“ Home” provides basic shelter, is a place to establish security, and is the place where one “belongs.” It should provide the highest possible level of independence, function, and comfort. Most older people prefer to remain in their own homes rather than relocate, particularly to institutional living. At least 88% of seniors want to “age in place.” The ability to age in place requires helping the older person to stay where he or she wants with appropriate support for changing needs. Older people want to remain independent and not become a burden on their families, although this varies by ethnic group. Americans are a mobile society, and families often do not all live in the same place. Many younger families have two-worker situations, making it difficult to help with older members of the family who may be living alone and perhaps not in close proximity. A mobile, youth-oriented society may find it difficult to fully comprehend the insecurity that elders feel when moving from one site to another in their later years. In addition to the stress of relocation and the initial anxiety of adapting to a new setting, elders typically move to ever more restrictive environments, often in times of crisis. This lecture considers the various options along the continuum of care and living environments. The major issues are the choice and control elders have about relocation, assistance provided to the elder in making personally appropriate choices, the stress of relocation, and the anxiety surrounding institutionalization. Nursing care is focused on providing orientation, information, resources, advocacy, safety, comfort, and creation of as home-like an environment as possible in whatever situation the elder is encountering.
About 10 million Americans need long-term care. Among the current generation of people entering their senior years, 69% will need some type of institutional or community long-term care. Long Term Care includes services provided to seniors and people with disabilities or chronic conditions that render them unable to perform activities of daily living such as bathing, dressing, transferring, etc. People may also need supervision or assistance in basic functions as they choose to remain in their homes. Thus, Long Term Care includes not only care in nursing and assisted living facilities but home and community services as well. The Long Term Care settings in North Carolina likewise include adult care homes, continuing care retirement communities, multi-unit assisted housing with services, and hospice care. The ability to perform ADLs defines independence and the inability to perform ADLs measures disability in many disorders. The long-term care system is best defined in terms of the people who require and use it. They are described in one instance as “functionally dependent on a long-term care basis due to physical and/ or mental limitations.” Another more detailed description of long-term care consumers is “those persons requiring health care, personal care, social, and supportive services over a sustained period of time.” Older adults are major users of virtually all healthcare services. Needs of the aging population are diverse and multitudinous. Needs of older adults fluctuate as life demands change. The continuum of care consists of preventive services, partial and intermittent care services, and complete and continuous care services. This continuum includes opportunities for community-based services, institutionally-based services, or a combination of both. To plan care for older adults effectively, nurses must be familiar with the various forms of care available. Services must address physical, emotional, social, and spiritual factors. Services must consider unique and changing needs. Care and services must be flexible. Services must be tailored to needs. Most people will rely heavily on unpaid help from family and friends. Still, spending for long-term care services is huge. Although we usually think of long-term care as being for the elderly, nearly half of the people using long-term care are non-elderly.
