Nursing Home Administrators Research Articles

Applying the Advancing Excellence in America's Nursing Homes Circle of Success to improving and sustaining quality

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process.

Electronic Health Records Use and Barriers and Benefits to Use in Skilled Nursing Facilities

The purpose of this study was to determine the levels of automation for 21 clinical functions and the benefits and barriers to electronic health records use in skilled nursing facilities in one of the Midwestern states in the US. A cross-sectional design was implemented. Data were collected from nursing home administrators using a mail and online survey approach. A total of 156 usable questionnaires of 397 distributed were returned, for a 39.30% response rate. While many facilities reported fully automated Minimum Data Set assessments, licensed nurse clinical notes, and care plans, there remained a predominant reliance on paper for functions, such as diagnostic tests and consults. Although many facilities had advanced toward using automation to produce quality reports, they were lagging behind in the use of automated clinical decision support and summary reports. The top two barriers included the amount of capital needed and the cost for hardware and infrastructure. Facilities with paper records were more likely to identify those barriers for functions, such as clinical notes and assessments. The top three benefits were quality patient care monitoring, management control of performance, and anywhere/anytime easier access to clinical data. The study concludes with recommendations to nursing home leaders and other stakeholders.

Nursing Home Residents Dying With Dementia in Flanders, Belgium: A Nationwide Postmortem Study on Clinical Characteristics and Quality of Dying

There is a lack of large-scale, nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia. We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Flanders, Belgium. To obtain representativity, we conducted a postmortem study (2010) using random cluster sampling. In selected nursing homes, all deceased residents with dementia in a period of 3 months were reported. For each case, a structured questionnaire was filled in by the nurse most involved in care, the family physician, and the nursing home administrator. We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia. Main outcome measures were health status, clinical complications, symptoms at the end of life, and quality of dying. Health status, clinical complications, symptoms at the end of life, and quality of dying. We identified 198 deceased residents with dementia in 69 nursing homes (58% response rate). Age distribution was the same as all deceased residents with dementia in Flanders, 2010. Fifty-four percent had advanced dementia. In the last month of life, 95.5% had 1 or more sentinel events (eg, eating/drinking problems, febrile episodes, or pneumonia); most frequently reported symptoms were pain, fear, anxiety, agitation, and resistance to care. In the last week, difficulty swallowing and pain were reported most frequently. Pressure sores were present in 26.9%, incontinence in 89.2%, and cachexia in 45.8%. Physical restraints were used in 21.4% of cases, and 10.0% died outside the home. Comparing stages of dementia revealed few differences between groups regarding clinical complications, symptoms, or quality of dying. Regardless of the dementia stage, many nursing home residents develop serious clinical complications and symptoms in the last phase of life, posing major challenges to the provision of optimum end-of-life care.

Nursing home recruitment: Trials, tribulations, and successes

Many challenges are inherent when conducting research in the older adult population as well as in the nursing home environment. The safety and quality of care provided in nursing homes need further examination through research. The purpose of this paper is to discuss research issues and recruitment barriers experienced by a research team collecting data for a study assessing the education and learning needs of nursing home nurses in central Illinois and related resident outcomes. Research barriers identified in this study include organizational and administrative barriers in addition to staff barriers. The strategy that was most helpful in gaining access to nursing homes in central Illinois was face to face contact. Future nursing home researchers are encouraged to familiarize themselves with the nursing home environment, communicate with nursing home trade associations, and develop personal contacts with area nursing home administrators.

