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Staying Current on Regulations and Reviewing Health Outcomes Data


Gregg Warshaw, MD, Medical Editor

warshawRegulation plays a major role in the health care industry and health care insurance coverage. The various regulatory bodies protect the public from a number of health risks and provide numerous programs for public health and welfare. Regulations and standards are necessary to ensure compliance and to provide safe health care to every individual who accesses the system. Tracking, measuring, and enhancing health care outcomes are critical aspects of regulation that measure quality and determine appropriate reimbursement. The articles in this issue address clinical and regulatory updates and add to the literature regarding health outcomes of older adults living in assisted-living facilities (ALFs).

Chronic constipation can occur due to the aging process and can present as a functional gastrointestinal disorder, such as constipation-predominant irritable bowel syndrome or chronic idiopathic constipation. Constipation results in lower quality of life and increased economic burden. Management of chronic constipation in older adults is critical to avoid unnecessary hospitalizations and potentially serious complications. Malcolm Fraser, MD, CMD, CAQGM, and colleagues provide regulatory and clinical updates on the management of chronic constipation in post-acute care facilities, including bowel-specific updates from the Final Rule on the Requirements of Participation from the Centers for Medicare & Medicaid Services (CMS; effective November 28, 2017). Updates on linaclotide use and costs in older adults with chronic constipation are also provided. 

Historically, long-term care (LTC) providers primarily only needed to know the current procedural terminology code that covered the intensiveness of the service they provided their patients. As the US health system evolves away from fee-for-service reimbursement and toward value-based care and reimbursement models, LTC providers will need to educate themselves on what new options are available and determine how their organization should evolve in response. Column editor Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD, discusses how the CMS Hierarchical Condition Category coding is becoming increasingly prevalent in the changing health care environment and how LTC providers can respond.

The population of older adults residing in ALFs in the United States is growing, yet  data are lacking about use of acute health care services by ALF residents because, unlike nursing homes, ALFs are not closely regulated. More data for ALFs are urgently needed if providers are to efficiently meet the needs of this growing, high-risk population. In their retrospective cohort study, Mairead M Bartley, MD, MB, BCh, and colleagues aimed to characterize the association between ALF residency and hospitalization over a year and compare the results with those of an age- and sex-matched community cohort by using outcomes data retrieved from electronic health records.

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