Hospital Care, Health Services, Long-term care Flashcards
(96 cards)
1
Q
Almost what percent of people 65 years of age or older are hospitalized each year in the US
A
20%
A rate nearly 4x of general population
2
Q
what is a common and feared complication of hospitalization of older adults
A
Hospital-associated disability
3
Q
7 pt goals of hospital care
A
- Different pt have different goals - “Can you tell me about what you would like us to accomplish while you are in the hospital?”
- Prolong Survival
- Relieve sx
- Maintain/Regain Ability to Walk or Care for self
- Avoid Institutionalization
- Reassurance
- Comfort and Peace When Dying
4
Q
goal of care of hospital care
A
To maintain and promote the patient’s independent function in the hospital and at home after discharge
5
Q
How to design and implement strategies to achieve the goals of hospital care
A
- Requires a team w/ expertise in multiple domains:
- rehab
- pharm
- social and community resources - Although physicians have the expertise to treat illness, nursing, social work, and therapy expertise are also required
6
Q
comprehensive assessment in hospital care
A
- Hospitalized older adults require a comprehensive assessment of their physical, cognitive, psychological, and social functioning - in addition to problem-focused assessment
- Perform Cognitive and psychological assessment - Mental status and affect
- Note Mobility & ADLs prior to onset of acute illness & at admission
- Assess Social functioning - Check for Social isolation, loneliness, lack of social supports; determine need for in-home support services, meals, and transportation assistance
7
Q
Factors that can contribute to a hostile environment in a hospital
A
- Bed rest and low mobility are major contributors to functional decline
- Crowded hospital rooms
- Slick polished floors
- Lack of access to adaptive devices (walker, cane, eyeglasses)
- Attachment to IV poles, oxygen tubing, caths, cardiac monitors
-
Undernutrition is another factor
- Up to ¼ of hospitalized older adults receive less than 50% of daily protein-energy intake
- NPO status, poor appetite, unappetizing diet - In-hospital drug adverse event
8
Q
T/F: Even short periods of bed rest can result in significant loss of muscle mass and strength
A
T
9
Q
Complications of Geriatric Hospitalization
A
- ADLs
- bed rest/immobility
- psych
- medication issues
- undernutrition/malnutrition
- UI
- pressure ulcers
10
Q
New ADL deficits occur in as many as what % of pts how old admitted to an acute care hospital from the community
A
30% of patients 70 years of age or older who are
11
Q
complication from bed rest/immobility?
A
Loss of muscle mass and strength
1 day in bed = 3 days to recover/ regain strength
12
Q
factors contributing to bed rest/immobility
A
- Difficulty transferring independently from bed
- “Fall risk”
- Use of restraints
- Lack of access to assistive devices (e.g., cane, walker)
- Attachment to external devices (e.g., IV pole, urinary catheter, oxygen tubing)
- Lack of encouragement to get out of bed
13
Q
preventives for bed rest/immobility
A
- reduce fall risk: assistance with ambulation and transferring, nonslip socks/surfaces, asssistive devices and handrails
- remove unnecessary catheters
- promote mobility: OOB for all meals, ambulate 3-4x/d, order PT, low beds and raised toilet seats
14
Q
psych considerations that contribute to hazards of hospitalization
A
- feel worthless, fearful, and a sense of loss of control
- Increased risk of acute care related delirium - Can persist for days to weeks after discharge from an acute hospital stay
15
Q
preventives of psych problems from hospital care
A
- frequent assessment of sx
- avoid deliriogenic meds/devices - BZD and anticholinergics, restraints, catheters
- appropriate lighting
- promote mobility
- hearing/visiona adaptations - glasses/hearing aids, good lighting and nightlights, closed captioning on TV
- promote healthy sleep - avoid extra vitals/labs at night, turn deeping into vibration
- promote orientation - calendars and clocks
16
Q
medication issues that contribute to the hazards of hospitalization
A
- Polypharmacy - Results in ADR’s, increased risk of falls, prolonged use of multiple drugs
- Increased risk of ADR’s - Approx.10%-15% of older patients experience an in-hospital adverse drug event
17
Q
preventives for medication issues in the hospital?