Prevalence of Parkinson Disease and Parkinson Disease Dementia in Community Nursing Homes

To estimate the prevalence of Parkinson disease (PD) and Parkinson disease dementia (PDD) in community nursing homes. To estimate how many residents who meet criteria for PDD have been diagnosed with PDD and prescribed a Federal Drug Administration (FDA)-approved treatment for PDD. Three private Saint Louis metropolitan area nursing homes. Fifty-five residents with a chart diagnosis of PD from a total of 714 residents were identified. Sixteen subjects or families did not give consent and two were excluded from the study because advanced stage of the illness impaired evaluation. Thirty-seven subjects with an established diagnosis of PD participated in the study. A chart review was used to identify the study sample: residents with an established diagnosis of PD. Consent was obtained from the nursing home administration, families or guardians, and the residents themselves (where applicable). Study data were obtained from review of residents' medical charts, family/caregiver interview, resident interview, resident cognitive testing (Mini-Mental State Examination, clock drawing test), and resident depression assessment (15-item Geriatric Depression Scale). Diagnosis of PDD was defined using existing literature and described below. Data were analyzed using SPSS version15. Of the 714 nursing home residents, 55 (7.7%) met criteria for PD. Of these, 37 participated in the study and 18 (48.6%) met criteria for PDD. None were diagnosed with PDD in the charts and 11.1% (2 of 18) were on FDA-approved treatment. In this sample of nursing home residents, the prevalence of PD was 7.7% and the overall prevalence of PDD was 3.7%. PDD remains an unrecognized entity in the nursing home setting. Close to half (48.65%) of nursing home residents with PD may have PDD at any given time and they remain undiagnosed and largely undertreated.

Consistent Assignment of Nurse Aides: Association With Turnover and Absenteeism

Consistent assignment refers to the same caregivers consistently caring for the same residents almost every time caregivers are on duty. This article examines the association of consistent assignment of nurse aides with turnover and absenteeism. Data came from a survey of nursing home administrators, the Online Survey Certification and Reporting data, and the Area Resource File. The measures were from 2007 and came from 3,941 nursing homes. Multivariate logistic regression models were used to examine turnover and absenteeism. An average of 68% of nursing homes reported using consistent assignment, with 28% of nursing homes using nurse aides consistent assignment at the often recommended level of 85% (or more). Nursing homes using recommended levels of consistent assignment had significantly lower rates of turnover and of absenteeism. In the multivariate analyses, consistent assignment was significantly associated with both lower turnover and lower absenteeism (p < .01). Consistent assignment is a practice recommended by many policy makers, government agencies, and industry advocates. The findings presented here provide some evidence that the use of this staffing practice can be beneficial.

Use of HIT for adverse event reporting in nursing homes: Barriers and facilitators

Background & objectiveApproximately 8 million adverse events occur annually in nursing homes (NHs). The focus of this research is to determine barriers and health information technology (HIT)-related facilitators to adverse event reporting among U.S. NHs. MethodsSurveys were returned by 399 nursing home administrators using a mailed survey approach. Respondents were asked to report on their adverse event reporting processes focusing on barriers and role of HIT facilitators. ResultsAbout 15% of NHs had computerized entry by the nurse on the unit and almost 18% used no computer technology to track, monitor, or maintain adverse event data. One-third of nursing directors conducted data analysis “by-hand.” NHs without HIT were more likely to not be accredited (p = 0.04) and not part of a chain/corporation (p = 0.03). Two of the top three barriers focused on fears of reporting as a barrier. ConclusionsThis study found numerous barriers and few HIT-related facilitators to assist with adverse event reporting. Improvements in facilitating adverse event reporting through the use of HIT approaches may be warranted.

San Diego's Area Coordinator System: A Disaster Preparedness Model for US Nursing Homes

Almost 2 million Americans rely on nursing homes for care, and many require daily or near daily contact with the health care system to remain alive and functional. In October 2007, Southern California experienced a series of wildfires that burned over 500, 000 acres and caused 14 nursing homes to evacuate more than 1200 residents. In response to this event, nursing home administrators and officials from various health care and emergency management agencies in San Diego County collaborated to form a model for nursing home emergency preparedness. This report describes the model, known as the area coordinator system, and discusses its strengths and limitations, and whether it ought to be replicated in other areas of the country.

