Inappropriate medications can be detected using various screening tools assessing of the quality and safety of prescriptions (e.g., the screening tool of older persons’ potentially inappropriate prescription (STOPP) and the screening tool to alert doctors to the right treatment (START) (Table 10). Although Gooneratne et al.  suggests regular ICS usage in COPD when FEV1 is lower than 50% predicted, this is not a current recommendation for care in COPD and is not recommended here for the treatment of COPD in LTC residents.
From the perspective of the LTC facility, there are issues with insufficient resources in the LTC facility , inconsistent medication reconciliation [120–122,124], lack of robust and differential education of COPD (including recognition, diagnosis, treatment, and management) [132–135], and compliance with federal regulations .
Specific to LTC resources, about 67 000 paid, regulated LTC-service providers (i.e., nursing homes, RCFs, HHAs, hospices, and adult day service providers) served approximately 9 million people in the United States in 2014 . LTC services were primarily provided by RCFs, followed by nursing homes, HHAs, adult day services providers, and hospices. More than 1.5 million nursing employee full-time equivalents and approximately 35 200 social work employee full-time equivalents worked in the five LTC sectors, serving roughly 9 million people in 2014. Average nursing staff hours per resident (or participant) per day were higher in nursing homes than in RCFs and adult day services centers for all types of nursing staff (i.e., registered nurses, licensed practical nurses, licensed vocational nurses, and aides) (Fig. 8). The average of total nursing hours per resident per day in nursing homes was more than twice the ratio for adult day services centers. In licensed nursing staff (i.e., registered nurses, licensed practical nurses, and licensed vocational nurses), the average hours per resident per day were 1.41 (1 h 25 min) for nursing home residents, 0.46 (28 min) for adult day services centers participants, and 0.37 (22 min) for RCF residents . Most nursing homes (97.4%) and the majority of RCFs (82.4%) offered pharmacy or pharmacist services, compared with only 4.8% of HHAs (4.8%) .
The greater percentage of LTC service users are patients aged at least 65 years: 94.4% of hospice patients, 92.9% of RCF residents, 84.9% of nursing home residents, 82.6% of HHA patients, and 63.7% of participants in adult day services centers participants  (Fig. 9). Age composition varied by sector, with RCFs (52.6%), hospices (47.3%), and nursing homes (41.6%) serving more persons aged at least 85 years.
The CMS guidelines for the Initiative identify several services to increase and implement for decreasing the proportion of potentially avoidable hospitalizations, many of which are relevant for patients suffering from COPD:
These guidelines aim to improve the quality of care for long-stay Medicare–Medicaid enrollees residing in LTC facilities by reducing avoidable hospitalizations; therefore, the services listed above are ultimately relevant for improving health outcomes and transitions of care, while simultaneously reducing cost for the same quality of care.
To ensure optimal patient management, effective care models should identify the right treatment for the right patient at the right time . Although the GOLD guidelines provide general recommendations for the medication pathway for patients with COPD , specific recommendations are needed for COPD patients living in LTC facilities. A proposed algorithm by Dekhuijzen et al.  for deciding on the appropriate inhaler device begins with deciding whether or not the patient can inhale medication consciously, followed by whether or not the patient has sufficient PIFR and ending with whether or not the patient has adequate hand–lung coordination. In this algorithm, nebulizers are reserved for patients who cannot consciously inhale, as well as for patients who can consciously inhale but cannot generate a minimal respiratory flow and have poor hand–lung coordination.
The authors propose a potential treatment algorithm for patients with COPD in LTC settings, which focuses on three primary patient aspects to consider when deciding on medication and device: inspiratory flow, hand dexterity and coordination, and cognitive capacity (Fig. 10). The algorithm begins with a resident with diagnosed COPD or who has recurrent respiratory symptoms that could indicate a new diagnosis of COPD or could help to rediscover patients previously diagnosed with COPD but whose diagnosis may have been lost over the years due to numerous transfers between facilities (or some other breakdown of communication). Patients with PIFR of less than 60 l/min would be precluded from devices requiring higher flow rates (namely, DPIs), as would patients with poor dexterity and/or significant cognitive impairment. Patients should be monitored during treatment to verify proper inhaler technique, as well as to determine whether the medication is working.
The authors would like to acknowledge that many more concerns exist within the spectrum of care for LTC residents with COPD that were not discussed in detail in this supplement. Advance care planning is a critical step in all LTC patients and an important part of the evaluation and treatment of these patients. In addition, a thorough assessment of comorbidities, impairments, and current medications should be performed in all LTC patients when considering the appropriate type and delivery of treatment for their COPD. Lastly, there are several nonpharmacological approaches to COPD treatment that may be of benefit to LTC patients, including exercise training, nutritional counseling, education, psychological support, and pulmonary rehabilitation.
The quality of care for LTC residents with COPD is heterogeneous in regard to both the patient and the facility. For patients, care should be driven by appropriate diagnosis, symptom severity, and comorbidities. For facilities, care should be driven by staff education, interstaff communication, and interfacility communication. Appropriate treatment for LTC residents with COPD ultimately needs to be based on patient preference, patient's ability to perform treatment, and patient prognosis. It is the consensus of this group that nebulization should be used for LTC patients with low PIFR, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. In addition, given that COPD is major cause of morbidity and mortality and can result in economic and social burden, LTC facilities should put more emphasis on acknowledging and addressing COPD, which in turn may improve health outcomes, improve quality of life, and lower patient/facility costs.
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