Acute/ subacute – patients Long-term care institutions – residents Community-based care providers – clients Long-term care consumers are not defined by a single disease or condition. Instead, they require services because of functional disabilities – limitations on their ability to function independently. It is the disability itself, rather than the disease, that is addressed by long-term care. An individual might have functional limitations caused by a combination of diseases such as diabetes, arthritis, and heart disease. They may also suffer some loss of cognitive ability. Consumers of long-term care are largely (though not exclusively) elderly. Elderly (65 and older) make up 55% of total long-term care population. The most elderly (older than 75) use the long-term care system at a disproportionate rate. The number of people in the US over 65 years old was approximately 35 million in the year 2000 and is projected to reach 70 million by the year 2030, with those over 85 years expected to grow from 4 to nearly 9 million. One result of the growth of the elderly population has been their growing economic and political power. Since the 1990’s the elderly have become a potent, well-organized, and much listened to constituency. American Association of Retired Persons (AARP), the Council of Senior Citizens, and the Gray Panthers. The AARP is the nation’s leading and most powerful organization for people aged 50 and older. The organization has substantial influence on policy making at the federal and state levels. AARP has 36 million members – over 50% of older adults. The name is misleading, because many members of AARP are not retired. AARP is a nonprofit, nonpartisan membership whose primary goal is to help older people live with independence, dignity, and purpose. An important component of the organization is its lobbying ability and influence on legislative issues of importance to older adults. With the assistance of AARP, the rights of older adults continue to be heard loudly on Capitol Hill. Nonelderly users – 42% adults under age 65; 3% children. Physically & mentally disabled, victims of traumatic injury, younger pts with Alzheimer’s dz, AIDS, mental disease or mental retardation. More likely to be suffering from a single, albeit disabling disease or condition than are the elderly. Physically disabled – care needs are complex and intensive, functional limitations are often extreme. Often is an absence of mental or emotional disability. Congenital defects or birth accidents. Physical or chemical accidents (traumatic brain injury, drug overdose). Spinal cord injuries. Among heaviest individual users of the full range of long-term care services, and they use those services for many years – much longer than typical elderly long-term care consumers – thus creating a disproportionate burden on the long-term care system. May be politically active, like the elderly. Mentally ill/ Developmental disability – often afflicted from birth or at a relatively early age, they also use highly intensive long-term care services for many years. Less attention – societal stigma. Boomers – born between 1946 and 1964. Begin to retire year 2011. 40 million Americans 65 years and older. By year 2025, youngest of boomers reach retirement age - # Americans aged 65 years and older will have grown to 63 million. They will have big impact on system far beyond numbers – they will be better educated and will demand much more from the system.
Current system has developed in hit-or-miss fashion. Grown in response to three factors – 1. Need, 2. Demand, 3. Availability of reimbursement. “ Nursing homes” now Nursing facilities – Omnibus Budget Reconciliation Act (OBRA) of 1987. “Boarding homes” residential care facilities. Nursing facilities – health care facilities licensed by the states, offering room board, nursing care, and some therapies. They include facilities certified by Medicare as SNFs and others that used to be called intermediate care facilities, the primary difference being the amount of nursing care and the number of therapies provided. SNF’s provide 24-hour nursing care plus such other services as intravenous, oxygen, physical, speech, and occupational therapy, wound care, and education. Assisted living – long-term care alternative for people who need more assistance than is available in a retirement community but who do not require the medical and nursing care provided in a nursing facility. Assisted living facilities provide personal care to people needing assistance in activities of daily living. Residential care includes boarding homes, continuing care retirement communities, and adult foster homes. Subacute care – one of newer terms in long-term care, has grown as a cost-effective alternative for those individuals needing more than nursing facility care and less than hospital care. Provide highly skilled nursing care, therapies, and more medical supervision than nursing facilities. It is highly focused care designed to bridge acute and long-term care and entails a relatively short length of stay (but longer than stay in typical hospital). Multidisciplinary teams work toward a goal of moving the patient home or to a lower level of care. Both government payment sources (primarily Medicare) and managed care organizations favor subacute care as a means of providing intensive high-quality care at a lower cost. Hospitals and nursing facilities see it as a means of filling empty beds and gaining a growing portion of the health care market. Adult day care – provides daily (not overnight) services for chronically ill individuals who are not able to function on their own bur are able to live at home with the assistance of informal caregivers. It provides meals, social and educational activities, assistance with personal care, and supervision for the care recipient. At the same time, it provides a few hours of relief for the caregivers, often allowing them to maintain employment. Home health – services provided in consumer’s home. These services might include any combination of the following: care management, nursing care, therapies, nutrition consultation, wound care, or homemaker services.They are not provided on a round-the-clock basis but, rather, for a few hours daily as needed. Home health is seen as a major means of avoiding institutionalization. Hospice care provides emotional and physical support for persons with terminal illness. It is usually provided in the home.
