2016 MEMBERSHIP DIRECTORY ENCLOSED

A publication for Wisconsins Long-Term Care Profession by

SPRING 2016

Communication: The Key

to the Revolving Door
Continuing the Effort to Reduce Readmissions

Including: Thats a Wrap: 2015-16 Legislative Session Draws to a Close

CHAASE Shaping the Minds of Tomorrows LTC Administrators

Workforce Survey Shows Serious Crisis

ANALYZE

WELCOME
Innovation

WHCA/WiCALs

The only thing thats constant is change. This change presents a range
of challenges for Wisconsins long-term care provider community.
The workforce staffing crisis, changes in reimbursement from
managed care to bundled payments, the redesign of Wisconsins
Family Care program these are all both changes and opportunities.
The theme of our Spring Conference this year is Innovation. But
change is different than innovation: change is a process, innovation
is a response. To put it another way, change is what happens to us,
and innovation is how we respond. Ultimately, innovation is the
vehicle by which we maximize our opportunities.

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I am proud to have the opportunity to serve the Wisconsin

Health Care Association and its members. In my career, I have
worked as a newspaper reporter, legislative chief of staff, as well
as a communications and policy advisor. For the last five years, I
have served as WHCA/WiCALs Communications Director and
managing editor of this magazine. Now, I am honored to follow in
the footsteps of George F. MacKenzie and Thomas P. Moore as this
associations new Executive Director.

Social media and email marketing support

DESIGN

DEVELOP

ENHANCE

This past January, Tom Moore, the 32-year Executive Director

stepped down from the helm of the Wisconsin Health Care
Association. Tom capably led the membership of our association
through many important changes in his tenure. As we approach this
new period in our associations 65th year, it is worth reflecting back
on where weve come from. Just two other individuals have served
as full-time Executive Directors of our Association. The first, when
the association was named the Wisconsin Association of Nursing
Homes, was George F. MacKenzie. In fact, it was George who
started the association by getting into his car and driving all over
the state of Wisconsin to encourage the operators of nursing homes
that they needed to come together to work in the common interests
of their collective need for Advocacy, Education and Excellence. In
the 1980s, Tom took up the mantle and steadily led our members
through many periods of both change and innovation.

If we havent met, Id like to take this opportunity to briefly introduce

myself. I was born in Madison, and Wisconsin is my home. I come
from a medical family with my father, a grandfather, an uncle, an
aunt, two brothers, a sister-in-law, and several cousins who are
physicians. Then there are the nurses. I have a sister-in-law whos
a nurse practitioner and several cousins who are registered nurses
as well. I went to Calvin College for my undergraduate degree, and
came home to Madison for graduate school at UW-Madisons La
Follette School of Public Affairs.

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My first exposure to long-term care was visiting my Aunt Pat, who was
suffering from the effects of a brain tumor, and living in a nursing home.
She depended on the consistent care provided by the nurses who protected
her dignity and tended to her needs when she couldnt care for herself.
While I was young, I remember being grateful that my grandparents and
my Uncle Roger had the help they needed to care for Pat.
When I was in college, my grandparents lived in a continuum of
care campus that included independent living, assisted living and a
skilled nursing facility right across the street from Calvin. It was there
where I first saw as an adult the benefits to the quality of life that a
continuum of care campus can provide to not only a resident but a
family as a whole. In their apartment, I was able to have dinner with
my grandparents every week all through college, until my grandfather
was hospitalized and passed away from heart disease at the age of 87
in my senior year.
Since my grandparents lived in a community that emphasized
quality care that was so close to where I went to college, I was able
to develop a relationship with them for several formative years in my
adult life. I was able to help teach a man who delivered ice blocks by
horse-drawn wagon as a child, to use email.
Ultimately, I believe our society will be judged by how we care
for our most vulnerable members, including the frail elderly and
disabled. Long-term care communities and the frontline caregivers
who serve in those communities provide an essential service that I
am proud to represent. In the years to come we will face many of
the same challenges that George and Tom, my Aunt Pat and my
grandparents experienced. Its essential that Wisconsins long-term
care provider community continue innovating to provide residents
the quality care they deserve in a constantly changing environment.
Thank you for the opportunity to serve you. On behalf of WHCA/
WiCAL staff, we are honored to help you provide quality care that
your residents need everyday. Please let me know if theres anything
that we can do to serve you and your facility.
Best Regards,

John J. Vander Meer, MPA

Executive Director
Wisconsin Health Care Association
Spring 2016 | CONTINUUM 3

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Spring 2016

CONTENTS
6
Continuum is published for the
Wisconsin Health Care Association
and the Wisconsin Center for
Assisted Living
131 W. Wilson Street, Suite #1001
Madison, WI 53703
Phone: 608.257.0125
Fax: 608.257.0025
www.whcawical.org

The Ins and Outs of the Legislatures Action on Long-Term Care Issues
The Wisconsin State Legislature was busy this Spring prior to adjourning its 2015-2016 floor
period. This legislative session, both the Senate and the Assembly considered many issues that
would affect the long-term care provider community. The Speakers Taskforce on Alzheimers and
Dementia introduced 10 bipartisan bills, some of which passed both chambers and were signed
into law. One of those bills, which would require CBRFs to obtain a signed acknowledgement form
before administering psychotropic medication, was defeated in the Senate.

WHCA/WiCAL recently joined other state provider associations to conduct a statewide provider survey
of workforce needs. Wisconsins recovering economy, rapidly changing labor market, and inadequate
Medicaid payments are having a dramatic impact on the ability of Wisconsins skilled nursing and assisted
living facilities to attract and retain caregivers.

Managing Editor
Jim Stoa
Publisher
Dean Gille

10

Creative Director
Sara Rice
Layout & Design
David Cox

In an effort to address costly hospital readmissions, the Affordable Care Act (ACA) created the
Hospital Readmissions Reduction Program (HRRP). In the post-ACA world, care providers are
beginning to create post-acute care networks. The key for long-term care facilities to help reduce
preventable readmissions will be to improve efforts to communicate with hospitals, with residents,
and with other members of an individuals interdisciplinary health care team.

12

For more information in advertising in

Continuum call 608.257.0125 or go to
www.whcawical.org/continuum.
If you are planning on moving and
would wish to continue receiving
Continuum, call 608.257.0125 and
inform WHCA/WiCAL of your new
address.

Bluestone Physician Services provides on-site primary care services for residents living in assisted living, memory care
or group home communities. The physician-led care teams visit the patients on a regular basis and collaborate with the
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2016 Badger Graphic Systems.

All rights reserved. The contents of this
publication may not be reproduced by
any means, in whole or in part, without
prior written consent of the publisher.

Call 262.354.3744 or visit BluestoneMD.com to learn more.

