Patients with criminal backgrounds are often denied admission to long-term-care facilities without considering their clinical needs or understanding how risk factors for violence can be mitigated.
The AMA House of Delegates is asking APA to work with the long-term-care provider and correctional-care communities to develop national best practices on how best to provide care to, and develop appropriate care plans for, individuals with criminal backgrounds and/or violent tendencies in long-term-care facilities.
That directive is part of a comprehensive report by the AMA’s Council on Medical Service (CMS) about the problems associated with treating individuals in long-term-care facilities who have criminal backgrounds or who may be violent, while ensuring the safety of other residents. (It was one of several CMS reports approved at the House; a second report of importance to all physicians addresses the AMA’s concerns about the Value-Based Modifier program, a feature of the Affordable Care Act to encourage physicians treating Medicare patients to abide by quality measures; see sidebar).
Psychiatrist Barry Wall, M.D., alternate delegate to the House of Delegates from the American Academy of Psychiatry and the Law, told Psychiatric News that the CMS report on long-term-care residents with criminal histories is a timely one because the number of older prisoners is exponentially rising and because the cost of providing care within corrections systems, and in the communities to which inmates return, is increasing.
The Value-Based Payment Modifier (VBM) program, developed by the Centers for Medicare and Medicaid Services (CMS) as a part of the Affordable Care Act (ACA), needs to be repealed or significantly modified, said AMA delegates said when they approved a report on the VBM at last month’s Interim Meeting of the AMA House of Delegates. The report, by the AMA Council on Medical Service, urges the AMA to continue to advocate for repeal or modification of the VBM program and encourage national medical specialty societies to pursue the development of relevant performance measures—which could be incorporated into quality measurement and improvement programs—that demonstrate improved quality and lower costs.
The VBM program is being implemented in response to the ACA, which directs CMS to establish a system of differential payment based on comparisons of the quality and cost of care furnished. The VBM is a budget-neutral payment modifier that will be phased-in beginning in 2015, according to policies finalized as part of the 2013 Medicare Physician Fee Schedule. CMS is required to apply the VBM to all physicians submitting claims under the Medicare physician fee schedule by 2017.
“The AMA’s position is that it is extremely difficult, if not impossible, to come up with a modifier that is going to work for all specialties at the individual level,” explained Council on Medical Service Chair-Elect John McIntyre, M.D., past chair of the Section Council on Psychiatry. “There is too much variability in terms of service and setting. So the AMA position is that it has to be repealed entirely or very significantly changed.”
The report can be accessed at http://www.ama-assn.org/assets/meeting/2013i/i13-addendum-refcomm-j.pdf by clicking on “Hospital-Based Physicians and the Value-Based Payment Modifier.”
“On the one hand, many persons with criminal convictions are not violent, most violent behavior is not due to mental illness, and violence and aggression in long-term care facilities are mostly committed by residents with cognitive impairment instead of criminal backgrounds,” Wall said. “On the other hand, there is a void in the current literature on long-term-care residents with criminal backgrounds, and such persons can be stigmatized or, in my experience, denied admission to long-term-care facilities based solely on their rap sheet without examining their clinical needs or understanding how risk factors for violence can be mitigated. So it’s important to research and address best practices to ensure proper care before and after prison release so that persons with criminal backgrounds can access the long-term care they need.”
Barry Wall, M.D., an AMA alternate delegate from the American Academy of Psychiatry and the Law, says there is a void in the literature on long-term care for former inmates, who can be denied admission to long-term-care facilities because of their criminal past.
The CMS report, approved by the House, outlines the dearth of evidence-based best practices, as well as the multiple factors that complicate the subject of violence or aggression in long-term care. “To date, there is little information and data concerning how to best manage residents with criminal histories in long-term-care facilities, especially those with the potential to be violent and/or aggressive,” the report states. “Therefore, long-term-care facilities are navigating how to address providing care to this population without any national best practices or accepted standards of care. Without national best practices or accepted standards of care, long-term-care facilities and the physicians and other health care providers caring for long-term-care residents are faced with determining how care plans should differ based on crimes committed and a resident’s likelihood to reoffend.”
The CMS report notes also that there is a question of how approaches to risk assessment and care planning should differ in addressing residents with criminal histories who have the potential to be aggressive or violent and residents with cognitive impairments and mental illness who also may have aggressive and violent tendencies.
John McIntyre, M.D., chair-elect of the CMS, told Psychiatric News that the report originated with a resolution two years ago from the American Medical Directors Association seeking guidance on how to treat individuals coming into long-term-care facilities from jails.
“We felt as a council that we were not able to come up with specific recommendations, so we are asking APA to work with the National Commission on Correctional Healthcare and other relevant groups to provide guidance,” he said. “People coming out of jails and prisons have a right to quality care in a nursing home setting, but you also want to have a safe environment for all residents.” ■
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