The continuum of care for older adults consists of preventive services, partial and intermittent care services, and complete and continuous care services. Institutional care (care delivered in an institution) – nursing facilities, assisted living/ residential care, and subacute care – most of their care is provided in facilities developed for that purpose. Non-institutional care (community-based) – adult day care, home health, hospice. Care provided in consumer’s home. Payers – increased emphasis on community-based, non-institutional services such as home care. Goal is to maintain independence and self-care capacity as long as possible. Supporting and coordinating community services and resources available to older adults is very important to achieve this. Changing eligibility rules. Most people prefer to be cared for at home. The distinction may not be as clear as it seems. Hospice care regular has both an institutional and noninstitutional component. Also, provider organizations are increasingly offering not only multiple levels of institutional care, but also noninstiitutional services such as home care. It’s better to make the distinction as to institutional and noninstitutional services , not providers. Adult day care is non-institutional, because the services, though delivered in an institution, are less than 24-hour care. Adult day care is community-based, since the consumer is not residing in an institution, but at home. Home and community-based care are the most common arrangements for older Americans. About 70-80% of noninstitutionalized older people receive care from friends and family or paid helpers (supplements).
There are approximately 1.5 to 2 million nursing home residents (4% to 5% of the older adult population), but predictions are than there will be 5.3 million Americans residing in nursing homes by 2030, representing more than a threefold increase in the next 20 years. Clearly this calls for increased education and recruitment of gerontological nurses to this setting as well as creation of new models of care. PREVALENCE: 4-5% (cross-section of elderly population) INCIDENCE (lifetime risk): Among the current generation of people entering their senior years, about half of all older women (47%) and nearly one-third of all older men (27%) will spend some time in a long-term care facility during their lives. Approximately one in four older adults will spend some time in a nursing home during the last years of their life. The incidence increases with age. In the 85+ population, one in five is in a nursing home (20% risk). 20% of the old-old. This is of great concern, due to the exponential growth of the old-old population. Nursing home residents represent the most frail of the older adult population. Residents of nursing homes are predominantly women, 80 years or older, Caucasian, widowed, and dependent in activities of daily living and instrumental activities of daily living. The average age for a nursing home resident is 85. It is the level of function, not the medical diagnosis, that influences the need for long-term care. Typically, residents of nursing facilities have dependencies n their ability to fulfill activities of daily living; many are incontinent and more than 60% are cognitively impaired. In many cases, their needs for 24-hour care were not able to be met in the home or residential care setting, or their needs may have exceeded the family’s ability to provide required care. Admission to a nursing facility was not the first or most desirable choice. In many situations, family members tried to assist in caregiving, but found that caregiving needs exceeded the family’s capacities. By the time the decision to seek nursing facility care is made, many families are physically, emotionally, and financially drained, adding to whatever guilt, depression, and frustration they feel about the situation. Often, a crisis triggers the need for placement in a long-term care facility, placing families in the position of having to seek and decide on a facility under less than ideal circumstances. Institutionalization – a very stressful time for the new resident and family. An important function of the gerontological nurse is to help residents and their families as they face the challenges of selecting and adjusting to a nursing facility. National average $76,460 – More than 1-1/2 times the average annual income in US of $48,201. NC average - $66,830 Most LTC services are rising at a rate faster than inflation which makes this expense very difficult for middle class families or seniors on fixed incomes.
Often, a resident’s move to a nursing home is sudden and unexpected.
About three-quarters of residents in nursing facilities are women. Opportunity for gerontological nurses to practice in a variety of settings. They can fill administrative and management roles as director of nursing, supervisor, unit nurse coordinator, or charge nurse. Nurses’ roles and responsibilities can differ vastly in different settings. They can fill specialized roles, such as staff development director, quality assurance coordinator, infection control coordinator, geropsychiatric nurse specialist, or rehabilitative nurse. Of course, nurses can also be direct care providers to residents. Independent nursing practice and the ability to develop long-term relationships with residents and their families are among the exciting features of nursing in this setting. Functions are varied and multifaceted. Admission assessments and the completion of the MDS assessment tool are coordinated by a registered nurse, and most of the entries on the MDS rely on nursing assessment. Problems identified through the MDS assessment tool direct care planning activity. The written care plan guides nursing actions; staff are held accountable by regulatory agencies for ensuring that care plans are accurate and followed. Nurses ensure that nursing assistants provide care appropriately and monitor residents to evaluate the effectiveness of care and to recognize changes in status.