PUBLISHED APRIL 2016

STAKEHOLDER SPOTLIGHT
CHAASE Shaping the Minds of Tomorrows LTC Administrators
Under Doug Olsons Leadership, Students Prepare for Future

Published by

1155 Wilburn Road

Sun Prairie, WI 53590
608.834.3400
www.badgergraphics.com

COVER STORY
Communication: The Key to the Revolving Door
Continuing the Effort to Reduce Readmissions

Account Manager
Abbie McDowell

4 CONTINUUM | www.whcawical.org

DATA DIGEST
Workforce Survey Shows Serious Crisis
Survey Statistics Demonstrate Need for Long-Term Caregivers

Editor
Melissa Keller

Bringing the Clinic to YOU.

CAPITOL CONNECTION
Thats a Wrap: 2015-2016 Legislative Session Draws to a Close

Douglas Olson, Ph.D., FACHCA, is a Professor with the Health Care Administration (HCAD)
program at University of Wisconsin-Eau Claire, and has also overseen the development of the Center
for Health Administration and Aging Services Excellence (CHAASE) for the past 14 years. Dr. Olson
discusses his thoughts on the future of long-term care and how CHAASE and the UW-Eau Claire
HCAD program are helping students adapt and grow with new challenges facing the long-term care
provider community.

18

LTC LEGAL LETTER

Medicare Overpayments
Long-Awaited Overpayment Rule Issued
On February 12, 2016, CMS published a final rule affecting Medicare overpayment obligations.
The rule outlines reporting and returning requirements for Medicare overpayments to implement an
obligation under the Affordable Care Act to make repayment within a 60-day time period. Failure to
timely return overpayments may subject providers to significant penalties.

22

CLINICAL CORNER
Reflections on Care of the Feet
Bluestone Physician Services Point to the Importance of Proper Foot Care
Bluestone Family Doctor Matthew Grade, MD, discusses the sometimes overlooked need to monitor
and care for a residents feet.

Spring 2016 | CONTINUUM 5

Capitol Connection

Thats a Wrap: 2015-2016 Legislative Session

Draws to a Close

The Ins and Outs of the Legislatures Action on Long-Term Care Issues
By Jim McGinn

ssembly Speaker Robin Vos

(R-Burlington) and Senate Majority
Leader Scott Fitzgerald (R-Juneau) have
adjourned the 2015-2016 session of the
Wisconsin Legislature. While the initial
session schedule for the 2015-2016
biennial session period included limited
floor periods in April and May, both
legislative leaders commented their work
is done for this session.

In 2015, Assembly Speaker Robin

Vos announced the formation of three
bipartisan task forces, including the
Alzheimers Task Force. Speaker Vos
directed task force members to look
to improve and promote communitybased resources and raise awareness, as
well as address legal issues and determine
possible state participation in treatment
and research.

One of the primary reasons for an

early adjournment could be related
to a January 21, 2016 memo from
Legislative Fiscal Bureau Director Bob
Lang, which included an analysis of
economic forecasts and tax collection
and expenditure data of the current
fiscal year, and projections for each fiscal
year of the current biennium.

Chaired by Representative
Mike
Rohrkaste
(R-Neenah), the task
force announced in
January the introduction
of 10 bipartisan bills
to improve the care
of
those
suffering
from these diseases by
providing community-based resources
and
education.
Representative
Rohrkaste noted the legislation was
developed using the input from experts,
caregivers, state officials and community
members, many of whom attended the
six task force hearings conducted around
the state.

Specifically, Director Lang projected

the closing, net general fund balance
at the end of this biennium (June 30,
2017) to be $70.2 million. This is
$94.3 million below the $164.5 million
balance that was estimated prior to our
review. The $94.3 million reduction
is the net result of several adjustments
in state spending and to decreased
estimated tax collections.

In mid-February, the State Assembly

passed the following 10 bills introduced
by the task force:
AB783, relating to funding for
virtual dementia tour licenses
AB784, relating to funding
Alzheimers research at UWMadison
AB785, relating to a dementia
specialist certification program
AB786, relating to a pilot
program to create dementia
crisis units
AB787, relating to funding for
respite care
AB788, relating to funding
for dementia care specialists in
ADRCs
AB789, relating to continuing
legal education requirements
AB790, relating to dementia
training grants for mobile crisis
teams
AB791, relating to psychotropic
medications in CBRFs
AB792, relating to operators
license review

WHCA/WiCAL supported or had no

position on all of the proposed bills with
the exception of one bill, recognizing
support and collaboration is essential if
Wisconsin is to succeed in the battle with
Alzheimers and related dementia.
AB791 would require communitybased residential facilities (CBRFs)
to obtain a signed acknowledgement
form (created by DHS) from a CBRF
resident, or their legal decision maker,
before administering to that resident
a psychotropic medication that has a
federally-designated black box warning
to a resident with a degenerative brain
disorder. The intent of the bill, according
to its co-sponsorship memo, was to
ensure that families are informed of the
black box warning before psychotropic
drugs are administered.
WHCA/WiCAL, and all other state
provider associations opposed the

bill because CBRFs do not prescribe

any medications, only physicians and
other medical professionals do and
information or conversations on the
use of psychotropic medications should
be between the resident/legal decision
maker and the residents medical doctor
or prescriber.

The substitute amendment to AB791,

as well as the other bills, was approved
by the State Assembly and messaged
to the Senate for its consideration.
However, the Senate did not take the
bill up for consideration and it failed to
pass before the legislative floor period
was adjourned.

On February 18, a substitute

amendment was introduced to AB791
changing some of the provisions of the
bill. Specifically, when first administering
a psychotropic medication, a CBRF
would have been required to provide or
email an informational form created by
DHS. The informational forms required
a signature acknowledging: notification
indicating the resident has been
prescribed a medication with a black
box warning; information from the Food
and Drug Administration on the specific
med; and how to contact the prescriber if
additional information is requested.

On March 15, the Senate was in

session all day adopting more than 80
bills and resolutions, adjourning the
2015-2016 session late in the evening.
The Senate adopted some of the bills
recommended by the Alzheimers Task
Force, including:
AB786, requiring DHS to
propose a pilot program for
two or more counties to create
dementia crisis units.
AB787, providing a $1 million
increase for respite care under
the Alzheimers Family and
Caregiver Support Program
AB790, providing $250,000
to DHS to award grants to
counties or regions of counties
for their mobile crisis teams to
obtain training on recognizing
and serving individuals with
dementia.

YOU NEED BUSINESS

INSURANCE.
BUT YOU DONT NEED TO BE IN THE INSURANCE BUSINESS.

With the reported low general fund

condition statement, the Legislature
was limited in enacting measures that
cost money.
Despite limited resources, the final
weeks of session included passage of
more than 200 bills and resolutions in
the Assembly, including bills advanced
by the Speakers Task Force on
Alzheimers and Dementia.
6 CONTINUUM | www.whcawical.org

It should be noted the Senate

unanimously approved AB674, relating
to visitations of residents of hospitals,
hospices, skilled nursing facilities and
CBRFs by adult children. Referred to
as the Casey Kasem bill, the measure
allows an adult child who is prevented
from visiting or communicating with
his/her parent to petition a court for
visitation.
In late March, Gov. Scott Walker signed
the above bills into law.

