Caring for the Ages asked its editorial advisers to predict, from their distinct perspectives, the major issues they expect to arise in the field of post-acute/long-term care during 2015. Predictions coalesced on the topics of quality outcomes, workforce issues, and finances and reimbursement. Nicole Brandt, PharmD, MBA, CGP, professor, geriatric pharmacotherapy, pharmacy practice and science, University of Maryland School of Pharmacy, Baltimore: ▸There will continue to be this transformation to value-based health care and this will impact how the care is delivered in the PA/LTC market. Hopefully, we will see an integration of health information exchange during care transitions, especially in light of impact on reimbursement due to readmissions.▸Medication management and managing high cost medications will continue to be areas that need attention. Expensive specialty medications for conditions such as hepatitis C, cancer, and multiple sclerosis will continue to impact drug spending and the burden both on PA/LTC facilities and payers, as well as patients.▸There needs to be a concerted effort to look at how to effectively integrate or communicate with health care systems and providers to improve the delivery of care and minimize transitions in care. There needs to continue to be a collaborative, interprofessional approach to meeting the increasingly complex medical and medication needs of the patients served in the PA/LTC setting. Janet K. Feldkamp, RN, BSN, LNHA, JD, partner, Benesch Friedlander Coplan & Aronoff LLP, Columbus, OH: ▸The Office of Inspector General and other state and federal fraud-fighting entities will continue to vigorously investigate and prosecute health care fraud, including violations of the false claims act, Stark law, and other fraud statutes. The focus will be across all types of health care entities, including skilled nursing facilities, home health, and hospice.▸Elsewhere, [violations] related to infection control in the SNF setting will continue to be actively cited. Expect to see more citations and increasing scope and severity citations because of the prevalence of multi-drug resistance organisms and the recent focus on Ebola in the United States.▸Additionally, we likely will see litigation related to the use and enforcement of arbitration agreements in SNFs in states that do not have a statutory or regulatory prohibition on their use with admission agreements. This litigation continues in many jurisdictions. Robert M. Gibson, PhD, JD, senior clinical psychologist, Edgemoor DP SNF, Santee, CA: ▸There is clearly a great deal happening with funding and growing financial pressures in long-term care. At the same time, I expect continued pressure on LTC facilities to cope with higher acuity, both medically and in terms of psychological and psychiatric issues. As placement pressures continue, we will likely see continued growth in the numbers of younger adults in long-term care, as well as a continued shift of medically impaired persons in the correctional system to the community and, in many cases, to long-term care. With declining mental health resources and a lack of resources for persons with brain injury or neurodegenerative conditions, these segments of the LTC population will also continue to grow, thus increasing the need for effective behavior management and mental health services. In general, I anticipate the need to be increasingly flexible and to do more with less. Daniel Haimowitz, MD, FACP, CMD internist, Levittown, PA: ▸There has definitely been a trend towards expansion of services out of institutions and toward home- and community-based care. Partly this is due to expectations of baby boomers, but it ties into financial pressures. It certainly provides an opportunity for practitioners outside of the traditional PA/LTC setting (assisted living, PACE, house call practices, etc.).▸Financial drivers are always key issues. Medicare and Medicaid are in the midst of potentially very radical changes – bundled payments, ASOs, combined Medicare-Medicaid managed care programs for LTC patients, etc. These are driving real changes in the marketplace. Already, hospitals are making it clear to nursing homes that quality metrics (and clearly the related financial implication) will drive referral patterns. As a result, nursing homes will try moving up the acuity chain into more Medicare post-acute care and fewer chronic LTC patients.▸I hope medical directors will help the nursing homes step up their game and play a major role in helping staff understand and implement the Quality Assurance and Performance Improvement (QAPI) process and INTERACT. Elsewhere, the role of non-physician health care professionals in the PA/LTC world will continue to expand.▸I hope that the coming year brings more recognition of the Choosing Wisely campaign, and I think we'll see more interest in genomic medicine, specifically targeting individuals and their personalized medication use. The concept is interesting, and I believe this issue will continue to expand. Linda Handy, MS, RD, Commission on Dietetic Registration, San Marcos, CA: ▸I predict that long-term care will be impacted by the recently completed Centers for Medicare & Medicaid Services Hospital Patient Safety Pilot Initiative that includes detailed surveyor worksheets developed to challenge surveyors as they assess hospitals' compliance with QAPI and infection control. This impact has already started and will carry over into LTC surveys as surveyors ask for more documentation of performance improvement and criteria (What residents are screened for weight variance meetings? How are nutrition interventions followed for effectiveness? What has been evaluated for the root causes of weight loss?). [Facilities will have to] follow through on weaknesses identified and show how effective corrective actions and staff competency are demonstrated. Facilities also will be expected to show how they demonstrate that the infection control officer designee is involved in preventing foodborne illness. I believe that we would benefit from studying these surveyor worksheets and apply them to long-term care to ensure our own compliance. Jeffrey Nichols, MD, president, New York Medical Directors Association, New York: ▸The top issues will be related to finances, as they always are. Although many facilities are dependent on Medicare Part A reimbursement – or managed care equivalents – to cover inadequate Medicaid rates and declining private pay census, there will be a serious squeezing of these referrals. Instead, providers and insurers are increasingly looking at intensive home care as a cheaper alternative to SNF care, especially for many of the standard orthopedics cases that have been the bread and butter of most subacute programs. As a result, facilities will need to refocus their rehab programs and align their services to the needs of referral sources and a sicker resident population to survive.