Long-term care, terminal care, and rehabilitation

Question 1

Terminal care - stats

Answer 1

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)

Question 2

Terminal care - symptom control

Answer 2

pain: morphine
agitation: midazolam, levomepromazine
N&V: levomepromazine
SOB: morphine, midazolam
secretions: hyoscine butylbromide

Question 3

Long-term care - epidemiology

Answer 3

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

Question 4

Long-term care - socioeco policy

Answer 4

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

Question 5

Long-term care - residents

Answer 5

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

Question 6

Long-term care - delivery

Answer 6

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

Question 7

intermediate care - BG

Answer 7

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

Question 8

interim care

Answer 8

waiting for POC or placement, or delayed community care

temporary bed or RH placement

Question 9

intermediate care - d/c planning

Answer 9

expected date set at initial assessment
who and what needed
early referrals e.g. social work (section 2 and 5)

Question 10

intermediate care - preventing admission

Answer 10

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

Question 11

intermediate care - aims

Answer 11

prevent admission
early d/c (reduces stay length)
prevent premature LT care placement

Question 12

intermediate care - referral criteria

Answer 12

from GP or hospital
ongoing health and social care (need)
achievable goals (benefit)
consider Barthel index (pre-, post-morbidity, and 1/52 later;

Question 13

intermediate care - discharge options

Answer 13

rehab ward
home +/- POC (up to 4/d, up to 2 carers)
care home placement

Question 14

long-term care: common issues and solutions

Answer 14

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

Question 15

rehabilitation process

Answer 15

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

Question 16

restorative rehab

Answer 16

return to optimum function

rehab therapies, reduce barriers
information giving
skills training
goal-setting and encouragement
behaviour change

Question 17

adaptive rehab

Answer 17

mitigate effects, improve coping

information giving
goal-setting and encouragement
aid/appliances, adaptations

Question 18

rehab levels

Answer 18

3: non-specialised, for non-specific decline, primary/GP; ADAPTIVE
2: local specialised rehab
1: specialised (trauma/rehab), tertiary/specialists; RESTORATIVE

Question 19

rehab settings

Answer 19

community vs. hospital
primary vs. secondary
acute vs. less acute

intermediate care at home or RH
community stroke team
day hospital

Question 20

rehab teams

Answer 20

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

Question 21

rehab challenges

Answer 21

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

Question 22

rehab barriers

Answer 22

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)