The basic activities of daily living consist of these care tasks.
Although rates vary, the average cost of care in nursing facilities is in excess of $ 60,000 annually. Routine daily rates usually include room, board, nursing care, therapeutic activities, and social services, with other services, such as physical therapy and speech therapy usually being charged separately. In most cases, Medicaid is the largest source, supplying nearly half (46%) of the reimbursement they receive. Medicaid generally provides full coverage for residents who meet financial qualifications, although the rate is set by the state Medicaid agency. Other variables affecting the rates paid by various reimbursement sources include the specific services used, the number of ADLs with which assistance is needed, and factors such as private versus two-bed rooms. The limited reimbursement by Medicare of nursing home costs shifts the burden of payment to the individual resident or to the federal and state governments (Medicaid). For many older people, the costs are excessive. For those who can afford care, many have spent down all their savings paying for that care. There is growing concern nationwide related to the financing of long-term care and the ability of states and the federal government to continue to support costs through the Medicaid programs. Often the Medicaid reimbursement from the state does not cover the costs of nursing home facilities and causes facilities to operate in the red or close down. Reimbursement levels now often do not cover actual costs to the providers, and there is fear that if further cuts are made, the often precarious quality of care in these settings will be further compromised.
Medicare accounts for only about 13%, with private pay and other sources (such as Medicaid) making up the rest. As more nursing facilities venture into subacute care and/ or skilled nursing, the Medicare portion will rise. Also, as private long-term care insurance grows, albeit slowly, it will have more of an impact on the reimbursement mix of nursing facilities. Medicare places some hard and fast restrictions on coverage in nursing facilities: * It covers only skilled nursing care * It must follow a 3-day qualifying hospital stay * The care is limited to 100 days per benefit period (1 st 20 days are free) * It requires copayment ($141.50/day in 2011) for days 21-100. A copayment is usually a set amount, rather than a percentage. *A benefit period begins the day you're admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods. *The benefit period begins the day the person goes into a hospital or skilled nursing facility. The benefit period ends when the beneficiary has not received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. There is no limit to the number of benefit periods.
Nursing homes are one of most highly regulated industries in the United States . Although nursing homes recognize the need to enact legislation to ensure quality, the lack of additional funding for legislated initiatives has left many nursing homes struggling to maintain quality and meet standards with few resources. Criteria and standards often create a bureaucratic structure and a punitive environment that challenges those caring for nursing home residents. Federal and state regulations have become more onerous and time consuming than the care. Omnibus Budget Reconciliation Act (OBRA) of 1987 and frequent revisions and updates designed to improve the quality of resident care; have had positive impact. Some of the requirements for OBRA and subsequent legislation include the following: comprehensive resident assessments, increased training requirements for nursing assistants, elimination of the use of medications and restraints for discipline or convenience, higher staffing requirements for nursing, social work staff, standards for nursing home administrators, protection of resident rights, and quality assurance activities. A growing concern is the lack of adequate staffing, particularly professional nurses, in nursing homes. Current federal standards require only one RN in the nursing home for 8 hours per day – a figure quite shocking considering the ratio of RNs to patients in acute care, even with shortages in that setting. Despite drastic increases in the acuity level of nursing home patients, and the well-documented positive relationship between nurse staffing and quality of nursing home care, care continues to be provided in US nursing homes almost devoid of professional providers. The bulk of care is provided by unlicensed nursing personnel, and shortages are acute at this level as well. The documentation specific to nursing facilities is known as the Minimum Data Set (MDS). This federally mandated assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories. The MDS is a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes. It is a series of scripted interviews centered around the residents’ cognition, activity, personal preferences and pain. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems, residents’ needs, and wants, and help improve the quality of their care. -The MDS (Minimum Data Set) is the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. It is a federal database concerning resident data. -The MDS standardizes communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies. Nursing facilities that receive federal funds must complete for all residents a resident assessment instrument within 14 days and a care plan within 21 days.