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Jim McGinn is the

Director of Government
Relations for WHCA/
WiCAL. He can
be reached at
jim@whcawical.org.

217_SL_0215

Spring 2016 | CONTINUUM 7

Data Digest

Workforce Survey Shows Serious Crisis

Why are direct-care workers leaving healthcare?

and the worst Medicaid reimbursement

system in the country.

Survey Statistics Demonstrate Need for Long-Term Caregivers

What Are the Reasons CNAs or DCWs Have Taken Jobs Outside of Healthcare?

By Kate Van Camp

80%

76%
70%

70%
60%

ow are long-term care workforce

staffing needs keeping up with
demand? Not very well, according to
results from a February 2016 workforce
survey conducted by WHCA/WiCAL
along with other state provider associations
LeadingAge Wisconsin, Wisconsin
Assisted Living Association (WALA) and
Residential Services Association (RSA).
Wisconsins recovering economy, rapidly
changing labor market, and inadequate
Medicaid payments are having a dramatic
impact on the ability of Wisconsins
skilled nursing and assisted living facilities
to attract and retain caregivers.
Given these changes, members of all
four associations conducted a survey to
identify the nature and impact of staff
shortages that Wisconsins long-term care
facilities are experiencing. The survey
included 689 facilities, including skilled
nursing facilities (SNFs), communitybased residential facilities (CBRFs),

residential care apartment complexes

(RCACs) and adult family homes
(AFHs) throughout the state. The results
of the survey demonstrate the long-term
care workforce crisis that exists.
Although the results of the survey
indicated significant vacancies in all
caregiver categories, existing shortages
are particularly profound for certified
nursing assistants and direct care workers
who serve on the front lines of care in all
long-term care facilities. Skilled nursing
facilities reported an average 15% CNA
vacancy rate, which translates to 1 in 7
CNA positions being unfilled.
The escalation in vacancy rates is
attributed to a number of factors
which are beyond the facilities control,
as 48% of respondents expressed
problems in securing any applicants
for vacant positions. Additionally, 70%
of facilities expressed that job applicants

did not possess requisite experience or

qualifications.

50%

The decline in the number of individuals

willing to provide long-term care services
comes at a time with the greatest demand
for their services as the population
rapidly ages. Wisconsins booming
demand for long-term care workers
cannot be met without making wages
for these jobs more competitive so that
providers can attract enough workers.
The magnitude of that commitment
cannot be reconciled with a complete
absence of Medicaid funding increases
to provide wage and benefit increases to
those individuals who will provide the
services. Since a 2014 study by Eljay,
LLC, Wisconsin has gone from an on
average $35.99 loss per Medicaid patient
day to a $52.84 loss per patient day.
This means that based on current data,
Wisconsin has the highest shortfall per
Medicaid patient, per day in the country

30%

54%

40%
30%

20%
10%
0%

Better Pay

Nearly 50% of the nearly 700

respondents said they had no applicants
for vacant positions and 70% said there
were no qualified applicants.

Better Hours

Other

How are facilities keeping properly staffed?

What Strategies Have You Used to Keep Your Facility Properly Staffed?
14%

Other
Internal Pool

39%

Outside
Temp Agency

33%

Financial
Incentive

69%

Double Shifts/
Overtime

79%

Ask Staff to
Pick Up Hours

WORKFORCE SURVEY
FAST FACTS:
14% or 1 in 7 direct care staff positions
are unfilled.

Better Benefits

97%
0%

20%

40%

60%

80%

Care Worker Vacancies

If Qualified Applicants Were Available, How Many Additional
Individuals Would Respondents Hire to Fill Vacancies?
3000

2826

2500
2000

Service Corporation
VISION We are a team of professional and compassionate long-term health care providers continuously
enhancing quality long-term health care through education, advocacy, relations, professional
development, innovation and partnership.
MISSION STATEMENT To advance the quality, value and professionalism of long-term care providers
through education to enhance quality long-term care for the benefit of residents, employees and the
long-term care provider community.
For more information Contact WHCA/WiCAL: 131 West Wilson Street, Suite 1001A, Madison, WI 53703 | 608.257.0125

8 CONTINUUM | www.whcawical.org

25% of respondents have at least 10

employees on BadgerCare.
56% of facilities said theyve had
CNAs leave to take jobs outside of
healthcare in the last 12 months
(76% said they left due to better pay
elsewhere).

1500
1000
500
0

429

RN

290

LPN

C.N.A./DCW

100%

This incredible deficit makes it

extremely difficult for providers to
offer wages that can attract and retain
qualified frontline caregivers. Our
recent survey reported an $11.25
per hour median wage for CNAs in
Wisconsin. This is reinforced by the
fact that 76% of respondents cited
better wages as the reason CNAs have
left for jobs outside of health care.
In addition to low wages, 97% of
facilities regularly ask staff to pick up
extra hours and 80% ask staff to work
double shifts or overtime.
Low wages and staff shortages not
only lead to current staff working long
hours, it sometimes requires facilities to
limit admissions. In the last 12 months,
facilities responding to the survey have
turned down 683 admissions due to
low staff numbers. Extrapolated to the
4,093 long-term care facilities across
the state, this means a potential 5,335
admissions may be turned down by
Wisconsin facilities in a 12-month
period.
Due to the importance of this
issue, WHCA/WiCAL has recently
developed a page on their website
to serve as a one-stop shop for all of
members workforce resource needs.
Please visit www.whcawical.org/
workforce for data and statistics
resulting from this latest survey
as well as other sources. This vital
information will serve as your guide
as you schedule meetings with your
legislators in upcoming months and
contribute letters to the editor in your
local newspapers to address this crisis.
Kate Van Camp is
the Director of Data
and Research Analysis
for WHCA/WiCAL.
She can be reached at
kate@whcawical.org.

Spring 2016 | CONTINUUM 9

Stakeholder Spotlight

CHAASE Shaping the Minds of Tomorrows

LTC Administrators
Under Doug Olsons Leadership, Students Prepare for Future

ng

i
om

n!

Soo

Get the information you need, when

and where you need it with ECS Mobile

Q&A

What are the biggest challenges that

young aspiring LTC administrators face?

ouglas Olson, PhD, FACHCA, is

a Professor with the Health Care
Administration (HCAD) program at
University of Wisconsin-Eau Claire, and
has also overseen the development of the
Center for Health Administration and
Aging Services Excellence (CHAASE)
for the past 14 years. Dr. Olson has
over 15 years of health care leadership
experience primarily in the field of senior
services. Dr. Olson has given numerous
national and regional presentations,
served on a variety of national association
boards,and has a variety of publications.
He is also involved in a variety of applied
research and consulting efforts focusing
on leadership, organizational roles and
best practices in the health and aging
services field.

