Lecture 1- Long term care Flashcards
The nursing home population characteristics
- Impairment in decision making- the big one!
- Need assistance with 3+ ADLs
- Dementia
- Orientation/memory problems
- communication problems
- bowel/bladder incontinence
Demographics of nursing home population
- vast majority is over 65 (90%)
- 3/4 are women
- most are widowed, with limited social supports
- underrepresented populations are hispaics, asian americans, and native americans
Average beds in a nursing home
About 100
Are most nursing homes for profit, non-profit, or government run?
FOR PROFIT!
Postacute care services in long term care facilities
- dialysis
- Orthopedic care
- Ventilators
- Post-op care
- Rehab care
- Wound care
- this is a big need- lower hospital stay lengths, but higher care needs
the vast majority of nursing home stays are for how long
Greater than 80% stay for longer than 90 days but less than 3 years
What is the majority funder of nursing home care?
Medicaid!- 65%
What qualifications do you need to have to get medicare to pay for nursing homes
- 3-day qualifying hospital stay
- gains in function has to be carefully documented
- 1st 20 days paid- after that up to day 100 need a co-payment
What percentage of nursing homes are chains?
about half
Staffing issues with nurses
- Huge turnover rates per year!!!!!
- ratio of RNs to other nursing staff has a big effect on quality of care
- the more turnover, the higher the rates of hospitalization for nursing-home residents
Staffing issues with doctors
- most primary care docs designate 2 hours or less to nursing home care
- perception is there is excessive regulation and paperwork with limited reimbursement
- Reality is it is challenging and fulfilling work
Staffing issue- culture
- closed-staff model improves care
- lower hospitalization rates in nursing homes that employ a limited number of committed doctors
- quality drug use correlelated with enhanced nurse-doc communication
Risk factors associated with nursing home placement
- increased age
- Low income, low social activity
- poor family supports
- accepting attitude toward nursing homes
- cognitive/functional impairment
Nursing home residents have high rates of hospitalization, most commonly due to __________
Infection
Issues with information transfer
- missing or illegible transfer summaries
- Omission of prescribed medications
- Advance directives not documented
- Psychosocial and behavior issues are not reported
INTERACT - Interventions to reduce acute care transfers
- developed to improve early Identification, assessment, documentation and communication about status changes in nursing home residents
- goal is to reduce hospital transfers
- so far has reduced them by 17%
Omnibus Budget Reconciliation Act (OBRA)
- set training guidelines and minimum staff requirements for nursing homes
- increases resident’s rights
- initiated minimum data set
- requires documentation for ALL meds, esp. psychoactive agents
OBRA Meds regulation
- requires MONTHLY evaluation of meds by a pharmacist
- NO unnecessary drugs can be given— those are defined as those given
- in excessive doses
- for excessive periods of time
- without adequate monitoring
- Without adequate indications for use
For psychoactive meds, gradual dose _______ are mandated unless a clinical contraindication exists and is documented in medical record
Reductions
The minimum data set
- periodic comprehensive clinical assessment of all residents
- is used to compile nursing facility quality measures!- things like pain, pressure ulcers, weight loss, depression, restraint use
Nursing home legislation
- “f-tags”- federal regulations given this tag number
- adherence to regulations assessed every 15 months
- failure to meet them cited in a “deficiency”- with penalties imposed based on severity
Major challenges of nursing home care
- necessitating individualized approaches to care (no everyone is the same)
- atypical and subtle illness presentation
- limited technology
- lot of cognitive impairment]
- keeping families involved and informed
- ethical and legal concerns
- a LOT of regulatory oversight
How to enhance nursing home satisfaction
- structure visits into their schedules
- Work together with whole medical team
- Document rationale behind EVERY med
Physician Responsibilities in Nursing home care
- COMPREHENSIVE ADMISSION ASSESSMENT
- develop care plan
- Periodic monitoring of chronic conditions
- prompt attention to acute issues
- communicate with entire team
- periodic review of meds!
- optimize quality of life and function
- determine resident’s decision making capacity
