Reinventing the Nursing Home: Getting the Kind of Long-term Care We Want Robert L. Kane, MD University of Minnesota  Schoo...
What is the Problem? <ul><li>Too often posed as a question of financing </li></ul><ul><li>Infrastructure is central </li><...
 
The Problems with Current Thinking about LTC <ul><li>Nursing home is at the center </li></ul><ul><ul><li>Alternatives to N...
Types of LTC Clients <ul><li>Physically dependent </li></ul><ul><li>Cognitively dependent </li></ul><ul><li>Rehabilitative...
What determines who should be cared for where? <ul><li>Patient preferences </li></ul><ul><li>Available support </li></ul><...
The Building Blocks of LTC <ul><li>Personal care </li></ul><ul><li>Housing </li></ul><ul><li>Medical Care </li></ul><ul><u...
Personal Care . Housing  Chronic Disease Care
Can’t Rely on a Name
Personal Care <ul><li>ADLs, IADLs </li></ul><ul><li>Supervision  </li></ul><ul><li>Supportive services  </li></ul><ul><li>...
Housing <ul><li>Minimal quarters/amenities </li></ul><ul><li>Supportive environment </li></ul><ul><li>Control of access </...
Medical Care <ul><li>Chronic disease management </li></ul><ul><li>Proactive primary care </li></ul><ul><li>Responsive  </l...
Prerequisites  for  Making Good Decisions <ul><li>Real options </li></ul><ul><li>Time  </li></ul><ul><li>Information </li>...
Limited Treatment Options
Goals Clarification <ul><li>Consumers and providers must share the same goals </li></ul><ul><li>Medical and social provide...
A Lot Depends on Interpretation
Potential LTC Goals <ul><li>Maintaining or improving function </li></ul><ul><li>Maintaining or improving quality of life <...
Merging Medical and  Social Care <ul><li>Shared goals </li></ul><ul><li>Social goals generally around compensatory care </...
Developing Individualized Care Plans <ul><li>Each client/patient should be identified in terms of their needs for personal...
Role of Risk <ul><li>Older people should not be denied the right to take risks </li></ul><ul><ul><li>Ageism  </li></ul></u...
Severity ,  i.e., cognition, function, prognosis. Preferences,  i.e., safety, autonomy, privacy, culture, atmosphere, aest...
Measuring Success in LTC <ul><li>Success is measured in terms of slowing the rate of decline </li></ul><ul><li>This concep...
Evidence of Successful LTC Observed Expected Outcome Time
Housing issues <ul><li>Minimal levels </li></ul><ul><ul><li>Personal private space </li></ul></ul><ul><ul><li>Bedroom </li...
Personal Care <ul><li>Skills </li></ul><ul><ul><li>Care </li></ul></ul><ul><ul><li>Observation and action </li></ul></ul><...
Medical Care <ul><li>Chronic care management  </li></ul><ul><ul><li>Proactive primary care </li></ul></ul><ul><ul><li>Trac...
Need Relevant Information
Information Technology <ul><li>Problems with too much as well as too little information. </li></ul><ul><li>Need to focus a...
Clinical Glidepath <ul><li>A Clinical Glidepath is a way to observe one or more parameters of a patient’s condition on a r...
Clinical Glidepath Expected Course o o o X
How You Implement Is Important
Policy Issues <ul><li>LTC is not simply a payment question </li></ul><ul><ul><li>Private payers cannot find the care they ...