A
frequent review of medical care plan
- review meds for efficiacy and appropriateness
- review SE and DDI
- review age/dz appropriate dosing
18
Q
factors that contribute to undernutrition & malnutrition
A
- NPO orders
- Poor appetite
- Unappetizing or unfamiliar diet
- Lack of access to dentures
- Difficulty in self-feeding
19
Q
preventives for undernutrition/malnutrition
A
hydration + nutrition
- Avoid unnecessary NPO
- Order the least restrictive diet possible
- Add nutritional supplementation
- Ask caregivers to bring in dentures
- Encourage companionship
- Provide assistance with meals
20
Q
factors that contribute to UI
A
- Loss of independent ambulation to restroom
- Lack of assistive toileting devices - bedside commode, raised toilet seat
- Use of adult diapers
- Urinary catheter placement - Damage to detrusor muscle with foley insertion, Loss of normal bladder contractions, Increased risk of infection
21
Q
preventives of UI in the hospital
A
healthy toileting
- Promote mobility
- Utilize assistive devices
- Schedule voiding while awake
- Avoid diapers and catheters
22
Q
Only takes how much time of not moving for oxygen reduction to the bone to the skin
A
2 hours
23
Q
factors that contribute to pressure ulcers in the hospital
A
- not moving for 2h
- Loss of independent ambulation and position changing
- adult diapers
- Poor nutrition = reduced skin integrity
24
Q
Poor nutrition leads to what 3 things that contribute to pressure ulcers
A
- altered immune function
- impaired collagen synthesis,
- decreased tensile strength (Wound Care Advisor)
25
preventives of pressure ulcers in the hospital
maintain skin integrity
* Daily skin assessment
* Promote mobility
* Position change every 2 hours
* Avoid diapers
* Maintain nutrition
* Use pressure reducing bedding
26
key components of hospital care
1. Patient and caregiver **engagement**, starting at admission
1. **Early identification** of post discharge care needs
1. Use of **interprofessional teams** to properly address needs throughout the hospitalization, as well as after discharge
1. **Invested time and resources** to improve patient understanding about the reasons for admission and what is required to manage their health at discharge
- Inform patient and caregiver of signs/symptoms that need intervention
- Inform patient and caregiver of who to contact for questions
1. Special attention to **medication reconciliation** and **patient instruction**
1. Enhanced **communication** between inpatient and outpatient clinicians
27
Prevention of Complications of hospital care
***Many complications can be prevented!!***
1. Need a dedicated effort to maintain patient **mobility** in the hospital
1. Clinicians should set **walking expectations** early for each patient and **assess compliance daily**
1. Although symptoms and **fear** of injury may limit some patients, most are motivated by avoiding functional decline and simply being asked to walk
1. Clinicians should treat **pain** that may be inhibiting mobility
1. Ensure **assistive devices** are available with appropriate training
1. **Remove unnecessary tethers** such as bladder or intravenous catheters, O2 lines, and cardiac monitoring
1. Unnecessary bladder catheters, in addition to causing iatrogenic infection and limiting mobility, are associated with increased **delirium** risk
1. Delirium is preventable in many patients with simple prevention measures
28
what is the Hospital Elder Life Program (HELP)
* Taken over by American Geriatric Society
* GOAL: **Prevent delirium** in older hospitalized adults
* Strategy: **Implement mobility, cognitive, sleep, and nutrition protocols** on general medical wards throughout the hospital
* Evidence: Trials show a 33% reduction in the incident of delirium and improvements in severity and duration in those who do develop delirium
29
6 factors that the HELP model promote
1. quiet environments
2. improve cognition
3. nonpharm sleep
4. hydration and nutrition
5. early mobility
6. hearing vision adaptions
30
what is the Acute Care for Elders (ACE) Model
* GOAL: **prevent functional decline and improve the quality of care** during acute hospitalization - go home with same ADLs they came in with