Implementation of Quality Assurance and Performance Improvement Programs in Nursing Homes: A Brief Report

The purpose of this article was to investigate nursing homes' (NHs') readiness to implement a quality assurance and performance improvement (QAPI) program as required by Section 6102 of the Affordable Care Act. Nursing home administrators (NHAs) in 3000 NHs (response rate, 67%) were surveyed using a 70-item questionnaire to assess: (1) current facility approaches to quality, (2) NHA's self-assessed knowledge of QAPI techniques; and (3) the use of QAPI techniques. The Online Survey, System for Certification and Administrative Reporting data and the Area Resource File were also used to examine and compare facility and market characteristics. As rated on a scale of 1 to 10, NHs are more likely to use quality assurance (rating, 7.2) and least likely to use total quality management (rating, 4.1). Few NHAs use tools for QAPI such as flow charts (23%), Plan-Do-Check-Act cycles (13%), or run charts (9%). A gap in knowledge of quality improvement tools has been identified signifying that the new QAPI regulations may pose an issue for NHAs who possibly lack the knowledge and technical expertise to implement a comprehensive QAPI program.

Managing Up, Down, and Across the Nursing Home

The director of nursing (DON) is an essential member of the top management team in nursing homes and in a key position to improve the quality and value of care. This article describes and examines the roles and responsibilities of DONs as perceived by a convenience sample of current/previous DONs and nursing home administrators (n = 29). Data were collected through in-depth semistructured interviews and analyzed using content analysis and thematic analysis. The findings reveal a broad scope and wide variation in the DON position across settings, with inextricable linkages between clinical care and other aspects of care delivery, such as managing fiscal and human resources (HR). As RN licensure is the only Federal requirement for the DON position, suggesting a clinical focus, the findings highlight a policy-practice gap. Research is needed to address this gap, focusing on the requisite preparation DONs need to effectively and cost-efficiently lead initiatives for quality improvement.

The Influence of Teams to Sustain Quality Improvement in Nursing Homes that “Need Improvement”

Qualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement." A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. The qualitative analysis revealed a subgroup of homes ("Full Adopters") likely to continue quality improvement activities that were able to effectively use teams. "Full Adopters" had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. "Full Adopters" also selected care topics for the focus of their quality improvement team, instead of "communication" topics of the "Partial Adopters" or "Non-Adopters" in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. "Full Adopters" had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems. Results of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.

Nursing home administrators’ perspectives on a study feedback report: a cross sectional survey

BackgroundThis project is part of the Translating Research in Elder Care (TREC) program of research, a multi-level and longitudinal research program being conducted in 36 nursing homes in three Canadian Prairie Provinces. The overall goal of TREC is to improve the quality of care for older persons living in nursing homes and the quality of work life for care providers. The purpose of this paper is to report on development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives on the usefulness, meaningfulness, and understandability of selected data from the TREC survey.MethodsA cross sectional survey design was used in this study. The feedback reports were developed in collaboration with participating facility administrators. FARs presented results in four contextual areas: workplace culture, feedback processes, job satisfaction, and staff burnout. Six weeks after FARs were mailed to each administrator, we conducted structured telephone interviews with administrators to elicit their evaluation of the FARs. Administrators were also asked if they had taken any actions as a result of the FAR. Descriptive and inferential statistics, as well as content analysis for open-ended questions, were used to summarize findings.ResultsThirty-one facility administrators (representing thirty-two facilities) participated in the interviews. Six administrators had taken action and 18 were planning on taking action as a result of FARs. The majority found the four contextual areas addressed in FAR to be useful, meaningful, and understandable. They liked the comparisons made between data from years one and two and between their facility and other TREC study sites in their province. Twenty-two indicated that they would like to receive information on additional areas such as aggressive behaviours of residents and information sharing. Twenty-four administrators indicated that FARs contained enough information, while eight found FARs ‘too short’. Administrators who reported that the FAR contained enough information were more likely to take action within their facilities than administrators who reported that they needed more information.ConclusionsAlthough the FAR was brief, the presentation of the four contextual areas was relevant to the majority of administrators and prompted them to plan or to take action within their facility.

