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The below is a story from the Betsy Lehman Center’s October 18 Patient Safety Beat Publication:

As the population of Massachusetts ages, the unique safety and care needs of geriatric patients are receiving increased attention in hospitals, due in part to new state requirements for identifying patients with dementia and optimizing their care.

Sturdy Memorial Hospital, a community hospital in Attleboro, started more than five years ago to develop better systems for emergency care of geriatric patients, work they have more recently expanded into inpatient units.

Other Massachusetts hospitals, including Boston Medical Center, are also finding they are already in good alignment with new requirements that went into effect this month directing acute care hospitals to have an operational plan for patients with dementia.

The law, signed by Governor Charlie Baker in 2018, was originally scheduled to go into effect in October 2021, but key provisions were postponed a year in deference to the pressures put on hospitals by the coronavirus pandemic.

Sturdy Memorial and BMC talk about their approaches

Dr. Brian Patel, who is an emergency physician, Sr. Vice President of Medical Affairs, Chief Medical Officer and Chief Quality Officer at Sturdy Memorial, is one of a number of champions of improved care for geriatric patients in the hospital setting.

Dr. Patel served on a workgroup convened by the Massachusetts Health & Hospital Association in 2018 to develop guidance for complying with the new law, which prompted Sturdy to implement recommendations from the MHA workgroup’s 2018 report ahead of the law’s effective date. “We knew this work needed to be done. We used the plan as a framework to start advancing our geriatric care,” he says.

Key takeaways

The law

As of October 1, 2022, a new state law mandates Massachusetts hospitals to create and implement a master plan for identifying patients with dementia and optimizing their care.

The background

Signed in 2018, the law was originally scheduled to go into effect last year but was postponed in deference to the pressures put on hospitals by the coronavirus pandemic.

Key takeaways

The context

As hospitals have prepared to comply with the law, many have found they already have at least some elements of a master plan in place.

The resources

Massachusetts Health & Hospital Association and the Alzheimer’s Association offer guidance for complying with the state law. Many hospitals also use resources from programs such as Nurses Improving Care for Health System Elders and Age-Friendly Health Systems.

Dr. Patel reports that Sturdy participates in NICHE — Nurses Improving Care for Healthsystem Elders — a program designed to enhance nurses’ knowledge and evidence-based practices in caring for older adults and has been working closely with the American College of Emergency Physicians, which accredited Sturdy as a Bronze Level 3 geriatric ED in 2018 and, more recently as a Silver Level 3 in 2022.

“The work we’ve been doing with ACEP and on and the inpatient side with NICHE overlaps with the Massachusetts requirements around management of dementia and delirium,” says Dr. Patel. Sturdy also uses components of the Age-Friendly Health Systems initiative offered by the John A. Hartford Foundation and the Institute for Healthcare Improvement.

Boston Medical Center also has leveraged a variety of resources to build an operational plan for geriatric and dementia care. Lisa Caruso, M.D., geriatrician and Director of Quality and Patient Safety in the Department of Medicine at BMC, says the hospital joined the Age-Friendly Health System program in 2017. Dr. Caruso recalls that creating a geriatric order set, implementing a mobility program and using the Confusion Assessment Method were among their first improvement projects. All address the issue of delirium, which Dr. Caruso says, “is one of the worst things that can happen for somebody who has dementia in the hospital.”

Optimal dementia care extends across six functional domains

The Alzheimer’s Association estimates that the number of people ages 65 and older with Alzheimer’s dementia in Massachusetts will have increased more than 15% between 2020 and 2025 and that people with Alzheimer’s disease have almost twice as many emergency department visits and hospitalizations as seniors without dementia. 

The MA Department of Public Health first issued recommendations for managing patients with dementia in acute care settings in 2017. Following up on its workgroup report from 2018, MHA published an operations “roadmap” in conjunction with the Alzheimer’s Association this summer.

