Lecture 1- Long term care Flashcards
The nursing home population characteristics
- Impairment in decision making- the big one!
- Need assistance with 3+ ADLs
- Dementia
- Orientation/memory problems
- communication problems
- bowel/bladder incontinence
Demographics of nursing home population
- 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
Average beds in a nursing home
About 100
Are most nursing homes for profit, non-profit, or government run?
FOR PROFIT!
Postacute care services in long term care facilities
- dialysis
- Orthopedic care
- Ventilators
- Post-op care
- Rehab care
- Wound care
- this is a big need- lower hospital stay lengths, but higher care needs
the vast majority of nursing home stays are for how long
Greater than 80% stay for longer than 90 days but less than 3 years
What is the majority funder of nursing home care?
Medicaid!- 65%
What qualifications do you need to have to get medicare to pay for nursing homes
- 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
What percentage of nursing homes are chains?
about half
Staffing issues with nurses
- 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
Staffing issues with doctors
- 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
Staffing issue- culture
- 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
Risk factors associated with nursing home placement
- increased age
- Low income, low social activity
- poor family supports
- accepting attitude toward nursing homes
- cognitive/functional impairment
Nursing home residents have high rates of hospitalization, most commonly due to __________
Infection
Issues with information transfer
- missing or illegible transfer summaries
- Omission of prescribed medications
- Advance directives not documented
- Psychosocial and behavior issues are not reported
INTERACT - Interventions to reduce acute care transfers
- 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%
Omnibus Budget Reconciliation Act (OBRA)
- 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
OBRA Meds regulation
- 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
For psychoactive meds, gradual dose _______ are mandated unless a clinical contraindication exists and is documented in medical record
Reductions
The minimum data set
- 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
Nursing home legislation
- “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
Major challenges of nursing home care
- 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
How to enhance nursing home satisfaction
- structure visits into their schedules
- Work together with whole medical team
- Document rationale behind EVERY med
Physician Responsibilities in Nursing home care
- 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
Strategies for enhancing quality of care
- specific consultation services, for example efforts to reduce falls
- Interactive educational programs
- Discussions with residents about preferences for care!
Role of medical director
- set quality standards
- Ensure compliance
- Work with administrator and director of nursing to ensure effective team care
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
B
What is the certification board used for medical directors in nursing homes
American Medical Directors Association (AMDA)