Q&A
How will nursing homes look differently
in 50 years?
Consumers will want something
different than what we have today, and
I trust that the caring and innovative
spirit of senior care providers will
respond. The focus on the resident
experience and the tradition of quality
and care of services will continue to be
enhanced. A broader view of the health
and well-being of our entire growing
senior population and the utilization of
advances in technology will influence
new approaches and models of care.
10 CONTINUUM | www.whcawical.org

Young aspiring administrators need to

capture the growing confidence they
gain in their early job experiences to
help them face the inevitable challenges
they will face when entrusted with the
responsibility of leading organizations
that take care and provide service for
very vulnerable aging individuals.
They also need to maintain a spirit of
optimism and hope while leading their
organizations in the current reality of
real constraints knowing that they have
to strive for a better future for those
that they lead and serve. Lastly, the
profession has to take on and support
the important role of mentoring these
talented individuals to help guarantee
their ongoing development, survival
and ultimate success.
How has the UW-Eau Claire HCAD
program adapted its curriculum to meet
demands of modern technology?
We have adapted by paying attention to
the push and pull of this next generation
of leaders that look at technology as
a requisite skill for their career. Our
program has leveraged technology to
improve and supplement our teaching
approaches. One good example that is
especially evident is with our delivery
and support of the practicum experience
for our students.
How would you describe the average
HCAD student?
We dont have average HCAD students,
they are each exceptional in their own

way. We find a mix of students drawn

to this field because they have a heart
for caring, a head for business and a set
of hands that like to work with people.
These are individuals drawn from a
generation that also want to make a
difference in the communities they serve
and for the people that they care for.
Recognized as a premier long-term
care administration program, how has
UW-EC HCAD influenced provider care
across the country?
We have strived to lift up this occupation
as a noble profession. We do not
tolerate the idea that this vocation is a
second-class occupation to other more
recognized and identified health care
occupations. We believe that taking
care and providing supportive services
for our nations ever-growing senior and
disabled populations is one of the most
critical fields. We believe that the true
reflection of our countrys values is how
we treat those that are vulnerable and less
fortunate at this point in their life span,
although so deserving because of the
sacrifices they have made for all of us.
What sets UW-EC HCAD and
CHAASE apart from other programs?
We are known for the respect and
value we place on partnerships between
academia and the professional
community of organizations. The
communication and dialogue we have
with the broader community has served
us well as we have paid attention to
the quality of our program experiences
and learning opportunities, solidified
Continued on Pg. 14

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Cover Story

Communication:
The Key to the Revolving Door
Continuing the Effort to Reduce Readmissions

Each of these three priorities lend

themselves to the growing need for longterm care facilities to evolve current quality
standards to meet the new CMS directives.

By Jim Stoa

ospital readmissions are costly.

The federal government in 2014
estimated the annual cost of Medicare
readmissions to be $26 billion, $17
billion of which was considered
avoidable. And the costs arent strictly
financial. Hospitalizations can be
stressful for patients, especially frail,
elderly, and disabled patients who
are more vulnerable to adverse events
during hospital stays.
Long-term care facilities see first-hand
the costs associated with readmissions.
As skilled nursing and assisted living
facilities rely on discharges from
hospitals to maintain their census, it is
critical for long-term care facilities to
work closely with hospitals in their area
to effectively manage care transitions.
In an effort to reduce Medicare
costs and to ensure the wellbeing of
Medicare recipients, Section 3025 of
the Affordable Care Act (ACA) outlines
the Hospital Readmissions Reduction
Program (HRRP). Administered by
the Centers for Medicare and Medicaid
Services (CMS), HRRP is a payment
penalty program designed to reduce
Medicare
fee-for-service
hospital
readmission rates for the conditions
that represent high costs to the
program. HRRP defines a readmission
as an admission to a qualifying hospital
within 30 days of a discharge from the
same or another qualifying hospital.
In Wisconsin, care providers have
already seen successes in limiting
hospital
readmissions.
Wisconsin
hospitals are penalized a Medicare
payment reduction of 0.38 percent per

12 CONTINUUM | www.whcawical.org

patient stay, which is well below the

national average of 0.61 percent.
Nationwide, HRRP is certainly having
an influence on readmissions rates.
Through an analysis of 3,387 hospitals,
the states quality improvement
organization, MetaStar estimates that
from 2007 to 2015, readmission rates
for targeted conditions declined from
21.5 percent to 17.8 percent, and rates
for nontargeted conditions declined
from 15.3 percent to 13.1 percent.
Shortly after passage of the ACA, the
readmission rate declined quickly,
especially for targeted conditions, and
has continued to fall at a slower rate
since October 2012 for both targeted
and nontargeted conditions.
The national downward trend in
readmission rates will help eliminate
many avoidable Medicare costs by
preventing costly stays shortly after a
discharge. More importantly, fewer
readmissions mean more stability in the
health and wellbeing of patients and
residents.
TRANSITIONS OF CARE
Wisconsin hospitals have built on
their successes in preventing avoidable
readmissions by raising the effectiveness
of post-acute care, such as decreasing
length of stay, increasing functional
improvement, improving discharges
back to the community, and increasing
customer
satisfaction.
Hospitals,
Accountable Care Organizations, and
Managed Care plans are all beginning
to use these metrics to form post-acute
care networks and to help inform
their referral decisions.

For more information on the

AHCA/NCAL Quality Initiative,
visit www.ahcancal.org/quality_
improvement/qualityinitiative

Hospitals are justifiably becoming

increasingly prudent of where they direct
patients along the transitions of care,
referring to the movement of patients
between health care settings. Hospitals
want to ensure that a discharged patient
experiences proper care throughout his
or her transitions of care.
So, SNFs and ALFs need to know their
performance in these areas if they want to
build strong partnerships with other care
providers as a part of transitions of care.
AHCA/NCAL Senior
Vice
President
of
Quality and Regulatory
Affairs, David Gifford,
MD, MPH, points
to
the
evolving
relationships between
care providers postACA as a driving factor
for why AHCA/NCAL has broadened
its Quality Initiative to further improve
the quality of care in Americas skilled
nursing care centers. The expanded
quality model includes three key
priorities:
Organizational Success (including
staff stability, customer satisfaction,
and preventing unintended health
care outcomes),
Short-Stay/Post-Acute
Care
(including hospital readmissions,
discharge, and functional
improvement), and
Long-Term/Dementia
Care
(including hospitalizations)

Based Purchasing programs, Gifford

says. This is why we are broadening
AHCAs Quality Initiative to address
readmissions. AHCA members who
have achieved silver or gold recognition
outperform the other SNFs in nearly
every quality metric we have measured,
including Five-Star, readmission rates,
occupancy, and profit margin.

