Long term care spring 2014 abridged

1

Long-Term Care

NURS 4100 Care of the Older Adult Spring 2014Joy A. Shepard, PhD(c), MSN, RN, CNE

2

Objectives

Describe the long-term care continuumDescribe various long-term care practice settings and roles for gerontological nursesDescribe the principles of rehabilitative nursingCompare and contrast community-based versus institutional long-term care

3

“There’s No Place Like Home”

4

Long-Term Care Continuum

Long-Term Care:“Care of those persons requiring health care, personal care, social, and supportive services over a sustained period of time”

5

Components of the Long-Term Care System

Consumers: Elderly users of

long-term care The elderly as a

political force Nonelderly long-

term care users Physically disabled

Mentally ill, developmentally disabled

Baby boomers: future long-term care consumers

6

Seniors Account for Half of the Total Population with Long-

Term Care Needs

7

Components of the Long-Term Care System

Providers:Nursing

Facilities Assisted Living/

Residential Care Subacute Care

Providers:Adult Day Care Home Health

Care Hospice Care

8

Institutional vs. Non-Institutional (Community-

Based) Care Institutional: • Nursing Facilities

• Assisted Living • Subacute Care

Non-Institutional:• Adult Day Care• Home Health• Hospice Care

9

Institutional vs. Non-Institutional (Community-

Based) Care

10

Impact of the Large Number of Boomers on LTC…

Will grow over the next 2 decades and beyond…

11

Looming Shortage

US will need to recruit 200,000 new direct-care workers each year to meet future demand among the Baby Boomers as they age http://www.reuters.com/article/pressRelease/idUS155188+29-Apr-2008+BW20080429

12

Major Sources Financing Long-term Care Expenditures

13

Nursing Facilities (Homes)

14


1.5-2 million residents (4-5% older US population) 5.3 million by 2030

Resident characteristics Predominantly women,

age 80+, white, widowed, dependent in ADLs & IADLs

More than 60% cognitively impaired

16,100 Nursing homes (US)Costs of care Vary by geographical

location, ownership, amenities

Average annual cost: $83,585 (US)

$7,000 month$66,830 (NC)

15

Getting Admitted into a Nursing Home…

Often a crisis makes it necessary…

16

Responsibilities of Nurses in LTC

Box 37-4, p. 503Administrative & managementDirect care providerGuardian of care/ advocacyGuardian of care/ advocacyCare coordinatorNumerous other rolesMDS

17

Activities of Daily Living (ADLs)

Bathing

(Average resident needs help with 4 ADLs)

•Dressing•Eating

•Toileting• Transferring

18

Financing Nursing Facilities

Reimbursement sources:Medicaid - 65%Medicare - 13%Private pay and

other sources – the remainder

Medicaid

Medicare

Private, other

19

Medicare Coverage

Restrictions:Covers only skilled nursing careMust follow 3-day hospital stayLimited to 100 days per “benefit period”Requires co-payment days 21-100

20


Regulations and quality of careHighly regulatedOmnibus Budget

Reconciliation Act (OBRA) of 1987 has had positive impact

MDS – Federal database

Nursing homes must have licensed nurse on duty 24 hrs/dayDuring one 8-hr shift each day, one of these nurses must be RN

21

Nursing Staffing Ratios in NC

“Daily direct patient care nursing staff, licensed and unlicensed, shall equal or exceed 2.1 nursing hours per patient per day” Also referred to as nursing hours per patient day ( NHPPD or NH/PD)http://www.hpm.umn.edu/nhregsPlus/state_regulation_attachments/north_carolina_regulation_attachments/north_carolina_patient_and_resident_care_and_services.pdf

Typical staffing ratio (area nursing homes):20-30:1 (RN or LPN)10:1 CNA

22

Delegation & Accountability/Responsibility

Delegation: Transferring to a competent individual the authority to perform a selected nursing activity in a selected situation. The nurse retains accountability for the delegation.Accountability/ Responsibility: Answerable for actions or inactions of self in the context of assignment or delegation.http://www.ncbon.com/content.aspx?id=682&terms=delegation

23

5 Rights of Delegation for RNs

Right taskRight circumstancesRight personRight direction/ communicationRight supervision/ evaluation

https://www.ncsbn.org/fiverights.pdf

24

(NC) Medication Aide – ICF/Skilled Nursing Facilities

CNA IComplete 24-hour NC Medication Aide training program Pass NC Medication Aide certification exam (NCBON)“Before allowing a medication aide to administer medications, the nursing home employer must conduct a clinical skills validation for those medication tasks to be performed in the facility. The validation must be conducted by a registered nurse”Registry – NC Division of Health Service Regulation Medication Aide “The licensed nurse maintains accountability and responsibility for the delivery of safe and competent care”https://www.ncnar.org/matcep.htmlhttp://www.ncbon.com/content.aspx?id=826

25

Question

Which question by the nurse would be the most appropriate to ask the unlicensed assistive personnel (UAP) after discussing the care the UAP is to give to a client? A. "Do you understand what you are to do for this client?" B. "Will you be able to complete this assignment before

you leave the unit today?" C. "Can you repeat the main points of what we just

discussed with regard to your assignment?" D. “Do you have any questions?"