* Uses **comprehensive geriatric assessment** and **interprofessional team-based care** - combo of geriatrician, geriatric nurses, geriatric trained staff, rehabilitation specialists and pharmacist
* STRATEGY: Develop **pt goals and to prevent common complications** - Deconditioning, cognitive decline, nutritional decline, polypharmacy
31
8 factors that the ACE units promote
1. mobility
2. healthy sleep
3. good nutrition
4. continence
5. orientation
6. inclusion of pt in POC
7. frequent review of med care plan
8. skin integrity
32
indications for indwelling catheter
* Urinary retention - Causing persistent overflow incontinence, symptomatic infections, or renal dysfunction; Cannot be corrected surgically or medically; Cannot be managed practically with intermittent catheterization
* Urinary incontinence - One of MC reasons for inappropriate catheters; Following failure of conservative, behavioral, pharmacologic, and surgical therapy
* Monitoring I&O’s
* Immobilized
* Avoid overdistension in surgical patients (ex: pts in long surgery)
* Intravesical pharm therapy - Bladder cancer, medication straight to bladder
* End of life care
33
The 2 most inappropriate indications for a urinary catheter
* Urinary incontinence that has not failed other managements
* Obtaining a urine specimen for testing in a patient capable for voiding spontaneously or reliably
34
CI of indwelling cath
1. Absolute CI - Urethral injury
2. Relative CI’s - consult urology
- Urethral stricture
- Recent urinary tract surgery
- Presence of an artificial sphincter - Helps treat incontinence
35
risks of indwelling cath
* **Iatrogenic infections - MCC of iatrogenic infections**
* Limits mobility → complications of immobility
* Bladder stones - Bacteria attached, form a film, start to secrete proteins/crystals, calcium and struvite can attach and form stone
* Bladder cancer with long term use (>10 y) - Causes chronic state of inflammation
36
alternatives for indwelling cath
1. Behavioral Interventions
- Bladder training - Kegel exercise, bladder diary (lengthening or shortening voiding intervals)
2. Scheduled/prompted toileting
- q2ham and q4hs
- Adjunctives to stimulate void - Running tap water, stroking the inner thigh, or suprapubic tapping
- Adjuncts to facilitate complete emptying of bladder - Large prostates, anything that leads to retention; Bending forward after completion of voiding
3. pharm
- Antimuscarinics: oxybutynin, tolterodine, darifenacin
- β-3 agonist: mirabegron
- α-Adrenergic blockers (BPH): Tamsulosin
4. surgery
37
SE of Antimuscarinics
MC dry mouth and constipation; Higher risk in elderly **decreased cognition**, dizziness/drowsiness
38
which medication as an indwelling cath alt
Doesn’t have anticholinergic SE
Much more expensive
β-3 agonist: mirabegron (Myrbetriq)
39
SE of Tamsulosin
orthostasis, dizziness
α-Adrenergic blockers in men with BPH
40
indications for surgery as an indwelling cath alt
* Indicated in patients who have failed more conservative measures
* Sling or bladder neck suspension in women
* Anatomic repair, prostatic resection if obstructing
41
with DC planning to long term facility, what must you consider?
* What are the patient goals?
* What types of care are most likely to achieve the primary goals for this patient?
* Does the patient need care in such a long-term or rehab setting and cannot reasonably get such care elsewhere?
* Having chosen the modality, what vendor can best provide those services?
* Is the patient prepared for the transfer to such a facility?
42
DC planning checklist includes what sections (6)?
1. pt and family ed
2. meds
3. functional status/home environment alignment
4. cognitive status/home environment alignment
5. medical equipment
6. FU and communication with primary provider
43
Discharge Orders (to someone assuming care)
* Admission Date:
* Discharge Date:
* Discharge To: Home or other location
* Diagnosis at Discharge: Both new and chronic conditions
* Condition at Discharge: (stable, fair, serious, critical, etc.)
* Discharge Medications: Meds and details (dose and frequency)
* Follow-up: Who are they seeing? When?
* Diet:
* Activity: What is the patient allowed to do?
* Special Instructions: Anything that doesn’t fall into these categories
* Patient education: Education on meds, complications to watch for, etc.