Even SNFs in rural areas without

much competition will need to change
and focus on these measures as their
payments will be linked to these
outcomes over the next several years,
Gifford says. Later this year, CMS will
specify how two percent of all of a SNFs
Part A payments will be linked to their
hospital readmission rates. We expect
CMS will add additional measures over
time. The proposed Requirements of
Participation for SNFs that CMS is
expected to finalize in the fall of 2016
also increase focus on discharges to the
community and these metrics.

AHCA members are given additional

resources to stay competitive as care
providers develop post-acute care
networks. The LTC Trend Tracker is a
web-based tool that provides member
LTC and post-acute care providers
access to key quality metrics. A benefit
available only to AHCA members, LTC
Trend Tracker allows skilled nursing
organizations to benchmark personal
data to those of their peers and examine
ongoing quality improvement efforts.
LTC Trend Tracker offers members
timely information and valuable insight
about their own performance compared
to that of the profession as a whole.

But when it comes to skin in the game,

long-term care facilities are already
there. Gifford points to a national trend
of hospitals creating exclusive lists of
referrals to transitions of care facilities
that routinely meet certain quality
standards, which helps those hospitals
drive down readmission rates.

Additionally, LTC Trend Tracker gives

members access to government data
collected by CMS on skilled nursing
centers providing facilities with
one central hub for reporting needs.
Members can use the Dashboard to
quickly see how they are trending on
key metrics compared to peers.

What we have seen at AHCA are

those members that have robust quality
management systems in place are doing
very well, being selected to participate in
these post-acute care networks, increasing
their occupancy and doing well in Value-

I strongly encourage members to login to LTC Trend Tracker and use this
important resource available exclusively
to our members, says John Vander Meer,
Executive Director of WHCA. The easyto-access dashboard feature can easily be

used as an effective method for measuring

quality benchmarks for your facilitys
internal quality measures, and the data
included there is very useful information
to share with referring hospitals.

Use LTC Trend Tracker to:

Compare your facility to peers (within
region, state, ownership type, etc.)
Access AHCA Quality Measures
Access AHCA Staffing Turnover and
Retention Report
Design, save, and schedule reports
LTCtrendtracker.com
Gifford points to these member resources
as tools to emphasize member facilities
commitment to quality as they seek to
build or strengthen relationships with
other providers in post-acute networks.
SNFs who can form these partnerships
and achieve performance at least 2-3
points better than the average rates on
these measures will be selected to stay in
post-acute networks, Gifford says. As a
result, they will see their referrals increase.
Those that cant will have a difficult time.
The
new
HRRP
penalties are motivating
factors for providers
among
a
patients
interdisciplinary health
care team, says Micki
Hill, Nurse Consultant
at
the
Wisconsin
Department of Health
Services Division of Long-Term Care
Bureau of Aging and Disability Resources.
CMS readmissions penalties have caused
us all to be more thoughtful and mindful
of the health care decisions and health
care leadership we provide, Hill says.
The penalties create a common goal for
patients, for their families, for health care
organizations, and for the state overall
Continued on Pg. 16
Spring 2016 | CONTINUUM 13

Stakeholder Spotlight Continued

national academic and association
relationships, and been able to offer
and respond to student and professional
needs with the support of our alumni,
friends and provider partners.
How can providers learn more about
participating in UW-EC HCADs
practicum?
The practicum is one of our signature
approaches, and we are interested in
solidifying the right number and quality
of practicum sites within the Midwest.
We are always paying attention and
responding to organizational requests
to become part of our affiliated sites,
especially with the expressed intent
of a longer term relationship. These
provider-sponsored stipend experiences
are a true example of a win/win/win
situation for students, providers and the
University. The student benefits from a
hands-on educational experience, the
site gains a new energy and perspective
to their organizational mix and faculty
are challenged to ensure the best possible
learning opportunity.
What keeps you up at night?
One of the things I struggle with the
most is the transition of our students or
recent alumni into the field. Without
pointing fingers at anybody, the
situation that disturbs us the most is
that after investing four or five years
in a promising new leader their first
job experience or onboarding is not as
good or healthy of an experience as it
could be, and that promising emerging
leader has a very negative exposure to
the profession. I often see us losing
those individuals to another field or
profession and they never come back.
What are your biggest concerns for the
field and the profession?
The talent gap we are approaching
in the upcoming horizon and how
we need to solve this challenge by
working across academic, provider and
association circles. I believe no one
14 CONTINUUM | www.whcawical.org

stakeholder group can solve this issue

alone. We need to have an environment
of mutual respect and collaboration so
we can attract, develop and retain the
top talent available in this country. We
have to appreciate what each of these
groups brings to the table and also work
across generational differences. This is
a noble profession and we deserve the
very best talent available in this country.
What are you most excited about in the
future?
Through the University of Wisconsins
granting of my sabbatical request,
the support of CHAASE and the
exceptional team we have with the health
care administration program, I have the
opportunity this next year to work on
a project that is going to culminate in
the development of national strategy
to enhance and expand both the
strength and number of senior care
administrative programs geographically
located across the country. I feel very
privileged to have the support of a wide
variety of stakeholders and individuals
representing these constituencies and
their interests. This effort is very well

aligned with the focus of CHAASE and

the needs of the profession and broader
field called to serve the residents,
patients and clients that are entrusted to
our care and service.
In closing, one of the things I love to
hear from recent graduates is how
come we didnt have the opportunity to
do that? Our program and the Center
are constantly trying to improve and get
better at what we do for our students
and the profession. We appreciate
the support of associations, like the
Wisconsin Health Care Association,
that serve as important partners with us
by providing guidance and support to
the education oftomorrows leaders, and
help us serve as a national leader in the
critically important profession of health
administration and aging services.
Doug Olson is the
Director of the UWEau Claire Center for
Health Administration
and Aging Services
Excellence (CHAASE).
He can be reached at
olsondou@uwec.edu.

As a long term care provider you have a very

difficult mission. Your challenge is to provide
the best care possible to a population with
ever increasing medical and behavioral needs
in an extremely litigious atmosphere and
while under regulatory scrutiny second only
to that faced by the nuclear energy industry.
It is important that when you need a lawyer
to defend you against allegations of abuse or
neglect you turn to a team of professionals
who make it their mission to defend long
term care facilities who face legal challenges
throughout Wisconsin.
The team at Siesennop & Sullivan, led by
Attorney Pat Sullivan, has the experience you
need to best respond to the legal challenges
you may face as a long term care provider.
Siesennop & Sullivan has been successfully
representing SNFs, CBRFs and RCACs
in jury trials, mediations and arbitrations
throughout Wisconsin for the last 15 years.
We understand the unique challenges that
caring for frail, elderly residents can present,
as well as the complex state and federal
regulations that long term care providers are
required to meet.
You know that there are plaintiff s lawyers
who specialize in suing long term care
providers. You too should have a team of
lawyers who specialize in this area of the law
and who have been defending against such
claims for years.