Should we feed back research results in the midst of a study?

BackgroundThis report is an introduction to a series of three research papers that describe the evolution of the approaches taken by the Translating Research in Elder Care (TREC) research team during its first four years to feed back the research findings to study participants. TREC is an observational multi-method health services research project underway in 36 nursing homes in the prairie provinces of Canada. TREC has actively involved decision makers from the sector in all stages from initial planning, through data collection to dissemination activities. However, it was not planned as a fully integrated knowledge translation project. These three papers describe our progress towards fully integrated knowledge translation—with respect to timely and requested feedback processes. The first paper reports on the process and outcomes of creating and evaluating the feedback of research findings to healthcare aides (unregulated health professionals). These aides provide over 80% of the direct care in our sample and actively requested the feedback as a condition of their continued cooperation in the data acquisition process. The second paper describes feedback from nursing home administrators on preliminary research findings (a facility annual report) and evaluation of the reports’ utility. The third paper discusses an approach to providing a more in-depth form of feedback (expanded feedback report) at one of the TREC nursing homes.FindingsSurvey and interview feedback from healthcare aides is presented in the first paper. Overall, healthcare aides’ opinions about presentation of the feedback report and the understand ability, usability, and usefulness of the content were positive. The second paper describes the use of telephone interviews with facility administrators and indicates that the majority of contextual areas (e.g., staff job satisfaction) addressed in facility annual report to be useful, meaningful, and understandable. More than one-half of the administrators would have liked to have received information on additional areas. The third paper explores how a case study that examined how involvement with the TREC study influenced management and staff at one of the TREC nursing homes. The importance of understanding organizational routines and the impact of corporate restructuring were key themes emerging from the case study. In addition, the Director of Care suggested changes to the structure and format of the feedback report that would have improved its usefulness.ConclusionsWe believe that these findings will inform others undertaking integrated knowledge translation activities and will encourage others to become more engaged in feedback processes.

The Relationships Among Licensed Nurse Turnover, Retention, and Rehospitalization of Nursing Home Residents

Individuals receiving postacute care in skilled nursing facilities often require complex, skilled care provided by licensed nurses. It is believed that a stable set of nursing personnel is more likely to deliver better care. The purpose of this study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs). We combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009. Using a two-way fixed effects model, we examined the relationships among licensed nurse turnover rates, retention rates, and 30-day rehospitalization rates. Results indicate that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate (est. = -.02, p = .04) controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate. These findings highlight the need for NH administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship.

Advance Care Planning and Dying in Nursing Homes in Flanders, Belgium: A Nationwide Survey

ContextIn Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce. ObjectivesTo investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received. MethodsThis was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident. ResultsAdministrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative. ConclusionPrevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.

Reducing Potentially Preventable Hospital Transfers: Results from a Thirty Nursing Home Collaborative