26

Question

The registered nurse monitors the performance of each unlicensed assistive personnel (UAP) and intervenes as necessary, obtains and provides feedback, and ensures proper documentation. Which right of delegation is the registered nurse demonstrating?A. Right taskB. Right circumstancesC. Right personD. Right direction/ communicationE. Right supervision/ evaluation

http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+on+Nursing+Practice&L7=Delegation+to+Unlicensed+Assistive+Personnel&sid=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2

27

Question

The registered nurse matches the complexity of the activity with the unlicensed assistive personnel (UAP) competency and with the level of supervision available. Which right of delegation is the registered nurse demonstrating?A. Right taskB. Right circumstancesC. Right personD. Right direction/ communicationE. Right supervision/ evaluation


28

Question

The registered nurse instructs and/or assesses, verifies and identifies the UAP's competency on an individual, task and patient-specific basis. Which right of delegation is the registered nurse demonstrating?A. Right taskB. Right circumstancesC. Right personD. Right direction/ communicationE. Right supervision/ evaluation


29

NC Nursing Homes - Regulations

NC Division of Health Service Regulation (formerly Division of Facility Services)Nursing Home Licensure & Certification Section

Licenses nursing homes in NC

Certificate of Need (CON)Centers for Medicare & Medicaid Services – 95% of nursing homesSurveys – every 9-15 months

30

NC Regulations

Office of Long-Term Services & Supports Nursing homes

List of Nursing HomesNC Nurse Aide I & Health Care Personnel RegistryNursing Home Residents' Bill of Rights

Long Term Care Ombudsman ProgramMental Illness in Long-Term Care Facilities Study (2008) Long-Term Services and Supports Action PlanA Long-Term Care Plan for North Carolina: Final ReportNC State Board of Examiners for Nursing Home Administrators

31

How Nurses Can Help Families Choose a Nursing

HomeNursing Home Comparehttp://www.medicare.gov/NHCompareCMS’s Online Survey Certification and Reporting

(OSCAR) databaseMinimum Data Set (MDS) Repository

Issues to consider: safe physical environment, dementia health, overall health, knowledgeable and available staff, quality of life, support, interdisciplinary team (Box 37-2, pp. 500-501)

32

Assisted Living Facilities

33

Assisted Living Facility (ALF)

“Special combination of housing, personalized supportive services, and health care designed to meet the needs, both scheduled and unscheduled, of those who need help with activities of daily living”Long-term care residential alternative More assistance than retirement community Less medical & nursing care than nursing facility

24-hr/day on-site support and assistance 39,500 ALFs (US)900,000 residents

34

Profile of Resident of Assisted Living Facility

80 years old (mean age)Female (69%)Needs help with at least two ADLs Bathing: 68% Dressing: 47% Toileting: 34% Transferring: 25% Eating: 22%

Needs help with IADLs Housework: 91% Medications: 86%

Length of stay: 27 months 34% move to nursing

facility 30% die while resident

35

Assisted Living Facility (ALF)

36

Services Provided Personal carePersonal care Health careHealth care SupervisionSupervision Social servicesSocial services Social & religious Social & religious

activitiesactivities

Exercise & Exercise & educational educational activitiesactivitiesTransportationTransportationLaundry & linenLaundry & linenHousekeeping & Housekeeping &

maintenancemaintenance

37

ALF Living Accommodations

38

Financing Assisted Living

Reimbursement Sources: Mostly self-pay Medicaid – small, but

growing

Average annual cost: $39,516 (US)

$3300 month $28,734 (NC)

39

Staffing/Work Force

Largely non-clinical (unlicensed personnel)Customer service focusFew staffing regulations – mostly based on nursing facility modelTraining staff to recognize residents’ privacy & independenceMedication Aide (Tech) – Adult Care SettingRegistry – NC Division of Health Service Regulation’s

Adult Care Licensure Section

40

Regulations

Few regulations until recentlyIncreasing number of states now regulating assisted livingVery little commonality or uniformity