44
Functional decline following serious ____ affects the ability of older adults to return directly from hospital to home
Leading to a need for _____ prior to return to community
illness or injury
institutional rehab
45
benefits of home-cased care
* improve functional status
* decrease hospitalizations
* delay long-term institutionalization
* reduce mortality
* provides unique opportunities for medical providers to assess functional capacity, social support, and safety in the home environment
46
Health Service options for Long-term Care in the Community
1. **Home medical care** - Medical services from clinicians who make house calls
2. **Home health agency care** - Skilled nursing, social work, rehab services, interdisciplinary home hospice services
3. **In-home social services** - Custodial assistance w/ ADLs, light housekeeping, shopping, and food prep (aka Home Health Aid and Attendance)
4. **Private case management services**
5. Home-dwelling elders have the option of attending **adult day health centers (ADHCs)**
- Participate in activities
- Receive limited amounts of nursing, medication administration, exercise, PT, and OT
47
Care Models in home-based care
1. **informal care** - Personal care provided by unpaid support networks.
2. **formal care** - Paid personal care assistants. Often are certified medical assistants or nursing assistants.
3. **medicare skilled home health care** - Nursing, occupational therapy, physical therapy, speech therapy, and social work.
4. **home-based medical care** - Physician- or nurse practitioner–led services. Wide variety of models, some of which include additional professionals such as physician assistants, nurses, social workers, therapists, and community health workers.
5. **home hospice** - Nurse-led interprofessional team including personal care assistant, social worker, chaplain, and a medical director.
6. **hospital at home and related services** - professionals who typically function in institutions such as hospitals, rehabilitation centers, or inpatient hospice who provide services at home.
48
difference between informal vs formal care
1. informal
- The dedicated labor of millions of unpaid caregivers is the cornerstone of successful care for homebound individuals
- Informal caregivers, the majority of whom are women, perform essential and challenging tasks - ranges from ADLs to medication management to symptom monitoring to care coordination
2. formal
- Paid assistance - ADLs, light housework, or errands; formal care is financed privately
49
what is Medicare Skilled Home Health Care
1. **signed order of physician**, an older adult may receive _in-home care from a home health agency for a **60-d** episode_
1. require special training and cert to administer to be safe and effective - nurses or therapists
1. Other examples: wound care, catheter care, physical therapy, training of patients or caregivers to manage medical conditions
- Must be homebound and have a need that requires a specialized skill (ex: Nursing, PT)
50
Most hospice care is provided by who?
an interprofessional team in the home
51
what is Home-Based Primary Medical Care
* Delivers healthcare and outpatient services to marginalized populations facing barriers d/t physical, mental, and social/environmental challenges.
* regularly meet to coordinate care.
* pts receive care from an interprofessional team of clinicians from multiple health professions, including, but not limited to: Nurses, Social workers, Pharmacists, PT, OT, Mental health professionals
* Reduces cost savings, higher satisfaction, and fewer hospital/nursing home admissions.
* has deeper assessment of functional, social, caregiving, and environmental aspects of patient health
* **pt-caregiver interactions in home are different** from those observed in the doctor’s office
52
Many older adults reside in what facility?
residential care facilities
* aim to serve who are **largely independent but require assistance with some instrumental ADLs**
* In concept, service recipients **need not lose their personhood and their autonomy to get care**
53
spectrum of residential care facilities
independent living --> assisting living --> nursing homes
54
residential care and assisted living use ____, such as a dining room, but they also retain ___
1. common facilities
2. their privacy
- Each resident is a tenant and has **control over a living unit**
- At minimum, each individually occupied dwelling unit contains a space for living and **sleeping, a bathroom**, and at least minimal **cooking** facilities
- Each unit can be **locked** by the occupant
55
As the tenant in a residential care and assisted living, the resident has control over what?
the use of their space
Care providers must be invited in
Care plans must be accepted by the resident
56
Majority of assisted living exists as what type of service?
privately paid services
57
Unlike residential care facilities (assisted living), the nursing home is a medical care model tightly regulated by ?
state and federal guidelines
58
A nursing home is a site for people needing access to ?