The IOM is a nonprofit, interdisciplinary organization that conducts health care-related policy studies and serves as an advisor to the nation to improve health (IOM, 2009). A report issued by the IOM (2004) contends that the vast majority of U.S. nursing homes are understaffed and that this lack of adequate staffing directly threatens the well being of nursing home residents. This report also calls for regulatory and legislative changes to enforce improvements in staffing. It further recommends “the U.S. Department of Health and Human Services should update existing regulations… that specify minimum standards for registered and licensed nurse staffing in nursing homes” (IOM, 2004, p. 10). NC requires a minimum of 2.1 nursing hours per resident per day. The IOM recommends 4.1 nursing hours per resident per day.
Before assigning/delegating nursing activities to staff, the licensed nurse needs access to information about the RN-validated competencies for each individual. Definitions: Authority - The source of the power to act. Accountability - Being responsible and answerable for actions or inactions of self, and of others in the context of delegation or assignment. In this context, the licensed nurse retains the accountability for appropriate assignment and/or delegation. The person to whom an activity is assigned and/or delegated is accountable for carrying out the task correctly. Assigning- Designating responsibility for implementation of a specific activity or set of activities to a person licensed and competent to perform such activities. Delegating - Transferring to a competent individual the authority to perform a selected nursing activity in a selected situation. The nurse retains accountability for the delegation. Supervision – The provision of guidance or direction, evaluation, and follow-up for accomplishment of an assigned or delegated nursing activity or set of activities. UAP (Unlicensed Assistive Personnel) - Any unlicensed personnel, regardless of title, who may participate in patient care activities through the delegation process.
Right Task One that is delegable for a specific patient. Right Circumstances Appropriate patient setting, available resources, and other relevant factors considered. Right Person Right person is delegating the right task to the right person to be performed on the right person. Right Direction/Communication Clear, concise description of the task, including its objective, limits and expectations. Right Supervision Appropriate monitoring, evaluation, intervention, as needed, and feedback. The delegating nurse is responsible for an individualized assessment of the patient and situational circumstances, and for ascertaining the competence of the delegatee before delegating any task. The practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated. Supervision, monitoring, evaluation and follow-up by the nurse are crucial components of delegation. The delegatee is accountable for accepting the delegation and for his/her own actions in carrying out the task. The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation and evaluation). This necessarily precludes a list of nursing tasks that can be routinely and uniformly delegated for all patients in all situations. Rather, the nursing process and decision to delegate must be based on careful analysis of the patient's needs and circumstances. Also critical to delegation decisions are the qualifications of the proposed delegatee, the nature of the nurse's delegation authority set forth in the law of the jurisdiction, and the nurse's personal competence in the area of nursing relevant to the task to be delegated. The licensed nurse maintains accountability and responsibility for the delivery of safe and competent care. Decisions regarding delegation of any of the above activities are made by the licensed nurse on a client-by-client basis. The following criteria must be met before delegation of any task may occur: Task is performed frequently in the daily care of a client or group of clients Task is performed according to an established sequence of steps Task may be performed with a predictable outcome Task does not involve on-going assessment, interpretation or decision-making that cannot be logically separated from the task itself As part of accountability, the licensed nurse must monitor the client’s status and response to care provided on an on-going basis.
