Publications by authors named "Steven A Levenson"

For more than half a century, there has been controversy and conflict over using psychotropic medications ("psychotropics") as strategies to modulate behavior, enhance mood, and address cognitive issues for nursing home residents. The current situation reflects a long history of investigation, reports, discussions, government and professional activity, and other attempted improvement. Although attention has focused primarily on the use of antipsychotics, particularly to manage symptoms associated with dementia, there are much broader issues.

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This article describes how medical directors can use a strategic approach [Smart Case Review (SCR)] to perform effective and efficient clinical case reviews and key medical director oversight functions simultaneously. SCR can be done either on-site or remotely, by using existing information in the medical record for a focused clinical discussion of patient symptoms and issues while simultaneously evaluating related clinical practices and facility processes and performance. Common problem-solving and cause identification methods apply to both patient- and process-related reviews.

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Despite much attention including national initiatives, concerns remain about the approaches to managing behavior symptoms and psychiatric conditions across all settings, including in long-term care settings such as nursing homes and assisted living facilities. One key reason why problems persist is because most efforts to "reform" and "correct" the situation have failed to explore or address root causes and instead have promoted inadequate piecemeal "solutions." Further improvement requires jumping off the bandwagon and rethinking the entire issue, including recognizing and applying key concepts of clinical reasoning and the care delivery process to every situation.

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Health care decision making is a process that includes definable steps in a desirable sequence. The process is universally relevant (i.e.

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While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the problems and identify their diverse causes. This fourth and final article in the series (divided between last month's issue and this one) recommends strategies to make sense of improvement and reform efforts.

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While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together.

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There is a pervasive effort to reform nursing homes and improve the care they provide. Many people are trying to educate and inform nursing homes and their staff, practitioners, and management about what to do and not do, and how to do it. But only some of that advice is sound.

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There are intense efforts to improve the quality of long-term care. However, it is unclear whether these efforts are based on understanding root causes of the deficits in quality. This article focuses on processes of clinical problem solving and decision making as a means to enable safe, effective, efficient, and person-centered care that reflects key principles discussed in the initial article in this series.

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For several decades, there have been efforts to "reform" nursing homes. Despite this, the calls for such reform continue unabated. Therefore, it might lead us to ask just what has been accomplished to date, and whether it is on the right track.

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Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia).

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This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation).

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Both physicians and consultant pharmacists have a longstanding role in nursing home care. The physician role was emphasized in 1974, when medical directors were required in all skilled nursing facilities. It was intensified in 1987, when the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) regulations required all nursing facilities to have a medical director and reinforced that each resident should have an attending physician who visits the resident at specified intervals.

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Nursing homes must provide sophisticated medical and personal care to a broad spectrum of residents and patients. Medications are an increasingly important part of that care. The risks and benefits of medications are widely published, but not necessarily recognized in the care of individual patients.

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Objectives: To identify the impact of the regulations implemented in Maryland in 2001, related to nursing home attending physicians and medical directors, and nursing home quality assurance requirements, on Maryland nursing homes, administrators, and physicians.

Design: Two surveys were mailed to all nursing home administrators in Maryland, one for their completion and one to give to their medical directors to complete. These surveys were to be returned by mail to the authors.

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