▸At the same time, 2015 will be the year when electronic health records finally reach many LTC providers. Most systems designed for use in nursing homes perform well on the finance/care planning/[Minimum Data Set] side but are poorly designed for clinical care or linkage to acute care and home care partners in the care continuum. Progress in this area will depend on whether medical directors and other practitioners are able to unite and insist that these problems are addressed as paper charts disappear. Dan Osterweil, MD, CMD, professor of medicine and associate director, multicampus program in geriatrics and gerontology, the Borun Center, Sherman Oaks, CA: ▸The pressures to meet the value-based purchasing propositions will increase both on nursing home providers and hospitals. As a consequence, medical providers will feel this pressure as well.▸The demand for quality will spill over to the post-acute space with increased demand for accountability that will come out of National Committee for Quality Assurance standards, delineating the responsibilities for post-acute complications between the hospitals and skilled nursing facilities. SNFs may join the crowd and be subject to financial penalties and rewards just as hospitals are.▸Last, but not least, the care coordination codes and PA/SNF coordination codes in fee-for-service medicine may shift the burden for care coordination between settings from institutions to practitioners. The next year will provide an opportunity to improve on cross-system coordination. Practitioners will be wise to consider hiring a care coordinator for their practice, especially those practices with more than 200 patients who have two or more chronic conditions and qualify for the per-member-per month fee. Barbara Resnick, PhD, CRNP, FAAN, FAANP, professor and Sonya Ziporkin Gershowitz chair in gerontology, University of Maryland School of Nursing, Baltimore: ▸There will be a continued separation and differentiation in long-term care between subacute and post-acute care patients and long-stay patients. Increasingly, there will be a growth in specific buildings and units for these different types of patients. In my crystal ball, I see that this will have many positive outcomes. Designated units that focus on rehabilitation and recovery will work on training staff to have the skills to provide rehabilitation nursing and medicine, and will facilitate the discharge in the most cost-effective and efficient manner. I further hope that this rehabilitation philosophy will translate to long-stay patients as well, and we will all begin to incorporate a function-focused care approach, regardless of setting.▸Another prediction (or at least a dream) includes a stronger focus on prevention, with immunizations that go beyond just flu and pneumonia vaccines and include zoster and tetanus-diphtheria-pertussis as routine vaccinations. Likewise, we will focus more on prevention of pressure areas and contractures, even at what is thought of as the end of life (as one never knows what might happen to or with our quite resilient older individuals during this time). Elsewhere, as more individuals live to 100 years or older, we may need to put more emphasis on prevention so that those years can be lived comfortably and with some quality. Karl Steinberg, MD, CMD, editor in chief, Caring for the Ages, Oceanside, CA: ▸We will see more of a move toward value-based payment and population health in the PA/LTC setting in 2015, and this trend will continue in years to come. With some of the new models, including later generations of accountable care organizations, many of our patients will be able to go directly from emergency department (or doctor's office) to skilled care in an SNF without a required hospital stay – just as our Medicare+HMO patients have been able to do for decades. That is a very good thing, because the hospital is not a good place to be when patients don't need to be there (with all due respect to our hospital and hospitalist colleagues). At the same time, it will be possible for a long-term custodial SNF resident to be bumped up to a skilled level without having to go to the hospital, which is also a very positive change.▸I also predict that the pilot programs for dual eligibles (Medicare/Medicaid) will be expanded, and we will see a continuing exodus of less functionally impaired SNF residents into residential care (assisted living, board-and-care facilities, etc.). This is another good development and a better way to spend our Medicaid tax dollars.▸Meanwhile, as desperately as the assisted living industry tries to cling to the “we are not medical” mantra, we'll see movement for increasing regulation in this arena – maybe even federal regulations at some point – as the level of chronic illness continues to increase in that setting.▸From the clinical side, I think we will continue to see less unnecessary use of antipsychotics, less use of sliding-scale insulin, better antibiotic stewardship (with less checking of urine studies for isolated single-symptom situations like cloudy or foul-smelling urine, a fall, or mental status changes, and thus less inappropriate treatment of asymptomatic bacteriuria), and more access to palliative care services and appropriate, informed advance care planning in our buildings.