Nursing Home Care Flashcards
1
Q
2 MC kinds of institutional long term care?
A
- nursing homes
- assisted living
2
Q
What is a skilled nursing facility?
A
- house persons requring care and supervision of a skilled nurse
- licensed and regulated by state agencies with considerable federal control through medicare and medicaid guidelines
- admission is based on case by case basis
- mostly staffed w/ CNAs
- few licensed nurses are present to conduct assessments, distribute meds, supervise CNAs, communicate w/ providers, and admin tx
3
Q
What are assisted living facilities?
A
- diverse
- can include small “mom and pop” homes caring for as few as 2 residents
- clusters of small homes w/ central admin
- larger freestanding facilities that look a lot like nursing homes
- buildings or wings w/in multilevel campus
4
Q
Characteristics of long term care residents?
A
- tend to be old, sick, poor and alone
- mean age: 78-85
- alzheimers
- multi-infarct dementia
- severe chronic heart disease
- amputation
- COPD
- widows
- no kids
- low income
5
Q
Diff in short and long stay care?
A
- short stay: for terminal care or rehab
- ## long stay: primarily medical problems, dementia
6
Q
Who pays for nursing homes?
A
- after medicare runs out:
47% medicaid
45% private pay
7
Q
Who pays for assisted living?
A
- neither medicare nor medicaid pays for most assisted living
- ends up private pay
8
Q
Job of the medical director?
A
- reqd for all SNFs
- ensures provider care, addresses legal and medical needs
- quality improvement
- committees susch as infection control, pharm, and utilization review
- reviews incident reports
- assists w/ development of policies and procedures for residents and staff
- oversees health program for employees
- conducts educational programs for employees, residents and families
- acts as spokesperson for facility in community and w/ regulatory and other health care agencies
9
Q
What does function oriented care mean?
A
- maximize what each pt can do independently
- rehab mind set
- assessment and care plan for fxnl status, establish prognosis, identify specific fxnl objectives and time frame to accomplish these
- monitor fxnl status improvement, preventing iatrogenic consequences
- plan a d/c date if possible - when not likely, strategies to maintain fxnl status should be developed
10
Q
Are use of restraints helpful?
A
Not really
- increase agitation
- rarely prevent falls or injuries
- constitute an unjustified infringement on resident autonomy
- types of restraints:
vest, wrist, ankle, chairs w/ locking lap trays, wrist restraints, safety belts, bed rails
11
Q
Alternatives to restraints?
A
- increased involvement for residents in structured activities
- assisted daily ambulation, regular toileting
- active listening
- therapeutic touch
- behavior modification
- search for physiologic causes of agitation: pain, constipation, infection
- recliner chairs
- carpeted floors
- lower beds
- motion detectors and position monitors
12
Q
Why are long term care residents considered medically underserved pop?
A
- lack personal relationships and individualized attention that characterize the best primary medical care
- logistics of traveling to long term care facility
- decisions are made via telephone
- medicare and medicaid reimbursements are low
- high resident and staff turnover
13
Q
Upside of having a resident w/ an involved family?
A
- tend to receive more staff attention and have medical problems detected earlier
14
Q
Provider’s role in taking care of pt in longterm care and dealing w/ the family?
A
-take time to meet w/ family
- anticipate future events and discuss in advance w/ family
- learn as much as possible about family dynamics, anticipate conflicts - on admission, when there is a major status change
- advanced directives
- don’t resucitate
- end of life measures
- withholding txs:
feeding tubes, abx for fever, whether to hosp. or not
15
Q
PA reimbursement in skilled nursing facility and nursing facility?
A
- all services PA is legally authorized to provide that would have been covered if provided personally by a physician
- reimbursement rate:
85% of physician’s fee schedule
16
Q
What are common infections in long term care settings?
A
- pneumonia
- urosepsis
17
Q
What is a common musculoskeletal disease in long term care settings?
A
- arthritis - manage w/ mobilization and acetaminophen (not NSAIDs)
18
Q
Why do falls and pressure sores occur? What should be assessed? Tx for pressure sores?
A
- reduced mobility leads to both falls and pressure sores
- assess cognitive status:
risk assessment, skin care, frequent turning and positioning, special beds, and mattresses - early tx for pressure sores:
protection from further pressure, shear and friction, debridement of necrotic tissue, maintenance of moist wound environment, protection from secondary infection, adequate nutrition
19
Q
Causes of constipation in long term care settings?