41

Tragic Case of GlenCare (ALF) in Mount Olive

Example poor quality ALF 5 residents died of hepatitis B; 3 others diagnosedState says facility failed to train medication techs for blood glucose monitoringhttp://www.witn.com/localnews/headlines/Two_More_Hepatitis_B_Cases_Confirmed_At_Mt_Olive_Facility_106777234.html

42

Cypress Glen (ALF) in Greenville

Example high-quality ALFMany amenitiesExpensive facility

http://www.cypressglenretirementcommunity.com/CypressGlenAssistedLiving.htm

43

NC RegulationsAssisted LivingAdult Care Homes

Licensed by State Division of Health Service Regulation (Group Care Section)

Group Homes (Developmentally Disabled)Multi-Unit Assisted Housing With Services

County Departments of Social ServicesRights of ResidentsElder Housing Information Medication Aide (Tech) – Adult Care Homes

44

Subacute Care & Rehabilitation Units

45

What is Subacute Care?

Inpatient restorative or rehabilitative health Immediately following debilitating illness, surgery, or injury General criteria for admission include: stabilization of some acute health care problem, need for rehabilitative services to restore physical function, ability to participate in daily rehabilitative therapy, anticipated discharge within approximately 3 weeks Care planning based on functional goals such as being able to walk around the house, climb stairs, assist or be independent in self care, perform exercises or be able to participate in more intensive rehabilitation once discharge for the inpatient setting http://www.subacutecare.info/consumer.html

46

What Is Subacute Care?

Comprehensive inpatient careComes after, or instead of, acute careBetween acute & long-term care

Usually for defined period of timeDeveloped for cost-savingsFastest-growing segment of health-care delivery system

47

StaffingInterdisciplinary Team:

Physicians or mid-level providersNursesPhysical therapists, occupational therapists, speech pathologists, recreational therapists, nutritionists, social workersNon-licensed staff

48

49

Reimbursement: Short-Stay vs Chronic

Subacute care (Medicare reimbursed, short stay) Chronic care (private pay or Medicaid) for frail, elderly residents requiring help with the activities of daily livingA 3-day qualifying stay in a hospital is required for skilled nursing care to receive Medicare reimbursement in a subacute care facility Must be a candidate for rehabilitation Periodic recertification – continued need for skilled care Resident’s progress toward established goals One hundred days of skilled care can be reimbursed per

“benefit period”

50

Vidant Regional Rehabilitation Center

Patients admitted to the Center must meet the following general criteriaMust be able to participate in therapy 3 hours a day Must be medically appropriate Must have functional & cognitive recovery potential Must have support & involvement of family http://www.uhseast.com/uhseast/ServicesDetail.aspx?id=52

84&linkidentifier=id&itemid=5284 http://whiteshoal.uhseast.com/rehab/video/rehab tour.wmv

51

Services Provided

• Rehabilitation• Chemotherapy• Physical Therapy• Parenteral Nutrition• Occupational Therapy• Dialysis• Respiratory therapy

• Pain Management• Cardiac Rehab• Complex Medical• Speech Therapy• Wound Management• Postsurgical Care• Ventilation Care

52

Skilled Nursing Facility (SNF) vs Nursing Facility (NF or

ICF)?Distinction based on: Whether skilled care or custodial care is provided Whether skilled medical or nursing care or rehabilitation is

requiredNursing facility (NF)/ nursing home Provides room, meals, and help with activities of daily living

& recreation (custodial care) Residents have physical or mental problems that keep them

from living on their own Require daily assistance with ADLs & IADLs

53

Skilled Nursing Facility (SNF) vs Nursing Facility (NF or

ICF)?Skilled nursing facility (SNF) –Skilled medical or nursing care, rehabilitation

Generally, Medicare doesn't pay for long-term careMedicare pays only for medically necessary skilled

nursing facility or home health careSkilled nursing care and home health aide services

only covered on part-time or "intermittent" basishttp://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3433

54

Skilled Nursing Facility vs Regular Nursing Home

Nursing homes (or nursing facilities) are defined as health care institutions that provide onsite 24-hour supervision, nursing services, and personal care. The two basic types of nursing homes are skilled nursing facilities and intermediate care facilities.A skilled nursing facility is an institution that provides inpatient 24-hour skilled nursing services, as prescribed by the client’s primary care provider. The emphasis is on the restorative and rehabilitative potential of the client. Only 5 % of nursing home residents require a skilled level of care. Medicare is the main reimburser.An intermediate care facility is an institution that provides basic custodial or nonskilled personal care, but not skilled nursing care. Custodial care is assistance with ADLs such as transferring from the bed to the chair, putting on clothes, bathing, and eating. The care provided by registered nurses and licensed practical nurses is less intense, but still vital for quality of care and positive resident outcomes. Medicaid and private pay are the main sources of payment.

