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Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
Reinventing The Nh
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Reinventing The Nh


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Robert Kane Presentation March 6-7 2009

Robert Kane Presentation March 6-7 2009

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