The roadmap calls for attention to:

• Advance care planning — including disease progression, health care proxy, advance directives and palliative care
• Staff training — including all patient-facing staff, using resources from initiatives such as the Nurses Improving Care for Health System Elders
• History, screening and assessment — engaging with the patient and care partner, assessing known and suspected diagnosis of cognitive vulnerability
• Dementia-capable environment — prioritizing safety and minimizing use of chemical and physical restraints
• Treatment and management — preventing delirium, managing dementia and delirium when it occurs
• Transfer and discharge — optimizing intra-hospital transfers, to/from outside facilities and home

Liz McCarthy, Health Systems Director at the Alzheimer’s Association, New England region, explained during a webinar co-produced with MHA, that hospitals need to work on all six domains simultaneously. “You’re not starting with one of these,” said McCarthy. “They’re all going to be happening at roughly the same time.” She also emphasized the importance of engaging with the patient’s care partner throughout the hospital stay and the role of senior leadership to sponsor and direct this wide-ranging effort. McCarthy served with Dr. Patel on the MHA workgroup in 2018.

Describing BMC’s operational plan, Deborah Whalen, R.N.P., Associate Director Quality and Patient Safety in the Department of Medicine at BMC, emphasizes collaboration among the hospital’s departments. This is particularly evident in planning for transitioning patients with dementia to discharge. “Because we’re a safety net hospital,” says Whalen, “we have always focused on transitions in the various settings. We often work with our community partners as we help our patients move them through the settings and back into the community.”

Whalen also reflects on how the state law helped her and her colleagues at BMC see the work they already were doing in a new light and showcase it in the operational plan. “The law requires that we have a plan available for the Department of Public Health to review, right? We went farther than that,” says Whalen. “We created a plan that is alive. Now when DPH comes, they can walk through our organization and see it in action.”

A Special Report examines Americans’ attitudes toward early detection, diagnosis and new treatments for Alzheimer’s disease.

2025 Alzheimer’s Disease Facts and Figures is a statistical resource for U.S. data related to Alzheimer’s disease, the most common cause of dementia. Background and context for interpretation of the data are contained in the Overview. Additional sections address prevalence, mortality and morbidity, caregiving, the dementia care workforce, and the use and costs of health care and services.

The 2025 Massachusetts Healthy Aging Data Report is available online at healthyagingdatareports.org.

The 2025 Massachusetts Healthy Aging Data Report includes the following tools:
• 386 community profiles (for every city and town and some urban neighborhoods)
• 165 maps listing community rates for each indicator (organized alphabetically and ranked high to low)
• 18 interactive web maps
• Infographic summarizing key findings
• Highlights Report
• Technical documentation

This toolkit was developed by the Care Planning Team of the Massachusetts Advisory Council on Alzheimer’s Disease and All other Dementias (Council). Its goal is to facilitate the development of person-centered dementia care plans that support living well with dementia. Its target audience is the wide range of individuals involved in effective dementia care planning. These individuals include people living with dementia, dementia care partners, families, community-based service providers, and health care providers. It was developed to help readers understand:

• the importance and benefits of person-centered dementia care planning;
• the unique characteristics of dementia that necessitate person-centered care plans; and
• what dementia care planning involves and includes.

In addition to guidance on dementia care planning, this toolkit provides examples of dementia care plans, and a section called “Dementia Care Planning Resources,” featuring links to helpful materials and tools, including those developed by the Council’s teams.

In September 2022, MHA and the Alzheimer’s Association introduced a roadmap to assist Massachusetts healthcare providers in preparing for the implementation of a state-mandated operational plan for Alzheimer’s and related dementias.

The state’s Alzheimer’s and Related Dementias Acute Care Advisory Committee – established by the legislature – in 2017 issued a report of recommendations to provide optimal care to persons with dementia in acute care settings. In 2018, these recommendations were incorporated into legislation and passed into law as Chapter 220 of the Acts of 2018: An Act Relative to Alzheimer’s and Related Dementias.

Section 8 of the law requires all licensed hospitals to complete and implement an “operational plan for the recognition and management of patients with dementia or delirium in acute-care settings.” In July 2021, the required date for implementation was extended from October 2021 to October 1, 2022, due to the COVID-19 pandemic.

The MHA roadmap outlines an operational plan for senior leadership, recommendations of who should be on the team to implement the plan; identification of the six broad categories of an operational plan and the pathways to take to implement it, and suggested outcome measures for ongoing quality assurance and performance improvement.

WATCH: MHA and the Alzheimer’s Association hosted a one-hour webinar, which includes case examples from hospitals implementing their own operational plans.

