AMDA – The Society for Post-Acute and Long-Term Care Medicine has named two clinician teams as its 2019 Choosing Wisely® Champions, honoring them for making significant contributions to advance the ideals of the ABIM Foundation’s Choosing Wisely campaign by working to reduce unnecessary tests, treatments, and procedures in health care.
The first team, led by David Nace, MD, MPH, CMD, utilized AMDA’s Choosing Wisely recommendation #3: Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract. The second team—Peter Jaggard, MD, CMD; Rosina Finley, MD, CMD; Fatima A. Naqvi, MD, CMD; and Karl Steinberg, MD, CMD, MHDC—focused on AMDA’s recommendation #9: Don’t recommend aggressive or hospital-level care for a frail elder without a clear understanding of the individual’s goals of care and the possible benefits and burdens.
Dr. Nace and his team developed guidelines and tools for improving the diagnosis and treatment of uncomplicated cystitis in post-acute and long-term care (PALTC) settings. Through educating facility staff and providers and using quality improvement processes, the team pilot-tested the guidelines and tools in 26 nursing homes across the country. Facilities using these resources demonstrated a significant reduction in the inappropriate treatment of asymptomatic bacteriuria and in reported Clostridium difficile cases. Excessive duration of antibiotic treatment was also reduced. The project team is now disseminating the guidelines and tools to more nursing homes nationally. In addition to promoting the value of Choosing Wisely, this effort helps nursing homes meet new Centers for Medicare & Medicaid Services (CMS) requirements on antibiotic stewardship and quality assurance and performance improvement (QAPI) programs.
“Sustainability is the ‘magic sauce’ in quality improvement,” Dr. Nace said, noting that in addition to developing and distributing the guidelines and tools, his team conducted one-on-one and group coaching calls, used a dashboard to highlight “all the things people were doing right,” and celebrated wins while learning from missteps. He said, “We are pleased to win this award. People are learning from our efforts. And, hopefully, it will move the needle [on antibiotic stewardship] a little.”
Dr. Jaggard and his team used the society’s Advance Care Planning) Series to develop, promote, and document the content of discussions between patients/families and their physicians regarding goals, values, and preferences for medical treatment. They introduced the materials in several facilities and trained practitioners on their use. The result was increased awareness and attention to person-centered care, palliative care, and end-of-life care, as well as improved transitions of care, pain management, patient/family satisfaction, and cost-effectiveness of care.
“While the goal for most post-acute residents is to rehabilitate function and return home, there is a subset of frail residents who need the opportunity to clarify and express their choices for shifting goals of care toward less aggressive care and more toward comfort care,” Dr. Jaggard said. “Offering Advance Care Planning in these settings increases patient choice and implementation of their preferences for appropriate levels.”