12. Long-Term Care

Question 1

what is long term care? how many people use it?

Answer 1

refers to the entire continuum of care that ranges from receiving in-home help with daily tasks to institutionalized care
- 93% of older people are able to live in their own home
- 25% of which use in-home assistance (home care)
- 3% are in assisted living
- 4% are in nursing homes (long term care)

Question 2

what is home care?

Answer 2

• broad array of medical and social services that are available to people who are still living in their own homes
• are provided by health care professionals, paid caregivers, and volunteers
• large percentage of home care is informal (13%), provided by family or friends

Question 3

what are some benefits of home care?

Answer 3

• maintained sense of identity
• maintained sense of control and autonomy
• familiarity of surroundings and community
• prevention or delay of institutionalization
• more cost effective for the government

Question 4

who is government funded home care used by most often?

Answer 4

those who:
- are single
- have lower income
- have more physical limitations
- had a recent hospitalization

Question 5

what is assisted (supported) living?

Answer 5

provide government regulated housing with a supportive environment to adults who…
- have physical and functional health challenges
- can live independently (but not unaided)
- can make decisions on their own behalf (are fine cognitively)

Question 6

what are the three ideal attributes of an assisted living facility?

Answer 6

1. physical space has a residential appearance/feel
   
   • provides personal space (full private bathroom)
   • access to shared indoor and outdoor spaces
2. “care” provided to promote normal lifestyle of resident
   
   • understanding of residents’ personal preferences and priorities
   • allows residents to have control, choice, dignity, and autonomy
3. meeting residents’ routine services and special needs
   
   • assistance with activities of daily living
   • meal provision
   • 24 hour assistance if necessary

Question 7

what contributes to greater well being after a transition to assisted living?

Answer 7

• greater control over transition
• design of facility and services optimizes person/environment fit
• smaller sized facilities
• positive co-resident relationships
• co-residents with similar levels of functioning
• few residents with high levels of frailty
• frequent family contact
• moving from a hospital or other assisted living facility (not moving from home)

Question 8

how are retirement homes paid for?

Answer 8

• also called independent living
• completely paid out of pocket
  
  • around 5,000 a month, 60,000 a year
• have to pay extra for assisted living services

Question 9

what are nursing homes?

Answer 9

• government regulated medical institution that provides a room, meals, skilled nursing and rehabilitative care, medical services, and protective supervision
• provincial and federal legislations establish a minimum level of care
• residents have multiple health conditions and/or moderate/severe cognitive impairment (dementias)
  
  • often extremely frail
• temporary residents include those recovering from major injuries, illness, or surgery

Question 10

how can nursing homes be made to feel more like home?

Answer 10

• individuals given time and voice in the placement decision
• defining home predominantly in terms of family and social relationships
• developing continuity between home and nursing home through activities and living arrangements

Question 11

what is elder abuse?

Answer 11

includes physical, sexual, and psychological abuse; financial exploitation; neglect; violation of rights

Question 12

what are the attitudes condoning elder abuse due to?

Answer 12

• role conflict, role ambiguity & work overload predict burnout
• attitudes condoning abuse predicted by burnout, role conflict, & role ambiguity

Question 13

what is the traditional medical model for nursing homes?

Answer 13

• hierarchical
• focused on physical needs
• routines for residents and front-line workers
• efficient, standardized, cost-drive, rule-compliant focus
• residents often isolated from family and community

Question 14

what would a culture change for nursing homes entail?

Answer 14

• voices of residents and carers respected
• focused on emotional needs
• enables continued growth
• treat everyone as individuals
• restructuring of staff roles and responsibility
• encourages connections to family and community

Question 15

what are the key principles of the eden alternative of nursing homes?

Answer 15

• close and continued contact with plants, animals and children
• daily life that includes variety and spontaneity
• maximizing decision making by elders and their families
• creating an elder-centred community focused on the well-being of elders and workers

Question 16

what has research on the eden alternative found?

Answer 16

findings suggest that there is …
- less helplessness and boredom
- similar levels of loneliness
- less use of antidepressants, anxiolytics, pressure sores
- lower infection rates and mortality
- less staff to staff interaction, greater feelings of responsibility, feeling confined to assignments

Question 17

what did a meta-analysis on for-profit and not-for profit nursing homes find?