A
- polypharm: antacids anticholinergics TCAs CCBs NSAIDs benzos neuroleptics - decreased physical activity - immobility - decreased oral intake - decreased dietary fiber intake - dehydration - loss of fxnl status - normal aging changes involving decrease gastric motility and peristalsis
20
Q
Tx for constipation?
A
- exercise
- hydration
- stool softeners
- bulk laxatives
- drug changes
21
Q
Why is there usually sig wt loss in longt term care settings?
A
- depression
- meds
- cancer
- swallowing disorders
- poor fitting or absent dentures
- advanced dementia
22
Q
Tx for wt loss?
A
- monitor food and fluid intake
- weigh pts at least once a month
- look for reversible causes
- simple form of diet:
soft diet, pureed, adequate staff time to assist pt w/ eating
23
Q
Impt health maintenance in pts in long term care settings?
A
- all new and prospective residents need to be screened for TB: 2 step (rules out booster phenomenon in the future)
- all pts should get flu vaccine, medical eval: hx, physical, and lab tests based on eval, routine lab assessment isn’t recommended
24
Q
What is the booster phenomenon?
A
- in PPD testing: occurs when person’s immune system has forgotten about an infection by mycobacterium tb until yrs later when the person is tested again for TB - PPD test reminds the immune system about the infection
- although initial TB test was negative, a 2nd TB test performed yrs later, may boost the immune system’s inability to react to tuberculin
- therefore no way of knowing if positive TB test result was due to recent TB infection or due to TB booster phenomenon
25
Why is home care so impt?
- bc overall goal of good geriatric medical practice is to maintain older persons in the familiarity, comfort and dignity of their own homes for as long as possible
26
What are the reasons for home care?
- aging society
- family caregivers provide 80% of care
- pressure to contain overall health care costs
- DRGs: shortening the period of an inpt convalescence
- managed care and health maintenance organizations have encouraged the use of home care as an alt to hospitalization
27
Why did home care decrease in 1997?
- concerns about growing medicare budget
- misuse of home care
- marked regional variation in utilization
- insufficient datat regarding return on investment
- medicare reset home care payments to 1994 stds - lower reimbursement
- restricted the avg number of reimbursable visits per pt
28
What techniques are available for better home care if families are willing to help provide care?
- infusion pumps
- dialysis units
- ventilators
- O2 concentrators
- monitoring systems
- it is expected that home care will continue to grow
29
What is the criteria for selecting pts for home care?
- clinical stability
- caregiver support
- appropriate enviro
- availability of professional services
- financial support: poorly covered at present by medicare and other insurers, self pay costs need to be est b/f initiating home care
30
Health care involvement w/ home care?
- physician must sign initial plan and any subsequent orders in timely manner
- physician must exercise medical judgement and supervision of care
- nurse clinicians and other home care professional, in consultation w/ provider, provide much of the in home assessment and hands on care of pts
- if possible, provider also personally performs assessment periodically at home
31
PA reimbursment for home care?
- all services PA is legally authorized to provide that would have been covered if provided personally by a physician
- reimbursement rate: 85% of physician's fee schedule
32
What does a provider perform during the "house call"?
- H and P
- counsel to pt and family
- med review
- nutritional screening
- assessment of enviro
- assessment of caregivers
- home support devices (safety)
- obtain specimens
33
Benefits of home care?
- improve desired outcomes of care
- medical legal actions involved in home care visits are almost non-existent
- still must be aware of medical liability
- appropriate risk management
- informed consent
- good communication
- documentation of care in medical record
34
Regulatory and coverage issues w/ home care?
basic entry criteria for medicare home health care:
- pt must be homebound
- leaving home must reqr assistance and considerable effort
- pt must reqr intermittent skilled care ordered by provider:
nurse visits
PT
ST
home health aide
35
Medicaid coverage of home care?
- varies b/t states
- all states provide some level of both skilled and custodial community services to pts who meet the medical and income criteria
- for geriatrics who have both medicare and medicaid, skilled services are covered by medicare, personal or custodial care is covered by medicaid
- both medicare and medicaid pay for certain types of home medical equipment