Nursing home (NH) residents experience frequent hospital transfers, some potentially avoidable. The objective of this report is to describe a replication of the Interventions to Reduce Acute Care Transfers program among member facilities of a New York City area NH provider association (INTERACT NY) and estimate its effect on hospital transfers. INTERACT is a program that provides tools and strategies to assist NH staff in early identification, communication, and documentation of changes in resident status. Funding was obtained from a New York State health workforce training grant to conduct 13 INTERACT education and training sessions in 2010-2011. INTERACT NY session topics included the implementation process; use of its simple standardized communication tools, advance care planning tools, care paths, and change in condition support tools; quality review of hospital transfers; exercises for refining clinical skills; teamwork; and lessons learned. Sessions engaged NH executives, department heads, front-line nursing staff and their labor union, and staff from NHs' partner hospitals. Pre-/post- INTERACT NY hospitalization rates per 1000-resident days were compared using paired t-tests, stratified by level of facility engagement with the program and by baseline hospitalization rates. All 100% of participating NHs were non-profit or public. Those with complete evaluation data had 377 beds on average. There were a total of 333 attendees of the program (mean 25.6 per session; mean 11.1 per facility over the course of the program; range 1-44 per facility). The most common attendees in order of frequency were (1) nurse administrators, (2) unit-based nurses, (3) medical directors and attending physicians, (4) nursing home administrators, (5) certified nursing assistants, and (6) case managers and social workers. Sixteen nursing homes implemented at least one INTERACT tool. Overall, there was a nonsignificant 10.6% reduction in hospital admissions from 4.07 to 3.64 per 1000 resident-days from pre- to post-INTERACT NY (P= .332). Among nursing homes with high engagement there was a nonsignificant 14.3% reduction in hospital admissions from 4.19 to 3.59 per 1000 resident-days (P= 0.213). Finally, among nursing homes in the highest tertile of baseline (pre-INTERACT NY) hospital admission rate, there was a nonsignificant 27.2% reduction in hospital admissions from 7.32 to 5.33 per 1000 resident-days (P= .102). Planning and implementation lessons from INTERACT NY leaders and participants are reported. INTERACT NY, a novel collaborative training program, resulted in good uptake of the INTERACT tools and processes among its member nursing homes. Changes in hospitalization rates associated with INTERACT NY were similar to those observed in previous implementations of INTERACT. The program addresses a growing interest in reducing potentially preventable hospital admissions among nursing home residents and providing alternatives to hospital care through standardized approaches to communication, early identification of clinical issues, decision-support, and support for partnerships between acute and post-acute care providers.

Experience and Education of Home Health Administrators and Nursing Home Administrators and the Relationship to Establishment Ownership

Administrators in long-term care may have an important influence on quality of care. Limited prior research has described the characteristics of nursing home administrators. Despite growing emphasis on home health care as an alternative to nursing homes, almost no research has described the characteristics of administrators of home health agencies. Using the 2004 National Nursing Home Survey and the 2007 National Home and Hospice Care Survey, we describe the career experience of administrators, and examine the relationship between experience and education of administrators both within and across the nursing home and home health sectors. We also explore the characteristics of nursing homes and home health agencies, including establishment ownership (e.g., nonchain not-for-profit), that are associated with being able to attract administrators with the most experience. We find that home health administrators have, on average, less experience than nursing home administrators. Among home health agencies, administrators with the least experience also tend to have less education. in nursing homes, administrators with less experience tend to have more education. Results from multivariate analysis suggest that chain for-profits may be the least able to attract experienced administrators. More research on the effects of different levels of experience and education among administrators is needed.

A Haven of Last Resort: The Consequences of Evacuating Florida Nursing Home Residents to Nonclinical Buildings

Nursing home administrators (n = 15) and directors of nursing (n = 15) who worked in nursing homes during the 2004-2005 Florida hurricane season participated in a series of 6focus groups. The purpose of the focus groups was to explore issues faced by nursing home administrators, nurses, and residents during hurricane evacuations. A primary finding was that evacuating nursing home residents to buildings that are not designed to support nursing activities (e.g., a school gymnasium or church) adversely affected resident feeding, sleeping, movement, and security. These nonclinical buildings also presented serious occupational health concerns for nursing staff members who provided care during emergencies. Recommendations for reducing patient and nursing staff injuries for those forced to evacuate to a nonclinical building as the result of an emergency event are provided.

