Long-term care, terminal care, and rehabilitation Flashcards
Terminal care - stats
500,000 deaths per year
54% of complaints
approx 55% prefer home, approx 20% actually die at home (25% cancer pt)
approx 25% prefer hospice, 5% actual (20% cancer)
approx 10% hospital, actual 60% (45% cancer)
approx 5% nursing home, actual 15% (10% cancer)
Terminal care - symptom control
pain: morphine
agitation: midazolam, levomepromazine
N&V: levomepromazine
SOB: morphine, midazolam
secretions: hyoscine butylbromide
Long-term care - epidemiology
formal care: ^age, women, living alone
F>M population and care population >65yo
living alone: ^#population, ^institutionalisation risk
60yo: 20%M 45% F
80yo: 35%M 65% F
formal care locations: home > institution
spending:
EU15: 7.6% health, 9.1% pensions; mostly instiutions
England LTC: 50:50 formal:institutions; 1.2% GDP
private england: 0.5% GDP, 85% institutional
Long-term care - socioeco policy
means-tested funding: 23,000 (assets includes property)
25% require 3rd party help
monitoring standards: CSA 2000, CQC 2008
38 minimum standards
review websites
home inspections: environment, care, daily life, complaints, management/staffing
Long-term care - residents
cognitive impairment: 50-75%
urinary incontinence: 50-75%
mobility issues (chair/bed bound): 25-50%
multiple diagnoses and medications: average 6.2 Dx, median 8 meds
behavioural Sx: 67%
malnutrition: 30% malnourished, 56% at risk
life expectancy: 1y in NH, 2y in RH
Long-term care - delivery
roles: managing multiple diagnoses and comorbidities incl. behaviour
reviewing and improving polypharmacy
nutrition: prevent and treat
end-of-life care
CGA improves outcomes
CH manager, GP, SW, PT/AT
problem list: linked/co-dependent Dx, patient priorities
intermediate care - BG
time limited: 4-6 weeks
setting: hospital, home, community, rehab, bespoke facilities, NH/RH
team: physio, OT, rehab, MH, SW, SALT, GP/specialist/Drs: TTOs (d/c), GP referral to community, phone GP (plan), capacity, coordinate MDT, consult family/services
interim care
waiting for POC or placement, or delayed community care
temporary bed or RH placement
intermediate care - d/c planning
expected date set at initial assessment
who and what needed
early referrals e.g. social work (section 2 and 5)
intermediate care - preventing admission
community matrons: care and monitor for deterioration
self-care, family, neighbours
GP and RRT (rapid response)
walk-in centers, NHS 111
ED d/c team (acute frailty units, RR frailty team)
emergency social care (assess home and need)
voluntary services
intermediate care - aims
prevent admission
early d/c (reduces stay length)
prevent premature LT care placement
intermediate care - referral criteria
from GP or hospital
ongoing health and social care (need)
achievable goals (benefit)
consider Barthel index (pre-, post-morbidity, and 1/52 later;
intermediate care - discharge options
rehab ward
home +/- POC (up to 4/d, up to 2 carers)
care home placement
long-term care: common issues and solutions
multiple illness; unpredictable course
lack of training, resources, and funding
unclear roles/responsibilities of MDT members
communication between patients, and services
variable access to care (esp. financially)
remuneration
regulation
staffing
rehabilitation process
body functions and structures: therapy, barriers, info and skills
capacity/ability: aids, adaptations; goal-setting, encouragement, behaviours
activity, environment, and personal factors
participation: co-operation, assistance, legal/societal
restorative rehab
return to optimum function
rehab therapies, reduce barriers information giving skills training goal-setting and encouragement behaviour change
adaptive rehab
mitigate effects, improve coping
information giving
goal-setting and encouragement
aid/appliances, adaptations
rehab levels
3: non-specialised, for non-specific decline, primary/GP; ADAPTIVE
2: local specialised rehab
1: specialised (trauma/rehab), tertiary/specialists; RESTORATIVE
rehab settings
community vs. hospital
primary vs. secondary
acute vs. less acute
intermediate care at home or RH
community stroke team
day hospital
rehab teams
community stroke rehab, falls teams care homes and intermediate care GP, community geriatrician CMHT, community matron, community dietetics, community SALT, OT, PT social work LT condition nurses Macmillan/Marie Curie nurses
rehab challenges
integrating services: IP, and d/c to rehab schemes
case management failure
inflexible care pathways
lack of key performance indicators (?stay, readmission, function at d/c, mortality)
‘managed decline’ role
rehab barriers
inadequate assessment
inadequate resources
inadequate management (e.g. contractures, bed sores)
depression
physical co-morbidities (HF, UTI, RTI, DVT/PE, metabolic, pain, constipation)
iatrogenic (polypharmacy, stop/start meds)