The National Academy of Medicine today launched Resource Compendium for Health Care Worker Well-Being, which highlights tools that are ready to be deployed and strategies to address systems issues related to health care workers’ burnout. The compendium, which is a product of the Action Collaborative on Clinician Well-Being and Resilience, of which AHA is a participant, organizes resources into six essential elements: advancing organizational commitment; strengthening leadership behaviors; conducting workplace assessments; examining policies and practices; enhancing workplace efficiency; and cultivating a culture of connection and support.

“Stress, trauma and burnout among front-line health care workers are at historic levels as we head into the third year of the pandemic,” said AONL CEO Robyn Begley, DNP, R.N., who serves on the collaborative’s steering committee alongside AHA President and CEO Rick Pollack. “Health care is, at its core, people caring for people. NAM’s detailed plans and actionable resources will help support well-being and resiliency of caregivers who continue to make sacrifices for all of us.”

The workgroup developing the compendium was led in part by AHA past-chair and Carilion Clinic President and CEO Nancy Howell Agee.

More…

Registration is FREE for both ANA members and non-members.

You may soon be faced with one of the most challenging aspects of the COVID-19 pandemic: The need for nurses with little or no critical care experience being called on to be part of a team caring for severely ill COVID-19 patients, many of whom must be on a ventilator to survive.
A FREE, On-Demand Series for ALL Nurses – Part of the ANA COVID-19 Webinar Series

Taught by a highly experienced critical care nurse specialist and educator, this program focuses on key skills needed when caring for a COVID-19 patient on a ventilator. Content is presented in an easy-to-understand – and use — manner. After viewing this webinar, you will be better prepared to be an effective part of a team caring for critically ill patients on a ventilator.

This 60-minute on-demand webinar contains four sections that you can view all at once or one at a time. Topics include:

• Basic ventilator settings and abbreviations such as rate, tidal volume, PEEP, and the modes of ventilation commonly encountered for patients with respiratory failure and ARDS
• How to assess a patient on a ventilator: Important differences compared to routine patient assessments
• Ventilator alarms: The how-to of ventilator alarm assessment and troubleshooting measures and interventions for apnea, high pressure (including how to suction a patient with an ETT), high minute ventilation, and low pressure/low minute ventilation
• How to assist during intubation

Register here…

A new MHA report, An Acute Crisis: How Workforce Shortages are Affecting Access & Costs, shows that there are an estimated 19,000 full-time job vacancies across Massachusetts hospitals, which has led to the closure of hospital beds and services, steep financial losses for facilities, and access challenges for

patients.

Fewer workers mean that fewer beds are available to patients at a time when demand for services due to patient care deferred during the pandemic is increasing. The workforce shortages are causing longer wait times, severe backups in transferring patients from emergency rooms to inpatient beds, and difficulty in transferring patients out of the hospital to post-acute care.

MHA’s report also details how the workforce crisis is putting additional financial pressures on hospitals, which are increasing wages to retain and attract workers, and expending historical amounts of money – up to approximately $1 billion this year – on nurse traveler agencies.

At any given time, more than 1,500 patients are stuck in acute hospital beds as they await placement to a specialized behavioral health bed or post-acute care. Approximately 20% of behavioral health beds in the commonwealth have been taken offline due to workforce shortages. Across all care disciplines, patients and their families are experiencing delays as they seek healthcare services.

“It is essential that community members and leaders understand the dire set of circumstances under which hospitals are now operating,” said Steve Walsh, president & CEO of MHA. “Our healthcare system has never been more fragile, and its leaders have never been more concerned about what’s to come in months ahead. They are exhausting every option within their control to confront these challenges, but this is an unsustainable reality and providers are in dire need of support. Healthcare organizations, payers, public officials, and the public must come together to find solutions before access to care is jeopardized.”

The MHA report also includes recommended steps Massachusetts can take to address the workforce crisis in the short- and long-term. While there are no easy solutions, priorities include the continuation of workforce flexibilities that have helped sustain hospital operations throughout the pandemic, advancing new models of care, taking bold steps to expand the professional pipeline, and investing in new training and educational opportunities for current workers. Recommendations also speak to the need for enhanced supports and protection for healthcare personnel.

The report, which details how many factors beyond hospitals’ control are destabilizing the Massachusetts healthcare system, comes at a time when the state’s Health Policy Commission is discussing further constraints on that system. The most recent state report shows that 78% of reporting hospitals showed negative total margins. While throughout the pandemic, state and federal government have provided meaningful relief funding, hospitals and their affiliated providers have reported an excess of $2.5 billion in pandemic-related losses.