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Reinventing The Nh

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Robert Kane Presentation March 6-7 2009

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Reinventing The Nh

  1. 1. Reinventing the Nursing Home: Getting the Kind of Long-term Care We Want Robert L. Kane, MD University of Minnesota School of Public Health
  2. 2. What is the Problem? <ul><li>Too often posed as a question of financing </li></ul><ul><li>Infrastructure is central </li></ul><ul><li>Those with funds cannot find the care they want </li></ul>
  3. 4. The Problems with Current Thinking about LTC <ul><li>Nursing home is at the center </li></ul><ul><ul><li>Alternatives to NH paradigm </li></ul></ul><ul><li>Negative attitudes </li></ul><ul><ul><li>Nothing can be done </li></ul></ul><ul><ul><li>Decline is inevitable </li></ul></ul><ul><ul><li>Good care does not make a difference </li></ul></ul>
  4. 5. Types of LTC Clients <ul><li>Physically dependent </li></ul><ul><li>Cognitively dependent </li></ul><ul><li>Rehabilitative </li></ul><ul><li>End of life </li></ul><ul><li>Coma/vegetative state </li></ul><ul><li>Sensitivity to environment </li></ul>
  5. 6. What determines who should be cared for where? <ul><li>Patient preferences </li></ul><ul><li>Available support </li></ul><ul><li>Cost </li></ul><ul><ul><li>Personal </li></ul></ul><ul><ul><li>Societal </li></ul></ul><ul><li>Societal dicta </li></ul><ul><ul><li>Risk taking </li></ul></ul>
  6. 7. The Building Blocks of LTC <ul><li>Personal care </li></ul><ul><li>Housing </li></ul><ul><li>Medical Care </li></ul><ul><ul><li>Especially chronic disease care </li></ul></ul><ul><li>Rare to find all three done well simultaneously </li></ul>
  7. 8. Personal Care . Housing Chronic Disease Care
  8. 9. Can’t Rely on a Name
  9. 10. Personal Care <ul><li>ADLs, IADLs </li></ul><ul><li>Supervision </li></ul><ul><li>Supportive services </li></ul><ul><li>Structured observations </li></ul><ul><li>Reliability </li></ul><ul><li>Respect </li></ul><ul><li>Personalized </li></ul>
  10. 11. Housing <ul><li>Minimal quarters/amenities </li></ul><ul><li>Supportive environment </li></ul><ul><li>Control of access </li></ul><ul><li>Varying levels of affluence </li></ul><ul><li>Congregation as needed or desired </li></ul><ul><li>Location </li></ul>
  11. 12. Medical Care <ul><li>Chronic disease management </li></ul><ul><li>Proactive primary care </li></ul><ul><li>Responsive </li></ul><ul><li>Coordination with social care </li></ul>
  12. 13. Prerequisites for Making Good Decisions <ul><li>Real options </li></ul><ul><li>Time </li></ul><ul><li>Information </li></ul><ul><ul><li>Benefits </li></ul></ul><ul><ul><li>Risks </li></ul></ul><ul><ul><li>Costs </li></ul></ul><ul><li>Clarity about goals </li></ul><ul><ul><li>What is most important to maximize </li></ul></ul><ul><ul><li>Consensus within family </li></ul></ul><ul><li>Guidance/Structure </li></ul>
  13. 14. Limited Treatment Options
  14. 15. Goals Clarification <ul><li>Consumers and providers must share the same goals </li></ul><ul><li>Medical and social providers must share the same goals </li></ul><ul><li>Goals and priorities may change depending on who is paying for the care </li></ul>
  15. 16. A Lot Depends on Interpretation
  16. 17. Potential LTC Goals <ul><li>Maintaining or improving function </li></ul><ul><li>Maintaining or improving quality of life </li></ul><ul><li>Safety </li></ul><ul><li>Autonomy </li></ul><ul><li>Not being a burden </li></ul><ul><li>End of life care </li></ul><ul><li>May have to set priorities </li></ul>
  17. 18. Merging Medical and Social Care <ul><li>Shared goals </li></ul><ul><li>Social goals generally around compensatory care </li></ul><ul><ul><li>Assessment to find problems </li></ul></ul><ul><ul><li>Services to meet identified needs </li></ul></ul><ul><li>Medical goals more therapeutic </li></ul><ul><ul><li>Making a difference </li></ul></ul><ul><li>Potential for common ground </li></ul>