To work as a medication aide in an intermediate care nursing facility or skilled nursing facility , an individual must have a high school diploma or GED, be listed on the Nurse Aide I Registry, successfully complete a 24-hour NC Board of Nursing-approved medication aide training program, pass the State medication aide exam administered by Pearson Vue, and be listed on the State Medication Aide Registry. Medication Aides are certified through the NC Board of Nursing. This Medication Aide course is designed to meet the training requirements for the North Carolina Board of Nursing (NCBON) Medication Aide Certification. This certification allows Nurse Aides to administer medications to long-term care patients. Topics include: oral, topical, and instillation medication routes; medical asepsis; hand hygiene; terminology; and legal implications. Upon successful completion of this course, students are eligible to take the NCBON Medication Aide Exam. A nursing facility must verify an individual is listed on the NC Medication Aide Registry before allowing an individual to work as a medication aide. An employer must keep a record of accessing the Registry and must note each incidence of access in their business files. Proof of access will be in the form of a date and confirmation number assigned to the employer during the access process. 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. The medication aide who wishes to function in a skilled nursing facility must be listed as a Medication Aide and a Nurse Aide I with the NC Division of Health Service Regulation prior to functioning as a medication aide in such a facility. Medication aides who pass medications in long term care/skilled nursing facilities should not be confused with medication aides who pass medications in adult care settings (including assisted living facilities). Medication aides who pass medications in adult care settings (informally referred to as medication technicians [med techs]) are listed on a separate Medication Aide Registry maintained by the NC Division of Health Service Regulation’s Adult Care Licensure Section.
The Nursing Home Licensure and Certification Section licenses nursing homes to operate in the State of North Carolina. A potential owner of a nursing home must apply for and receive a Certificate of Need (CON) prior to applying for a license to operate a nursing home. Once a CON is awarded, the Construction Section oversees the construction of the building and verifies compliance with physical plant requirements. Following those processes, the owner submits required documents to this Section and goes through an initial survey process. During the initial licensure survey, the nursing home's policies and procedures, staff qualifications and operational systems are reviewed to determine compliance with state nursing home rules. Licenses are effective for one year. The Nursing Home Licensure and Certification Section conducts inspections of nursing homes for participation in Medicare and Medicaid under an agreement with the Federal government. Ninety-five percent of the nursing homes in North Carolina participate in the Medicare/Medicaid program. A licensed nursing home applies for certification. Inspectors from this Section, commonly called surveyors, conduct an onsite initial survey to determine whether the home is compliant with federal requirements. When a home is found compliant with federal requirements, the Centers for Medicare and Medicaid Services is notified and a certification is issued. Routine inspections occur in certified nursing homes every nine - 15 months. Nurses, pharmacists, dietitians and social workers who have passed a federal surveyor qualifications test conduct these inspections. The surveys typically take three days to complete and involve the comprehensive review of a facility's compliance with resident rights, admission and transfer rights, resident behavior and facility practices, quality of life, quality of care, nursing services, dietary services, pharmacy services, physician services, infection control, physical environment and administration. Surveyors investigate complaints filed against a facility according to the severity level of the nature of the complaint. This Section receives approximately 2,000 nursing home complaints per year. Complaints are investigated timely and complainants receive feedback on the outcomes of the complaint investigation. If a nursing home is cited for regulation non-compliance, it receives a document called a Statement of Deficiency. The home is required to provide a plan of correction for each deficiency cited and may be subject to other penalties. Surveyors follow up with the home to assure the deficiencies have been corrected. http://www.ncdhhs.gov/dhsr/mlicpage.htm
