Realistic expectations
    2. Effective communication
    3. ABC[3] problem-solving
    4. Pleasant events
  • Training Program:
    • Competitive site selection process
    • Intensive virtual workshop, 6 months of consultation, competency based
  • Timeline
    • 2010: Pilot program
    • 2013-2018: Annual training - 17-23 sites/year
    • 95/134 CLCs trained at least once
    • Retraining 2014-2018: 41 CLCs, 9 retrained 2X
  1. Adapted from Staff Training in Assisted Living Residences (STAR; Teri et al., 2005)
  2. Community Living Center
  3. Activator-Behavior-Consequence

Quality Enhancement Research Initiative (queri) evaluation: Rationale/aims

  • STAR-VA training program with positive outcomes
    • Pre-post clinical impact for Veterans (decreased distress behaviors; decreased depression, anxiety, agitation)
    • Increased self-reported confidence among trainees, teams
  • However...sustaining a new care approach is challenging
    • E.g., staff turnover, teamwork challenges, resistance to new approaches, time, varying leadership priorities
  • QUERI evaluation*: STAR-VA implementation 2013-17, to inform sustainability intervention
    • Developed distressed behavior indicator (DBI)
    • Evaluated impact of STAR-VA on key quality outcomes (e.g., DBI, psychotropic use, staff injuries)
    • 20 teams interviewed re: facilitators/barriers and key practices for program sustainment

*In partnership with VHA Offices of Mental Health and Suicide Prevention and Geriatrics and Extended Care

Evaluation outcomes: highlights

  • Impact on psychotropic prescribing
    • Significant decrease in dose equivalents of as-needed antipsychotic and sedative hypnotic medications prescribed for agitation/anxiety in STAR-VA cases versus controls
  • Impact on staff injuries
    • Assaults with staff injury rates decrease the year of and following completion of STAR-VA training, compared to CLCs not trained
  • Minimum Data Set (MDS 3.0) behavior items used to develop valid Distress Behavior Indicator
    • Routine team administration captures relatively few symptoms; challenge to demonstrate potential STAR-VA impact
  • Sustainability facilitators to inform next steps
    • Critical: People and relationships, team interactions, supportive culture, integrating into usual routines