Answer 17

40 favoured not-for profit while 3 favoured for profit
not-for profits had…
- more staffing or better quality staffing
- fewer regulatory deficiencies
- patients with fewer pressure sores
- less use of physical restraints
remaining 37 had mixed results

Question 18

what do the effects of for profit and not-for profit nursing homes depend on?

Answer 18

• for-profit: investor owned corporations (large) vs. small businesses
  
  • motivations may be different
• not-for profit: municipality vs. charity run
  
  • different structure and process
• effects vary by management styles, motivations, and philosophy

Question 18

how do people pay for nursing homes?

Answer 18

facility based long-term care is not covered by the Canada Health Act
- residents are required to pay out of pocket
- costs vary widely by province
- costs vary widely by type of ownership and model of care
- in BC, the monthly rates are capped at 80% of the senior’s net income, subject to minimum maximum
- everything is covered from meals to medication

Question 19

how do the number and type of people in nursing homes change as they age?

Answer 19

• few individuals living in nursing homes until we reach around 80
• there are more women living in nursing homes compared to men, sex differences increase as we age
• overall, about 4% of seniors live in nursing homes in Canada

Question 20

how will the prevalence of people in long term care and funding change?

Answer 20

• by 2051, almost 25% of older adults will be 85 or older and there will be an increase in demand for long term care
• projected costs of public care in nursing homes and private homes will triple between 2019 and 2050
• baby boomers will age and fertility rates decline, there will be much more pressure on family members (usually women) to provide unpaid care

Question 21

what are community based services?

Answer 21

• individuals live independently at home but still use some support services
• with appropriate services, older adults can remain in their own homes, or at least in their own communities
• assistive technology advances can also benefit older adults living at home

Question 22

what are alternate level of care patients?

Answer 22

• patients that reside in hospitals but no longer need such a high level of care
• are simply waiting for a long‐term care bed
• lack of home care leads to more people waiting for long term beds

Question 23

what are adult day programs?

Answer 23

• for adults who need assistance or supervision during the day
• they receive a range of services in a setting that is either attached to another facility or is a stand‐alone agency
• can also count as respite care to provide family caregivers with a break while allowing the older adult to receive needed support services

Question 24

how do the lack of long term care facilities affect the first nations community?

Answer 24

- shortages are particularly acute in First Nations communities - first nations people are forced to move away to attend long-term care facilities - leaving the community deprives the younger people of the support, advice, and knowledge of Elders

Question 25

how and why do nursing homes overuse psychotropic medications?

Answer 25

- overuse psychotropic medication to control disruptive behaviour and treat mood disorders - these drugs can have serious side effects, including over-sedation, orthostatic hypotension, and movement disorder - makes them more susceptible to falls - overuse of psychosis medication and physical restraints is decreasing - other interventions require more staff, additional training for staff, and a greater institutional commitment to person‐centred care

Question 26

how can we enhance the process of relocation to a long term facility?

Answer 26

1. prepare and educate about transition process 2. complete and timely written and verbal communication across settings as individuals move from one care setting to another 3. an evaluation of individuals’ and caregivers’ personal preferences and goals 4. strong interprofessional collaboration among team members 5. the use of existing evidence‐based models of care to inform the relocation process

Question 27

what is the competence press model?

Answer 27

- predicts an optimal level of adjustment that institutionalized persons will experience - adaptation happens when their levels of competence match the demands, or “press,” of the institutional environment - qualities of the individual, psychological and physical, can range from low to high in competence - individual who is intellectually competent is best adapted in a highly stimulating environment

Question 28

how is the quality of nursing homes determined?

Answer 28

- there are requirements that nursing home operators must meet in order to keep their operating licences - recommendations made by the accreditation team are implemented prior to the next survey - provincial initiatives also aim to improve the quality of care

Question 29

what are some suggestions for improving long-term care?

Answer 29

- behavioural methods should be used more often, instead of more medications - these interventions help residents maintain self-care and independence - also improves staff-resident relationship - designing the institution less like a hospital can be beneficial - instead of assignment tasks to staff members, we should assign staff members to help with any of the needs of particular residents

Question 30

what is the greenhouse model of nursing homes?

Answer 30

- offers older adults individual homes within a small community of 6 to 10 residents and nursing staff - designed to feel like home - residents in these facilities are more likely to engage in social interaction than residents of traditional long‐term care facilities

Question 31

what is a surprising finding of the relationship between the greenhouse model and levels of depression?

Answer 31

- one study identified an increase in social interaction and in depressive symptoms - perhaps due to greater recognition of these symptoms in the open‐plan setting