Siesennop & Sullivan, Attorneys at Law

200 North Jefferson Street, Suite 200
Milwaukee, Wisconsin 53202-5900
Phone: 414-223-1731 | Fax: 414-223-1199
www.siesennopsullivan.com
Spring 2016 | CONTINUUM 15

Cover Story Continued

from a financial and economic standpoint,
as well as a health standpoint.
As member facilities enter a new world
of compliance and quality assurance
standards, stakeholders agree that one
common denominator dictates success in
transitions of care: an open dialogue with
patients and with other members of a
patients interdisciplinary health care team.
COMMUNICATION IS KEY
Medicare recipients regularly receive medical
care from multiple providers in their
communities, but a lack of communication
will leave providers along the care continuum
often unable to properly coordinate care,
which can lead to unnecessary tests or even
adverse medical events.
Bob Siebel, CPA, CHCA,
is President of Carriage
Healthcare Companies,
Inc.,
a
multi-state
operator of long-term
care facilities and a longterm care consulting
firm. As a multi-state
operator, Siebel has seen
the need to break down communication
barriers along the care continuum.
Improved relationships between members
of the continuum are absolutely essential,
Siebel says. Recent initiatives both at the
government and provider level have begun
to break down the silos that have existed for
years that have made pure patient-centered
care coordination almost impossible.
Providers must always work to improve
communication with other members of
the continuum, and SNFs and ALs must
be able to provide the upgraded levels of
staff training and technology that will
make their hospital partners comfortable
with their clinical abilities. One major
component of that is the willingness
of all parties to collaborate through the
entire episode of care and to share relevant
patient information through compatible
Electronic Health Records systems.
Thomas Kaster, Quality Coordinator of the
Partners for Patients project at the Wisconsin
16 CONTINUUM | www.whcawical.org

Hospital Association, says

that facilities along the care
continuum must not just
address communication
challenges from provider
to provider, but also the
communication between
providers and patients.
Among WHAs members, hospitals
that have worked hard to understand
the patient and family needs and
perspectives have made the best
progress in reducing readmission rates,
Kaster says.For example, the discharge
planning process for patients and
families can be confusing and stressful.
Several organizations have engaged
patients and families to help them
evaluate discharge planning resources,
discussions, and processes.By truly
understanding the patient and family
perspective, those hospitals have been
able to adjust their written materials
to reduce medical jargon, eliminate
information overload, and help better
prepare the patient and their family for
the next care setting.
Hill says that while there is no
single communication standard, its
important to remember that effective
communication always goes two ways
whether thats between different
providers along the care continuum or
between a provider and a patient.
Open lines of communication mean fewer
surprises for providers and greater health
literacy for patients and their families.
Patients and consumers who have a
high level of satisfaction experience
successful communications with their
interdisciplinary health care team which
can include their nurse, their doctor, their
MCO, their primary care provider, their
hospital discharge and care coordination
team, their public health and communitybased team, which could also include
Aging and Disability Resource Centers
(ADRCs) as well as other advocates
who participate in their care, meaning
meals, transportation, first responders, so

that trend with communication is very

important, Hill says.
Many providers have begun concerted
efforts to coach caregivers on best
practices in communicating in ways
that are easily understood.
Discharge planning is just one
driver in improving readmissions,
Kaster says. Post-discharge phone
calls have been another major driver
for improvement.When a patient is
contacted within 48-72 hours postdischarge, hospitals are able to identify
key gaps that, if not addressed, can
contribute to a readmission.
BUILDING COALITIONS TO ACHIEVE A
COMMON GOAL
Kaster emphasizes that the key for providers
to achieve greater success in reducing
readmissions is active engagement and
broad coalition-building.
Based on my observations and those
of WHAs member hospitals, skilled
nursing facilities that are actively engaged
in regional transitions of care coalitions
that are discussing meaningful patientcentered solutions have made a significant
impact on reducing readmissions,
Kaster says.The coalitions provide a
framework for collaboration and largescale improvement for all stakeholders
in a community who are accountable
for delivering care.The connections
made through the coalitions enable
all involved to evaluate the complete
health care continuum and find areas for
improvement and most importantly, work
together to address those opportunities.
So, how can long-term care providers
work with hospitals to improve their
success of halting the revolving door of
readmissions? Kaster says it always comes
back to communication as a key element
to any improvement in readmissions,
and he acknowledges it goes both ways.
I would encourage long-term care
facilities to look for opportunities to
Continued on Pg. 20

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Spring 2016 | CONTINUUM 17

LTC Legal Letter

Medicare Overpayments

information except in extraordinary

circumstances that CMS acknowledges
could justify an investigation that would
take longer than six months.

Long Awaited Overpayment Rule Issued

By Brian Purtell

s the accounting department asking

about several duplicate payments
received? Has a review identified a
coding error that resulted in higher
RUG classification? Has there been
an identified payment received that
included an unlicensed or excluded
individual? Is your facility waiting for
someone to ask for it back?
While previous obligations to make
repayment were place for identified
overpayments, now there is added
urgency to assure timely identification
and repayment of overpayments, as on
February 12, 2016 the Department of
Health and Human Services Centers for
Medicare and Medicaid Services (CMS)
published an important final rule
affecting Medicare providers regarding
overpayment obligations. Specifically,
the Rule clarifies and delineates
requirements regarding reporting and
returning Medicare overpayments to
implement what has been a statutory
obligation to make repayment within
the 60-day time period. Failure to
timely return overpayments may subject
the provider to significant penalties.

Providers should remain

diligent in assuring
accuracy of billing and
receipt of payments.
The overpayment Rule is required
by a provision in the Affordable Care
Act (ACA) and the final Rule comes
out nearly four years after its initial
proposed version. The final Rule
represents some improvement with
respect to several provisions, while

also containing new areas of potential

concern. An overpayment is broadly
defined as any funds that a person
has received or retained, that after
applicable reconciliation, they are not
entitled under the Medicare program.
Such person must report and return
the overpayment by the later of (a) the
date which is 60 days after the date on
which the overpayment was identified;
or (b) the date any corresponding cost
report is due, if applicable. Particularly
challenging has been the question of
when the 60-day time period begins
and the final Rule provides important
clarity with regards to this time period.
For timing purposes, an overpayment is
identified, and the 60-day time period
begins when either:
The reasonable diligence is
completed; or
The day the provider receives
credible information of a
potential overpayment and fails
to exercise reasonable diligence
to discover the actual repayment.
Reasonable diligence covers both
reactive investigative activities to credible
information of potential overpayments

as well as proactive compliance activities

to monitor claims. Meaning, when a
person receives credible information
concerning a potential overpayment,
they need to undertake reasonable
diligence to determine whether an
overpayment was received and to
quantify the amount. The 60-day period
begins then, but also the clock begins
on the day when the person received
credible information of a potential
overpayment if the person failed to
conduct reasonable diligence and the
person in fact received an overpayment.
The latter specifically obligates proactive
efforts and one cannot turn a blindeye toward possible concerns of an
overpayment.