Relationship Between Nursing Home Safety Culture and Joint Commission Accreditation

Safety culture interventions in hospitals have been found to be associated with improved safety practices and outcomes. Studies in nursing homes generally report a poorly developed safety culture. Voluntary accreditation provides a structure for organizing care processes and is known to stimulate continuous quality improvement and thereby has the potential to stimulate improvements in organizational safety culture. The impact of Joint Commission accreditation on patient safety culture perceptions among senior managers in nursing homes in the United States was assessed. A random sample of 6,000 nursing homes was selected from all 50 states. The Nursing Home Survey on Resident Safety Culture was sent to these facilities, and nursing home administrators and directors of nursing were instructed to complete the survey. Scores were computed using the instrument agreement scale, in which the percentage of positive responses represented the summary score. Students' paired sample t-tests were used to compare differences in scores between respondents from accredited nursing homes and those from nonaccredited nursing homes. Multivariate analyses were then used to examine the association between accreditation and each resident safety culture (RSC) subscale, controlling for facility and market characteristics. The analytic response rate for the sample was 67%. After facility and market characteristics were controlled for, senior managers in accredited nursing homes rated 8 of the 11 RSC domains significantly higher. Joint Commission accreditation appeared to be associated with a more favorable RSC in nursing homes. Assessing a nursing home's RSC is an organization's first step toward improving the culture of safety. These findings support the need for further discussion and facilitation of voluntary accreditation in nursing homes.

Spotlight on a geriatric, long-term care practice

We consult approximately 1000 charts per month in a variety of long term care settings (e.g., Skilled Nursing, Assisted Living, MRDD Intermediate Care Facilities) which equates to 1 x FTE or 40 hours per week. A typical day consists of meeting with the Director of Nursing and Licensed Nursing Home Administrator upon arrival to a facility in order to ascertain specific health needs/complications of the community residents. Depending on the situation, this may require directly meeting with the patient and/or family members for medication/disease state consultation. In addition to specific requests from facility leadership, each resident's chart is reviewed for appropriate supporting diagnoses, medication monitoring (e.g., laboratory, risk assessment scales, vitals, potential side effects, proper administration times/procedures), evaluate for unnecessary meds (e.g., duplication, duration, Beer's criteria, drug-drug interactions), and a variety of ambulatory care issues (e.g., diabetes, osteoporosis, dementia, hyperlipidemia, weight loss concerns) and regulatory compliance (e.g., gradual dosage reduction requests/documentation for psychotropic agents). As a consultant pharmacist to Skilled Nursing Facilities, I am also expected to destroy discontinued narcotic medications with a licensed nurse (usually director of nursing) and oversee proper medication availability and storage parameters are maintained (sometimes involves problem solving between nurse/facility staff and dispensing pharmacy).I've been practicing for 10 years. Consulting pharmacy practice has been a goal of mine since the practice was introduced when I was a pharmacy student.A combination of great family, friends, and teachers/mentors! I received a BS in Pharmacy from Butler University; Certification in GeriatricsTwo-fold: Discontinuation of unnecessary medications for improvement in psychosocial well being as well as (medication) cost savings; adding medically appropriate medications for preventative health measures and lower health system costs.Educating facility personnel on non-pharmacologic interventions for behavioral symptoms of dementia as well as advocate for appropriate medication management to prescribers and family members (reduce anticholinergic load, add appropriate dementia therapy, advocate for agents other than antipsychotics for behavioral symptoms of dementia when hallucinations/delusions not present).I work for a corporation that bills for professional consulting services at fair market value.I like the clinical aspect of care that can be provided directly (e.g., face to face consultations with patients or clinicians) and/or indirectly (e.g., consultation reports, usually to attending physicians). It offers a great amount of flexibility and can be tailored to accommodate a variety of communication styles.Consider joining a professional organization specializing in geriatrics; network with other professionals in the LTC industry (e.g., pharmacists, nurses, administrators, medical directors. pharmaceutical medical liaisons, dieticians, social workers).It is sometimes difficult to incorporate students and residents into daily activities depending on the territory/amount of travelling required. It is best to have interested individuals practice longitudinally with you for better understanding of consulting pharmacy practice (e.g., at one site rather than multiple settings). Students and residents are incorporated into my practice with chart reviews, facility staff education (e.g., inservices, supplying applicable educational materials, LTC industry updates), and (new) drug information, P&amp;T/pharmacoeconomic information.