We all are hearing, seeing and feeling the effects of what has become the most significant call to action today—resolving the Opioid Crisis. What does this mean for Nursing Home Administrators (NHAs)? As an NHA, I can relate to having residents express pain daily. As the prescription medication issue gains widespread attention, the approaches NHAs take may be quite different than past approaches. Administrators hold the role of not only caring for the residents in relation to this monumental crisis, but they also hold a significant role as an employer to be knowledgeable about and provide information to employees regarding resources for themselves or family members on the subject.
If you have been a patient in a hospital within the past 10 years, you were probably asked the question, “On a scale of 1–10, where do you rate your pain level?” The response to this question is known as the Pain Scale. Often, this assessment tool is referred to as the 5th vital sign indicating the status of the body’s function by indicating how much pain a person is currently experiencing. You may also remember the use of “smiley faces” on your medical record indicating whether you had no pain (identified by a 0) or excruciating pain (identified by a 10) Of course, if the medical staff were asking about the pain level you were experiencing, they would need to address the level, usually using medications. According to the American Society of Addiction Medicine (ASAM), this often means the use of very heavy hitting pain medications such as oxycodone, hydrocodone, codeine, morphine, fentanyl and others. This practice has been widely used in nursing facilities as well. If you're an administrator, I’m sure you’ve been asked during a survey, “What is your policy on controlling pain for your residents.” At that point, you go to your policies and procedures and trot out the policy on controlling pain. As we all know, part of the required facility assessment recently enacted in phase II of the long-term care regulations rolled out in November 2017, is knowing your resident population needs. A close look at how your facility controls pain for residents should be a high priority for your plan.
While no one wants to see a patient or resident in pain, the use of these significant pain medications has often led patients to become addicted to prescription opioid medications. This is certainly not the only reason for the current crisis, but it has contributed to the issue in significant fashion.
The Opioid Crisis in the United States
To have a grasp of how widespread the opioid crisis is, let’s look at some statistics. According to ASAM's Morbidity and Mortality Report, in 2015 there were 52,404 drug overdose deaths in the United States. Of those overdose deaths, 20,101 were due to prescription pain relievers and 12,990 were due to heroin overdoses. The reason you need to be aware of heroin statistics is that heroin use often begins with addiction through the use of prescription painkillers. Per the Centers for Disease Control, three out of four newly addicted heroin users begin using prescription opioid pain medications prior to moving onto heroin.
Opioid's and the Impact on Patient Care
So why is this issue critical in long term care? Think about the age and physical conditions of the people who present for admission to a skilled nursing facility. In many cases, common diagnoses for nursing home residents include Septicemia, Congestive Heat Failure, Pneumonia, Urinary Tract Infections and Acute Renal Failure, as published by Charles Crecellus in “Caring for the Ages” (note this list only represents a small portion of admitting diagnoses). These diagnoses are often accompanied by significant levels of pain and more often a prescription for an opioid pain medication from the admitting hospital physician.
So, what is the responsibility of the facility to manage the resident’s pain level while maintaining good quality initiatives related to the opioid crisis? Medicare and Medicaid regulations indicate that it is the responsibility of the facility to accomplish compliance on several significant points in the effort to control a resident’s pain. The Centers for Medicare and Medicaid Services' (CMS) regulation F697 says, “The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.” And the intent of this regulation states, “Based on the comprehensive assessment of a resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident’s choices, related to pain management.” The regulation also addresses the use of opioid medications as well, stating that “Opioids should be selected and dosed in accordance with current professional standards of practice and manufacturers’ guidelines in order to optimize their effectiveness and minimize their adverse consequences. Adverse consequences may be especially problematic when the resident is receiving other medications with significant effects on the cardiovascular and central nervous systems. Therefore, careful titration of dosages based on monitoring/evaluating the effectiveness of the medication and the occurrence of adverse consequences is necessary. The clinical record should reflect the ongoing communication between the prescriber and the staff which is necessary for the optimal and judicious use of pain medications.”
Frequent and ongoing dialogue with the resident’s physician and the facility consulting pharmacist will provide the nursing home administrator, director of nursing and other members of the interdisciplinary team with the knowledge of how to address the use of opioid medications for their residents.
Opioids and the Impact in the Workplace
The employees of your facility have a need for not only information on how to care for the residents related to the opioid crisis, but also themselves and their family members as well. As an employer, you must have solid policies in place to address the organization’s stand on drugs in the workplace. If, for example, a nurse comes to you identifying that they have an addiction issue, you will need to act appropriately on assisting that individual to obtain treatment. Because the nurse holds a professional license he or she can receive treatment and have their license protected under various laws dependent upon individual state laws. Be sure to seek out legal advice if this situation presents itself in your facility.
There are also individual state initiatives currently addressing the opioid crisis. One such organization in PA is the Drug Free Workplace program (www.drugfreeworkplacepa.org). Through this organization, a company can create policies and implement programs to become a drug free workplace. They also have additional resources to assist those affected by opioids (and other) addictions to start on the path to sobriety. The Drug Free Workplace program is also available in other states.
Education on the extent of the opioid crisis in the U.S. is essential for an administrator. While the statistics about deaths related to these overdoses are staggering—and there appears to be little or no reduction in the immediate future—knowledge and a solid plan is essential to identifying gaps and implementing best practices for pain and medication management.
LW Consulting, Inc. has the expertise and ability to assist nursing homes with developing and strengthening their existing clinical programs. We can develop protocols and help you establish policies and procedures for all clinical areas within your facility. Ask us about our “Keys to Clinical Best Practice” program where we will not only help you establish best practices for pain and medication management, but ensure clinical compliance in all areas affecting comprehensive person-centered care planning.
Adhering to best practices for medication and pain management is essential to achieving compliance and positive outcomes in your resident population. Ask us about how our “Keys to Clinical Best Practice” program can help.