The practical effect of the revised

definitions is that there is a recognized
period of inquiry permitted to identify
and quantify the possible amount
subject to overpayment obligations,
however that is not an open-ended
period such that a provider could drag
out its review to delay the start of the
60-day period.
Upon identification of an overpayment,
many situations will lend to
identification of specific amounts at
issue; however, certain issues that could
affect hundreds or thousands of claims
make exact amount calculations difficult
or impractical. In recognition, the Rule
permits extrapolation as a means of
calculation. In recognition that certain
potential overpayment issues potentially
affect a large volume of claims, the Rule

indicates that a statistical sampling

and extrapolation are appropriate
processes under reasonable diligence in
investigating an overpayment. While the
rule seeks to permit certain flexibility,
the corollary to this allowance is that
providers also have an obligation to look
beyond a single claim of overpayment to
identify if there are issues that might be
systemic in nature.
The Rule allows for multiple means
and methods to return overpayments
in addition to the existing standard
voluntary refund process. Providers are
permitted to use the claims adjustment,
credit balance, self-reported refund
process or other appropriate processes
to report and return overpayments to
CMS. Also, an important improvement
from the proposed Rule is that CMS
modified the lookback period from
10 years to 6 years, meaning that the
provider would be expected to go back
as far as six years upon identification of
potential overpayments.

While certainly making clear that

one cannot simply ignore credible
information of overpayment to avoid
the clock starting, the modifications do
permit some opportunity from initial
discovery of a possible overpayment,
to quantify what amount is at issue
before the repayment clock begins.
Reasonable diligence further requires
a timely, good faith investigation of
credible information, which must occur
within six months from receipt of such

Providers should remain diligent in

assuring accuracy of billing and receipt
of payments. This final Rule makes clear
that providers must incorporate proactive
and ongoing monitoring of billing and
payment practices, as well as taking swift
action upon identification of a credible
potential overpayment having been
received. Having an effective corporate
and ethics compliance program, which
is already an obligation of all Medicare
providers, is even more important under
the final Rule and Wisconsins facilities
are strongly encouraged to maintain
vigilance in these areas.

Brian Purtell is the

Director of Legal
Services for WHCA/
WiCAL and the
Executive Director of
WiCAL. He can be
reached at bpurtell@
whcawical.org.

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Spring 2016 | CONTINUUM 19

WHCA Ad 2016.indd 1

3/18/2016 2:23:43 PM

Cover Story Continued

break down communication barriers and
build more informal communication
strategies with hospitals, Kaster says.
I think too much time is being spent
trying to produce the perfect transfer
form by both hospitals and skilled
nursing facilities. I would encourage
that more time and resources be spent
with engaging frontline staff to help
evaluate the current transitions of care
systems, identify opportunities, and
drive improvement.
The key lesson from the successes that
many care continuum networks are
having points toward engaging patients
and families, understanding their
perspectives and goals and designing
systems that meet those needs. Another
key is to engage all elements of the system,
since a change made by one stakeholder
may cause potential issues for others.
There definitely is a strong correlation
between having a strong relationship
and the ability to reduce readmissions,
Kaster says.The key word there is
relationship.When both organizations
are sharing a common goal and
understand each others perspective,
they are better able to work together to
build lasting solutions.
Proactive coalition-building between longterm care facilities, hospitals, and ADRCs
is already leading to successful transitions
of care networks here in Wisconsin.
For example, the Dane County Care
Transitions Community Coalition recognizes
that safe transitions of care and readmission
prevention efforts require contributions from
a broad base of stakeholders.
The coalition includes county hospitals,
skilled nursing facilities, home health
agencies, home care agencies, pharmacies,
and area agencies on aging, hospice, and
others. The coalition meets every other
month, rotating the host site amongst
member agencies. Monthly meetings
include informational sessions presented
by the members and group work sessions.
20 CONTINUUM | www.whcawical.org

The coalition has had great successes

in a number of areas, including
information sharing and networking
among coalition members; confidential
reviews of readmission and transfer data
provided by MetaStar; development
and dissemination of a community
emergency medical form patients/
families can complete and bring along
with them to an emergency room;
networking and agreement among
local home health agencies to follow
a standardized visit and educational
protocol for patients with congestive
heart failure; and development and
dissemination of an informational
brochure related to how community
home care agencies can help clinicians
and families with safe transitions and
readmission prevention.
Others have implemented comparable
care coordination partnership models
for success, including Gunderson
Lutheran Health System in La Crosse,
Bellin Health in Green Bay, and Aurora
Health Care in eastern Wisconsin.
Kaster says that from hospitals perspectives,
strong provider-to-provider relationships
regarding reducing readmissions have the
following characteristics:
Always have the patient and
family as their north star.
Share a common goal of ensuring
safe, reliable care for their patients.
Meet on a consistent basis to
evaluate transitions of care
performance and determine
opportunities for improvement.
Work on meaningful, patientfocused solutions together.
Engage their frontline staff to
drive improvement and create
consistency of performance.
Create formal and informal
communication strategies to
help break down barriers.
THE WORKFORCE SHORTAGE
Frontline long-term care professionals
often play a pivotal role in the post-acute
recovery and wellbeing of a resident
following discharge from a hospital.

Given CMSs dedicated focus to reducing

readmissions, its appropriate for longterm care facilities and hospitals alike to
consider the care quality and fiscal impact
of the ongoing long-term care workforce
shortage crisis. As providers are well
aware, caregiver staff vacancy rates are
at crisis-level proportions for skilled
nursing and assisted living facilities.

as they work to foster a stronger, more

communicative relationship with other
providers along the care continuum.

In February 2016, WHCA/WiCAL

and Wisconsins other long-term and
residential care provider associations
joined together to conduct a survey of
member providers focusing on caregiver
vacancy rates and other workforce
issues. The workforce survey which
you can read more about in this issues
Data Digest found that 1 in 7 frontline
caregiver positions remain unfilled,
which stretches the current workforce
to assure there is effective personnel to
meet residents needs.

We are just becoming involved with

initiating telemedicine within our facilities,
but our research to date clearly shows that
if properly implemented with appropriately
trained staff, the availability of telemedicine
will reduce the length of time that it takes
for the patient to be in direct contact with
an MD or Advanced Practitioner. Not
only does telemedicine provide real-time
vitals and line of sight with the medical
professional, but it also provides direct
communication with facility staff to
promptly implement interventions that can
negate the need for a hospital admission
or readmission, while also avoiding the
transfer trauma for the individual.