  18. 19. Developing Individualized Care Plans <ul><li>Each client/patient should be identified in terms of their needs for personal care, housing and medical care </li></ul><ul><li>There are many ways to meet each combination of needs </li></ul><ul><li>The plan should reflect the client’s (and family’s) preferences </li></ul>
  19. 20. Role of Risk <ul><li>Older people should not be denied the right to take risks </li></ul><ul><ul><li>Ageism </li></ul></ul><ul><li>Risks involve informed decisions </li></ul><ul><li>Need to understand the benefits and risks of an action </li></ul>
  20. 21. Severity , i.e., cognition, function, prognosis. Preferences, i.e., safety, autonomy, privacy, culture, atmosphere, aesthetics Personal Care Needs Health/ Clinical/ Medical Care Needs Housing Needs
  21. 22. Measuring Success in LTC <ul><li>Success is measured in terms of slowing the rate of decline </li></ul><ul><li>This concept can be applied to measures of both quality of care and quality of life </li></ul><ul><li>The problem is that the comparison to see the improvement is generally invisible </li></ul>
  22. 23. Evidence of Successful LTC Observed Expected Outcome Time
  23. 24. Housing issues <ul><li>Minimal levels </li></ul><ul><ul><li>Personal private space </li></ul></ul><ul><ul><li>Bedroom </li></ul></ul><ul><ul><li>Toilet </li></ul></ul><ul><li>More amenities as affordable </li></ul><ul><li>Small clusters </li></ul>
  24. 25. Personal Care <ul><li>Skills </li></ul><ul><ul><li>Care </li></ul></ul><ul><ul><li>Observation and action </li></ul></ul><ul><li>Systematic observation </li></ul><ul><ul><li>Clinical Glidepaths </li></ul></ul><ul><li>Respect </li></ul><ul><li>Concern </li></ul><ul><li>Compassion </li></ul>
  25. 26. Medical Care <ul><li>Chronic care management </li></ul><ul><ul><li>Proactive primary care </li></ul></ul><ul><ul><li>Track status and intervene early </li></ul></ul><ul><li>Avoid iatrogenesis </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Catheters </li></ul></ul><ul><li>Respect and incorporate social care </li></ul><ul><li>Interact with family </li></ul>
  26. 27. Need Relevant Information
  27. 28. Information Technology <ul><li>Problems with too much as well as too little information. </li></ul><ul><li>Need to focus attention on salient data </li></ul><ul><li>Validated protocols </li></ul><ul><ul><li>Professionals </li></ul></ul><ul><ul><li>Care givers </li></ul></ul><ul><li>Just in time information </li></ul><ul><li>Structured information </li></ul><ul><ul><li>Clinical glidepaths </li></ul></ul>
  28. 29. Clinical Glidepath <ul><li>A Clinical Glidepath is a way to observe one or more parameters of a patient’s condition on a regular basis to be able to compare the observed state with the expected state. </li></ul><ul><li>It is a tool to improve communication between patients and primary care providers. </li></ul><ul><li>If the patients stays within the expected course, nothing need be done. </li></ul><ul><li>But if the patient’s clinical course deviates, this change should trigger immediate closer attention to ward off a problem while it is early. </li></ul>
  29. 30. Clinical Glidepath Expected Course o o o X
  30. 31. How You Implement Is Important
  31. 32. Policy Issues <ul><li>LTC is not simply a payment question </li></ul><ul><ul><li>Private payers cannot find the care they want </li></ul></ul><ul><ul><li>Use payment to re-enforce service goals but not to create them </li></ul></ul><ul><li>Pay for services not housing </li></ul><ul><ul><li>Levels the playing field; eliminates the distinction between NHs and HCBS </li></ul></ul><ul><ul><li>Provide housing as needed and affordable </li></ul></ul><ul><li>Encourage coordination of medical and social care </li></ul><ul><ul><li>Start with shared goals </li></ul></ul><ul><li>Families are central to LTC </li></ul><ul><ul><li>Policies should support family care </li></ul></ul>
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