Nursing Homes are facilities that provide nursing or convalescent care for three or more persons unrelated to the licensee. A nursing home provides long term care of chronic conditions or short term convalescent or rehabilitative care of remedial ailments, for which medical and nursing care are indicated. Most of the residents are older adults who need long term care. Some residents are admitted for short stays of convalescent or rehabilitative care following hospitalization. All nursing homes must be licensed in accordance with North Carolina State law by the North Carolina Division of Health Service Regulation. There are over 300 nursing homes in North Carolina. The Division of Health Service Regulation regulates the number and location of nursing homes within North Carolina through the Certificate of Need program. Nursing homes that wish to receive Medicare and Medicaid reimbursement must be certified in accordance with federal law. These certification inspections are conducted by the Division of Health Service Regulation Certification Section. The Division of Health Service Regulation also has a Complaints Investigation Branch which investigates regulatory complaints within nursing homes. Facilities that violate licensure rules or the certification standards can be subject to sanctions, including fines. The Division of Health Service Regulation also maintains the North Carolina Nurse Aide I and Health Care Personnel Registry. While the Division of Health Service Regulation is responsible for ensuring regulatory compliance within nursing homes, the Long Term Care Ombudsman Program advocates on behalf of nursing home residents and provides a variety of services and assistance to nursing home residents, families, and providers. The Division of Health Service Regulation has responsibility for licensure and certification of nursing homes. The Division of Medical Assistance, the State Ombudsman, the Regional Ombudsman and the Nursing Home Community Advisory Committees (NHCAC's) also have roles and responsibilities related to the oversight of nursing homes. Further, boards of county commissioners, nursing home administrators, and NHCAC's also have important roles in the implementation of the Patients' Bill of Rights. In addition, the County Departments of Social Services have statutory responsibility for the investigation of the individual adult protective service (i.e. abuse, neglect, misappropriation) cases in nursing facilities. In order for a nursing home to participate in either Medicaid or Medicare programs it must be "federally certified" in addition to the licensure requirements. Certification surveys are conducted annually by federally trained survey teams located within the Licensure and Certification Section of the Division of Health Service Regulation of the State Department of Health and Human Services, and is a separate function from the inspections for receiving a license.
CMS's Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations. The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website. The State survey agencies are then responsible for entering survey information into the OSCAR database and providing updates as needed. Every attempt is made to assure the accuracy and timeliness of this information; however, we advise interpreting this information cautiously and supplementing it with information from the ombudsman's office, the State survey agency, or other sources. The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change. National database known as the Minimum Data Set (MDS) Repository The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident. Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission. All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources. Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.
An assisted living residence is a 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. The National Center for Assisted Living (NCAL) reports that assisted living settings have been known by as many as 26 different names, including residential care, personal care, adult congregate care, boarding home, and domiciliary care. There is no national licensing of these services, but they are licensed by state governments. Even there, the lack of uniformity in terms of what the services are called and how they are defined leads to great understanding. Put a bit more simply, assisted living is “a long-term care alternative for seniors who need more assistance than is available in a retirement community, but who do not require the heavy medical and nursing care provided in a nursing facility.” Assisted living is a residential long-term care choice for seniors who need more than an independent living environment can offer but do not need the 24 hour/day skilled nursing care and the constant monitoring of a skilled nursing facility. Assisted living provides security with independence and privacy, and it supports physical and social well-being with the health care supervision it provides. Assisted living costs less than nursing home care, but is more expensive than independent living. It is still fairly expensive. Older people or their families usually foot the bill. Health and long-term care insurance policies may cover some of the costs. Medicare does not cover the costs of assisted living.
The average resident in an assisted living facility is a female in her eighties, with an average stay of 3 years. The mean age of ALF residents is 80, but almost one half are 85 years of age or older. More than two thirds of assisted living residents are women. Most (80%) assisted living residents need some help with activities of daily living. Bathing is a common activity with which residents need help, followed by dressing, toileting, transferring, and eating. ALFs also provide help with instrumental ADLs. Instrumental ADLs include activities such as housework, shopping, meal preparation, money management, self-administration of medications, and telephoning. In one recent survey, 25% had moderate to severe cognitive impairment, 34% experienced urinary incontinence, 68% received assistance with bathing, and 86% received assistance with medications.