24-hour care and assistance with ADLS that cannot be accomplished at home for social, medical, and economic reasons
59
A nursing home includes what type of team
interprofessional team
* _on-site_: licensed nurses, nursing assistants, PTs, OTs, recreation therapists, and social workers
* _Not always on site_: Speech language pathologists, dietitians, pharmacists, chaplains, and physicians
Team oriented: everyone works together to provide residents with assistance with their daily care needs, acute medical issues, and functional mobility
60
goals of nursing homes
1. Provide **safe and supportive environment** for chronically ill and dependent people.
1. Restore and maintain the **highest possible level of functional independence.**
1. Preserve individual **autonomy**.
1. **Maximize quality of life**, perceived well-being, and life satisfaction.
1. Provide effective rehabilitative, medical, nursing, and psychosocial care to individuals discharged from an acute hospital in order to **facilitate their transition to their previous living environment**.
1. Provide **comfort and dignity for terminally ill pts** and their loved ones.
1. **Stabilize and delay progression of conditions**.
1. **Prevent acute medical and iatrogenic illnesses** and **identify and tx** them rapidly when they do occur.
61
Nursing home CARE categories
short-term care
long-term care
Hospice & end of life care
62
eligibility for short-stay rehab
Skilled needs (rehab or nursing) following hospitalization
goal: Improve function or medical condition and return home
63
services provided in short-stay rehab
Nursing, physical therapy, occupational therapy, recreation therapy, medicine, pharmacy, nutrition, social services
64
duration of stay in short-stay rehab
<100 d
65
financing for short-stay rehab
Medicare Part A for medical care and room and board (up to 100 days)
66
eligibility for long-term institutional care
24/7 assistance needs for safety or functional impairment
goal: Ensure safety and necessary medical and supportive care
67
services provided in long-term institutional care
Nursing, medicine, nutrition, recreation therapy, pharmacy, social services, rehabilitation only for new functional decline and potential to improve, restorative nurse
68
duration of stay in long-term institutional care
permanent
69
financing for long-term institutional care
Medicare for medical provider services; Medicaid or private pay for room and board
70
eligibility for hospice
<6-month prognosis from terminal condition, focus on comfort
goal: Symptom management, reducing care transitions at end of life
71
services provided in hospice
Hospice nursing and medical care, general nursing and medical care, nutrition, pharmacy, recreation therapy, social services
72
duration and financing for hospice
<6 mo
Medicare for hospice services; private pay for room and board
73
what types of nursing home residents are "short stayers"
1-3 months
* terminally ill
* short-term rehab
* medically unstable or subacutely ill
74
what type of nursing home residents are "long stayers"
3 months-years
* primarily cognitively impaired
* impairements of both cognitive and physical functioning
* primarily physically impaired
75
common conditions treated with rehabilitation
1. pulm rehab - COPD
2. cardiac rehab - post MI, CHF
3. PAD rehab - exercise rehab to improve distance walking
4. stroke rehab - 24-48 h post-stroke once stable
5. osteoarthritis and joint replacement rehab
6. falls
7. pain
8. deconditioning
76
* Assessment of motor control and impairments such as joint range of motion, muscle strength, and balance
* Assessment of gait and mobility
* Provision of appropriate assistive devices
* Exercise training to increase range of motion, strength, endurance, balance, coordination, and gait
* tx with physical modalities (heat, cold, ultrasound, and electrical stimulation), soft tissue and manual therapy techniques
what type of provider uses these methods
PT
77
* Evaluate self-care skills and other activities of daily living
* Home assessment
* Self-care skills training; recommendations and training in use of assistive technology
* Fabrication of splints
what type of provider would use these methods
OT
78
* Assessment of all aspects of communication
* Assessment of swallowing disorders
* Treatment of communication deficits
* Recommendations for alterations of diet and positioning to treat dysphagia
what providers use these methods
speech therapist
79
* Evaluation of self-care skills
* Evaluation of family and home care factors
* Self-care training
* Patient and family education
* Liaison with community
what provider uses these methods
nurse
80
Evaluation of family and home care factors
Assessment of psychosocial factors
Counseling
what provider uses these methods
social worker
81
Assess leisure skills and interests
Involve patients in recreational activities to maintain social roles
what provider uses these methods
Recreation therapist
82
Makes and fits prosthetic limbs
Makes a variety of orthotics including braces, ankle-foot orthoses, splints, and shoe inserts
Assesses fit of orthotics
what provider uses these methods
prosthetist orthotist
83
When to transport from nursing home to ER?