Staff vacancy rates have led 20 percent

of providers to limit admissions to their
facilities. Being a consistent part of a
transitions of care network is a challenge
when having to turn individuals away
due to lack of staffing capacity.
Experience shows that reduction of
readmission rates requires meaningful
reform of transitions of care services
by addressing the long-term caregiver
workforce shortage.
We only have anecdotal data, but it is
obvious that if staffing levels go from
optimal to closer to the minimums, face-toface time with residents is reduced and the
ability to assess subtle changes in condition
could be compromised and could result
in a readmission, Siebel says. We are all
aware that the changes in condition are
often detected because of the familiarity
brought out by ongoing contact between
a staff member and a resident, and if those
interactions are less frequent due to shortages,
the risk would inevitably increase.
TECHNOLOGICAL TOOLS
As CMS readmission requirements evolve,
so too do the resources available to facilities

Siebel, who operates mostly rural

facilities, says that the advent of
telemedicine has led to greater exposure
to patients and better understanding of
their continued health needs.

Telemedicine can help change that

by giving medical professionals a
direct and convenient method of
communicating with patients. That
direct line of communication often can
provide a medical professional with
more confidence in advising remedial
action that is in the best interest of the
patient while also avoiding readmission.
Some of the major challenges
surrounding readmissions are physicians
not having instant access to complete
information when we call them at 2
a.m., and therefore ordering a hospital
admission because they cannot properly
assess the resident, Siebel says.

who wake up each day determined

to give the best care possible to their
residents. If you have a best practice to
share, or if you are facing a challenge in
addressing readmission rates, WHCA/
WiCAL encourages you to post about
it on our online member forum. The
forum is available for WHCA/WiCAL
members to ask questions, share stories,
and offer helpful insight regarding
topics of interests to LTC peers across
the State of Wisconsin.

www.whcawical.org/forums

CONTINUING THE DISCUSSION

The discussion of reducing readmission
rates will evolve over time as CMS
updates its policies, technology
changes, and caregivers adapt. WHCA/
WiCAL is committed to continuing the
conversation. The most effective voices
we have are from our frontline caregivers

Jim Stoa is the Director

of Communications
for WHCA/WiCAL.
He can be reached at
jstoa@whcawical.org.

Senior Living Experts for over 30 Years

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2725 S. Moorland Rd., New Berlin, WI 53151 3701 E. Evergreen Dr., Suite 100, Appleton, WI 54913
Spring 2016 | CONTINUUM 21

Clinical Corner

DEMENTIA TRAINING COMPLIANCE CNA SERIES NURSING COURSES

Reflections on Care of the Feet

By Matthew Grade, MD

find feet fascinating. From a

scientific perspective, we find endless
complexity and beauty of form and
function. From a medical point of
view, we learn so much when we explore
symptoms and find how a complicated
system has failed in some way. Every
part of a persons body has a specialized
purpose, and from one person to the
next, endless variability.
In a literal sense, feet are the foundation
of each person. As a physician focusing
on people in assisted living and memory
care communities, I am acutely aware of
how that foundation can erode, and how
that affects each individuals ability to
maintain their health. Research studies
show a high correlation between gait
speed and life expectancy, in addition
to fall risk and consequences. The loss
of nerve function,circulatory function,
and skin integrity pose a serious risk of
hospitalization, pain, and even death.

The loss of nerve

function,circulatory function,
and skin integrity pose a
serious risk of hospitalization,
pain, and even death.
Each persons feet tell a story. There
are hereditary factors in the formation
of the structures, and the propensity
toward disorders like diabetes that have
profound effects on arterial supply. The
way each person plays and works, their
shoes and boots, and the care they have
received all have an impact. Many people
have anatomical challenges such as flat
feet,bunions, and hammertoes that
require careful shoes, insoles, and even
surgery. Lifestyle issues such as smoking
and many disease states create problems
22 CONTINUUM | www.whcawical.org

with arterial and nerve function. Venous

insufficiency causes chronic swelling and
skin inflammation, and makes it more
difficult to maintain an active lifestyle.
I have always been impressed by the
story of Jesus washing the feet of the
Apostles. Care of the feet is a way of
expressing respect for a person, and in
many instances Ive found that its often
neglected. Even if I think about it from
a modern cost-benefit analysis, I believe
that many hospitalizations of older
people for cellulitis of the lower leg,
ulcers, and severe arterial insufficiency
requiring surgery would be avoided
with proper attention to feet.
Starting with examination of structure,
I like to inspect the arches, check for
bunions and hammertoes, and look at
bony prominences that create friction.
Inspection of the skin, especially around
the edge of the heel, can reveal cracking
and scaling that is typically associated
with repeated moisture and drying.
I look for the redness and scaling that
indicate fungal infections. Toenails are
often thick and hard to trim. The fungal
skin infection can migrate into the
nailbed, especially on the toes that are
longer and are repetitively traumatized
as the foot slides forward and strikes
the inside of the shoe. Hammertoes can
form by the same mechanism, or by
crowding from a bunion. Wearing shoes
with a higher heel shifts more weight
toward the toes.
As arterial supply drops, the skin
becomes thinner, loses hair follicles,
and creates neuropathy with decreased
sensation and sometimes burning
pain. A bluish redness in the forefoot
comes from severe arterial insufficiency,
or sometimes from autonomic
dysfunction in diseases like Parkinsons

WHCA
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VENDOR

and paraplegia. Its important to realize

that both cold and heat produce an
increased oxygen demand, so any
soaking of the feet needs to be close to
body temperature.
Shoes are important for protection and
support, but sometimes create problems
of retained sweat and friction points,
so careful fitting is important. Insoles
may need to be replaced with ones that
absorb shock better (e.g. Sorbothane,
Spenco, Superfeet). Socks are important
for cushioning and keeping the skin dry.

EXCLUSIVE

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After basic bathing of the feet, using

a wet washcloth to rub off scale and
pulling it gently between the toes will
remove the dead skin that supports
fungal growth. After briefly drying the
feet, applying a cream like Eucerin helps
hold the water in the skin and maintain
flexibility. Coconut oil is excellent,
providing anti-fungal activity. After
the cream or oil, its best to put socks
on. Compression stockings help those
with edema, which is most often from
venous insufficiency, sometimes from
heart, liver, or kidney failure.
For most people living in Assisted
Living and Memory Care communities,
care of the feet can be provided by staff
and family members. In addition to
primary care providers, podiatrists can
be very helpful.
Like my father before
me, I am a family doctor.
The core of Bluestone
is acknowledging that
each person needs respect
and connection with a
community that cares.
My job is to listen,
understand, and serve.
Matthew Grade, MD

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www.DiscoverCESolutions.com | 866-650-3400

Wisconsin Health Care Association

Wisconsin Center for Assisted Living

131 W. Wilson Street, Suite #1001

Madison, WI 53703

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