55

Financing Subacute Care

Reimbursement Sources:

Medicare – 2/3- Pays as Skilled Nursing Facility (SNF)

Other 1/3:- Managed care- Medicaid- Private pay & other

56

Definitions Used in Rehabilitation

Functional status Capacity & performance of safe ADLs & IADLs Sensitive indicator of health or illness in elders Critical nursing assessment

ImpairmentDisturbance in structure or function resulting from

physiologic or psychologic abnormalitiesDisabilityDegree of observable and measurable impairment

57

Principles of Rehabilitative Nursing

Goal of nursing care: maximize physical functioning, prevent or minimize decline in ADL function, & plan for future care needsPromote living to one’s maximum potentialUnique set of strengths & abilitiesAcute & chronic illnesses

Attain highest QOL despite functional levelImproving functional capacity: well-being & QOL

58

Rehabilitation Nursing Care Interventions

Preventing infectionMaintaining correct body alignment, position, & ROMPreventing skin breakdownProviding adequate nutrition & fluidsProviding care: achieve realistic level of independenceTeachingMaking referrals to community agencies

59

Adult Day Care

60

Adult Day Care

Option for frail elders requiring daytime supervisionMany services are optional to meet needs Medical insurance usually does not cover charges Mostly private pay Average annual cost (adult day health care):

$15,236 (US) $11,817 (NC)

Center in Greenville: $22-$44 per day

61

62

What Is Adult Day Care?

Interim (less than 24 hour) careProvides a structured environmentGives family caregivers a break, or chance to hold a jobMix of social & health services

63

Philosophy & Benefits

Serves both consumers & caregiversHolistic approach to careMaintains or improves quality of lifeProvides safe, supervised setting

Can live with family without being a burdenSocial interaction with peersProgram of stimulating activitiesTherapy in a non-medical settingADL assistance with dignity

64

Types of Adult Day Care

Two categories of adult day care:Social Day CareAdult Day

Health Care

65

Staffing

Combination of professional & non-professional staffMix depends on focus (social or health)

66

Services Provided

Basic services provided by all types: Safe, secure

environment Social & recreational

activities Assistance with ADLs Transportation to & from

the center At least one meal, plus

snacks

67

Adult Day Health Services

In NC, licensed nurse must be present part of the dayRatio staff to participants 1:6Health care services:

Assessment Medications Monitoring Nutrition counseling Health education

68

Consumers of Adult Day Care

Between needing institutional care & being independentMost live with familyUnable to handle day-to-day tasksMost are elderlyMore women than men

Must be continentAble to communicate needs (mild to moderate dementia)No wandering behaviorsNurse screens admissions

69

Consumers of Adult Day Care

70

Caregivers

Three-fifths are spouses or adult childrenOther two-fifths are other relatives, friends, or neighborsMostly female (3/4’s)Average age: 57One-third over 65 themselves

71

NC RegulationsAdult Day Care/ Health ProgramsAdult Day Health Care NC State Standards for CertificationList of Certified Adult Day Care/ Adult Day Health ProgramsAdult Day Care FormsNC Association of Adult Day ServicesFamily Caregiver Support

72

Home Health

73

JCAHO Definition

Home health services are provided by healthcare professionals to patients in their place of residence This includes, but is not limited to, performing assessments, provision of care, treatment, counseling, and/ or monitoring of the patient’s clinical status by nurses, occupational therapists, physical therapists, speech-language pathologists, audiologists, social workers, dieticians, dentists, physicians and other licensed healthcare professionals in the patient’s homeIt includes the extension or follow-up of healthcare services provided by hospital professional staff in the patient’s home

74

How Home Health Care Developed

Public health department visiting nursesFreestanding visiting nurse associationsGrowth based on better reimbursement

75

Philosophy of Care

Takes services to consumers’ homesEligibility requirements (based on Medicare regs):

Physician-ordered IntermittentHomebound

76

Question

The home health agency’s medical chart of your 78-year-old client claims that she is homebound. However, she is not bedridden. So, could the “homebound” status still be correct?