1. Pain that can not be controlled at the facility
2. The need for further evaluation in order to properly treat the patient
- acute exacerbations of cardiovascular and pulmonary conditions
- infection and the need for parenteral antimicrobials and hydration
- falls, altered mental status, and behavioral changes that are difficult to manage
3. Family request
84
reasons to not transport from nursing home to ER?
* Patient is at **end-of-life** and the nurse or **staff is uncomfortable with the patient dying in their facility**
* Vague or intermittent sx that **can be further evaluated at the facility**
* Family request
85
demographics of a caregiver
* **34 million Americans** care for someone over the age of 50
* Most spend close to **24 h / wk** providing care (ADLs)
* Most caregivers are **married or living with a partner**
* **85%** are a parent, relative, with parents being most common
* Most **live close** to the care patient
86
tasks of caregiver
medication management
health system coordination
complex medical tasks such as wound care
87
positive parts of a caregiver
1. Most caregivers report positive experiences and exhibit satisfaction with their efforts
2. sources of fulfillment
- Providing regular care
- supporting the wishes of the recipient
- giving back to someone who cared for them
- continuing a family tradition
88
RF for caregiver stress
1. Long hours caring for someone with dementia
1. Lack of choice about caregiving role
1. Caregiver poor health
1. Caregiver lack of social support
1. Physical home environment making care tasks difficult
1. Low socioeconomic status
1. High levels of perceived suffering of care recipient
1. Living with the care recipient
1. Depression in the caregiver
1. Poor coping strategies
1. Perceived patient distress
1. Social isolation
1. Financial stress
1. Long duration of caregiver hours
89
outcomes of caregiver stress
1. Depression
1. Withdrawal
1. Anxiety
1. Anger
1. Loss of concentration
1. Changes in eating patterns
1. Insomnia
1. Exhaustion
1. Drinking or smoking more
1. Health problem
- Exacerbations of old ones
- Increased numbers of new ones like colds and flu
90
what helpful resources can a social worker find for caregiver stress
* caregiver support groups
* respite programs
* adult daycare
* hired home health aides
91
what componenets does medicare cover
* Medicare covers services (like lab tests, surgeries, and doctor visits)
* supplies (like wheelchairs and walkers)
* considered medically necessary to treat a disease/condition
92
Part A of medicare covers what (5)
* Inpatient care in hospital
* Skilled nursing facility care
* Inpatient care in a skilled nursing facility (not custodial or long-term care)
* Hospice care
* Home health care
93
Part B of medicare covers what?
1. Medically necessary services:
- Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice
2. Preventive services:
- Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best
- No cost for most preventive services
3. Clinical research
4. Ambulance services
5. Durable medical equipment (DME)
6. Mental health - Inpatient, Outpatient, Partial hospitalization
7. Getting a second opinion before surgery
8. Limited outpatient prescription drugs
94
Part D of medicare covers what
PRESCRIPTIONS
1. Each Prescription Drug Plan has its own formulary
1. Many place drugs into **different "tiers"** on their formularies - **each tier have a different cost**
1. you or your prescriber can ask your plan for an exception to get lower copayment
1. can make some changes to its formulary during the year within guidelines set by Medicare.
95
Part C of medicare covers what
Medicare Advantage Plan
1. Another way to get Part A and B coverage
1. Offered by Medicare-approved private companies - Must follow rules set by Medicare
1. Most MA Plans include drug coverage (Part D)
1. Usually need to use health care providers who participate in the plan’s network
1. Sets a limit on what you’ll have to pay out-of-pocket each year for covered services
1. Some plans offer non-emergency coverage out of network, but typically at a higher cost
96
If the change involves a drug you’re currently taking, your plan must do one of these:
- Provide written notice to you at least 60 d before date the change becomes effective
- At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change
