Lecture 1- Long term care

Question 1

The nursing home population characteristics

Answer 1

• Impairment in decision making- the big one!
• Need assistance with 3+ ADLs
• Dementia
• Orientation/memory problems
• communication problems
• bowel/bladder incontinence

Question 2

Demographics of nursing home population

Answer 2

• vast majority is over 65 (90%)
• 3/4 are women
• • most are widowed, with limited social supports
• underrepresented populations are hispaics, asian americans, and native americans

Question 3

Average beds in a nursing home

Answer 3

About 100

Question 4

Are most nursing homes for profit, non-profit, or government run?

Answer 4

FOR PROFIT!

Question 5

Postacute care services in long term care facilities

Answer 5

• dialysis
• Orthopedic care
• Ventilators
• Post-op care
• Rehab care
• Wound care
• this is a big need- lower hospital stay lengths, but higher care needs

Question 6

the vast majority of nursing home stays are for how long

Answer 6

Greater than 80% stay for longer than 90 days but less than 3 years

Question 7

What is the majority funder of nursing home care?

Answer 7

Medicaid!- 65%

Question 8

What qualifications do you need to have to get medicare to pay for nursing homes

Answer 8

• 3-day qualifying hospital stay
• gains in function has to be carefully documented
• 1st 20 days paid- after that up to day 100 need a co-payment

Question 9

What percentage of nursing homes are chains?

Answer 9

about half

Question 10

Staffing issues with nurses

Answer 10

• Huge turnover rates per year!!!!!
• ratio of RNs to other nursing staff has a big effect on quality of care
• the more turnover, the higher the rates of hospitalization for nursing-home residents

Question 11

Staffing issues with doctors

Answer 11

• most primary care docs designate 2 hours or less to nursing home care
• perception is there is excessive regulation and paperwork with limited reimbursement
• Reality is it is challenging and fulfilling work

Question 12

Staffing issue- culture

Answer 12

• closed-staff model improves care
• lower hospitalization rates in nursing homes that employ a limited number of committed doctors
• quality drug use correlelated with enhanced nurse-doc communication

Question 13

Risk factors associated with nursing home placement

Answer 13

• increased age
• Low income, low social activity
• poor family supports
• accepting attitude toward nursing homes
• cognitive/functional impairment

Question 14

Nursing home residents have high rates of hospitalization, most commonly due to __________

Answer 14

Infection

Question 15

Issues with information transfer

Answer 15

• missing or illegible transfer summaries
• Omission of prescribed medications
• Advance directives not documented
• Psychosocial and behavior issues are not reported

Question 16

INTERACT - Interventions to reduce acute care transfers

Answer 16

• developed to improve early Identification, assessment, documentation and communication about status changes in nursing home residents
• goal is to reduce hospital transfers
• • so far has reduced them by 17%

Question 17

Omnibus Budget Reconciliation Act (OBRA)

Answer 17

• set training guidelines and minimum staff requirements for nursing homes
• increases resident’s rights
• initiated minimum data set
• requires documentation for ALL meds, esp. psychoactive agents

Question 18

OBRA Meds regulation

Answer 18

• requires MONTHLY evaluation of meds by a pharmacist
• NO unnecessary drugs can be given— those are defined as those given
• in excessive doses
• for excessive periods of time
• without adequate monitoring
• Without adequate indications for use

Question 19

For psychoactive meds, gradual dose _______ are mandated unless a clinical contraindication exists and is documented in medical record

Answer 19

Reductions

Question 20

The minimum data set

Answer 20

• periodic comprehensive clinical assessment of all residents
• is used to compile nursing facility quality measures!- things like pain, pressure ulcers, weight loss, depression, restraint use

Question 21

Nursing home legislation

Answer 21

• “f-tags”- federal regulations given this tag number
• adherence to regulations assessed every 15 months
• failure to meet them cited in a “deficiency”- with penalties imposed based on severity

Question 22

Major challenges of nursing home care

Answer 22

• necessitating individualized approaches to care (no everyone is the same)
• atypical and subtle illness presentation
• limited technology
• lot of cognitive impairment]
• keeping families involved and informed
• ethical and legal concerns
• a LOT of regulatory oversight

Question 23

How to enhance nursing home satisfaction

Answer 23

• structure visits into their schedules
• Work together with whole medical team
• Document rationale behind EVERY med

Question 24

Physician Responsibilities in Nursing home care

Answer 24

• COMPREHENSIVE ADMISSION ASSESSMENT
• develop care plan
• Periodic monitoring of chronic conditions
• prompt attention to acute issues
• communicate with entire team
• periodic review of meds!
• optimize quality of life and function
• determine resident’s decision making capacity

Question 25

Strategies for enhancing quality of care

Answer 25

• specific consultation services, for example efforts to reduce falls
• Interactive educational programs
• Discussions with residents about preferences for care!

Question 26

Role of medical director

Answer 26

• set quality standards
• Ensure compliance
• Work with administrator and director of nursing to ensure effective team care

Question 27

Which of the following is true of medicare coverage?
A. medicare covers physical therapy in rehabilitation facilities but not in nursing facilities
B. Medicare may cover therapy in a nursing facility but only after a 3-day hospital stay
C. Medicare covers only the first 30 days of nursing-home care
D. Medicare may cover therapy if he stays in the hospital but not if he is discharged home

Answer 27

B

Question 28

What is the certification board used for medical directors in nursing homes

Answer 28

American Medical Directors Association (AMDA)