77

Home Health Agencies

Official or public agenciesVoluntary or private not-for-profit agenciesPrivate, proprietary agenciesInstitution-based agencies20,000 providers deliver home health care services to 7.6 million people

78

Types of Home Health Care

Home health agenciesHospice agenciesHomemaker & home care aide agenciesStaffing & private duty agencies

79

Staffing

Combination of professional & non-professional staffNursesHome Health AidesTherapistsSocial WorkersOther specialists

80

Services Provided

Skilled services, therapies Nursing, PT, OT, speech

therapy, social work, nutritionist)

Dental careLaboratoryEducation

Supportive servicesPersonal careHomemakingTransportation

81

Components of Home Health Care

Care of clients in the home Observe family dynamics Identify caregiver burden

Referrals for home care Discuss funding

Reimbursement sources for home care Medicare, Medicaid, insurance, public funding, self-

pay

82

Financing Home Health Care

Medicare – single largest payer (28%)

Medicaid – 19%Private funding

sources (insurance, private-pay) – 24%

Other government programs – 5%

83

Question

What agency is the largest single reimbursement source for home health care?A. MedicareB. MedicaidC. Private insuranceD. Self-pay

84

Consumers ofHome Health Care

Largely elderlySome need on-going careOthers need only temporary care following a hospital stay

85

Nursing Process in Home Health

Assessing Conduct careful and

complete data collection initially and on an ongoing basis

Diagnosing Identify actual or

potential problems—LPN/ LVNs contribute to this process

Planning Set priorities, establish

goals, decide on interventions

Implementing Carry out interventions

Evaluating Compare plan of care

with goals and review client’s progress

86

Home Health Care Nurses

Guidelines ANA Standards for Home

Health Nursing Practice ANA Standards of

Community Health Nursing

National Association for Home Care Bill of Rights

RolesProvider of careTeacherAdvocate

87

88

Concerns for the Home Health Nurse

Safety Assessment of, documentation of, and teaching of safety

measures

Infection Control Effective hand washing Use of gloves Disposal of wastes and soiled dressings Handling of linens Practice Standard Precautions

89

Legal Issues in Home Health

Privacy and confidentialityClient access to health informationFreedom from unreasonable restraintWitnessing of documentsInformed consentNegligence or malpractice

90

NC RegulationsHome HealthIn-Home Aide Senior Companion Division of Health Service Regulation Acute and Home Care Certification SectionProcedure for Establishing a Certified Home Health Agency

91

Home Health Review Question

Referral to a home care agency requires:A. A physician’s orderB. A client need for skilled nursing or therapyC. Unable to leave home without major effort (homebound)D. Full time care not needed (intermittent)E. Consent of the clientF. All of the above

92

Question

A 94-year-old man has been hospitalized and treated for pneumonia. At the end of his hospitalization, his family decides that they can no longer care for him because he is completely dependent in all activities of daily living and has become incontinent. His long-term prognosis is poor. To meet this client’s needs, the nurse discharge planner will apply for:A. Assisted living facilityB. 24-hour/day home careC. Intermediate nursing careD. Skilled nursing care

93

Hospice

94

Hospice

“Not a place but a philosophy”Dying is a normal part of life cyclePromotes the idea of “living until you die”Care is provided in multiple settings & supports the pt/family through dying process as well as providing bereavement support to surviving family

95

Hospice Care

Focus whole person Mind Body Spirit

Support & care Pts Family & caregivers

Continues after death of loved one

Last phase (6 months) of incurable disease Medicare coverage can

extend beyond that period if necessary

Live as fully & comfortably as possible

96

97

98

Hospice Care: Interdisciplinary Team of Professional Caregivers

Nurse Pain & symptom control Assesses pt & family’s

ability to cope Identifies resources for

care of pt Recognizes pt’s wishes Assures support

systems in place Bereaved family services

PhysicianPharmacistSocial workerChaplainOthers (volunteers)

99

Hospice Team

100

101

Hospice Settings

Home FreestandingHospitalHome health agencies with home care hospiceNursing home or other LTC settings

102

103

Question

Which of the following statements is true concerning hospice?A. Hospice is a special place of careB. Hospice care is a lifelong type of careC. Hospice is a model of care rather than a

place of careD. Hospice is designed for clients with

serious chronic illness

104

Palliative Care vs Hospice

Hospice & palliative: both focus on helping a person be comfortable by addressing issues causing physical or emotional pain, or sufferingPalliative: does not require pt to give up fight for a curePalliative: may be given at any time during a person’s illness, from diagnosis onHospice: pts with a life expectancy of mos not yrs (usually 6 mos)Hospice: set of defined services, team members, rules & regulations

105

Question

The gerontological nurse understands that palliative care is different from hospice in which of the following ways? Palliative care (Select all that apply):A. People no longer seek treatments for a cureB. May be provided at any time during a person`s illness, even from the time of diagnosisC. Focused exclusively on terminally ill patientsD. Can take place at the same time as curative treatmentE. Typically, provided in the hospital

Health & Medicine

Long term care spring 2014 abridged