The number and types of services provided in ALFs varies considerably, but they generally include: Three meals a day served in a common dining area Housekeeping services & maintenance Transportation Assistance with eating, bathing, dressing, toileting and walking Access to health and medical services 24-hour security and staff availability Emergency call systems for each resident' s unit Health promotion, exercise, & educational programs Medication management Personal laundry services Social and recreational activities Personal care services Various health care services – the types and intensity of services provided in most ALFs are very similar to those services provided by home health care agencies in consumers’ homes. Social services Supervision of persons with cognitive disabilities – many residents in assisted living suffer from some type of cognitive disability, although the extent of such disabilities may vary considerably. Cognitive disability means that an individual has a level of dementia or may simply be unable to understand and follow directions. Social and religious activities Although most ALFs offer all of the above, it is not necessary for every resident to use all of them. In fact, beyond the basic housing and supervision, many of the services are provided on an a la carte basis, with the residents paying only for what they use. Residents are evaluated prior to or at the time of admission to determine the services they need or desire. A service plan, not unlike a care plan in a health care facility, is developed and used as the basis for delivery of services. The service plan can be revised as needed and is reviewed on a periodic basis.
Basic daily charge - Varies by type of facility & resident’s living quarters - Single room, apartment, suite
Assisted living is more expensive than independent living and less costly than skilled nursing home care, but it is not inexpensive. Costs vary by geographic region, size of a unit and relative luxury. Costs can range from a low of $1200 per month to a high of $5000 per month. Across the nation, the median monthly rate per resident is $3000. Because ALFs vary so in the extent of services provided and in just how fancy those services and the living quarters are, costs also vary widely. The most common source of financing for assisted living is self-pay. Who pays the bill for an assisted living residence? Residents or their families generally pay the cost of care from their own financial resources. Depending on the nature of an individual's health insurance program or long-term care insurance policy, costs may be reimbursed. In addition, some residences have their own financial assistance programs. Government payments for assisted living residences has been limited. Some state and local governments offer subsidies for rent or services for low income elders. Others may provide subsidies in the form of an additional payment for those who receive Supplemental Security Income or Medicaid. Some states also utilize Medicaid waiver programs to help pay for assisted living services. Private pay – use of an individual’s own funds – remains the largest source of reimbursement for assisted living. Medicare does not cover it, although in some cases there is some coverage under Social Security Supplemental Income (SSI). Medicaid is small but growing source of reimbursement. The primary reason for this is the need for states to find cost-effective alternatives to more expensive nursing facility care. Assisted living costs are considerably less than nursing facility care because there is less need for expensive nursing care and therapies. Other reimbursement comes from private long-term care insurance and managed care organizations. The majority of expense for assisted living is out-of-pocket. Some Medicaid voucher programs will pay, but not a lot.
ALFs, like nursing facilities, are highly staff intensive, although there are some differences in the particular jobs. Although some ALFs employ nurses and other clinical staff, they are not necessary for provision of basic services. Most of the staff in ALFs are there to provide customer services such as preparing meals, housekeeping, and maintenance. Direct care is provided mostly by personal care attendants and certified nursing assistants. Nursing care is provided as needed. Other employees include activity directors, health and wellness staff, and those performing special services such as beauticians and nutritionists. Customer service focus – focus of staffing is on making the residents comfortable, happy, and safe. The customer service concept found in assisted living is not that different from what is found in hotels and resorts. Staffing levels in assisted living are much less controlled by regulations than at other levels of long-term care, although this is changing in many instances. When state governments do regulate assisted living, requirements for minimum staffing levels are not uncommon. One problem many ALFs have with such regulations is that they tend to be based on a nursing facility model. After all, that is where most regulating agencies have the most experience. In spite of the good intentions of the regulator, the nursing care model of staffing is not a good fit in ALFs. Training – particularly important because employees coming from outside healthcare or from other healthcare facilities may not be familiar with the services provided in ALFs. Those coming from outside have to understand the needs of the residents who, although the emphasis is on independence and as normal a lifestyle as possible, still require assistance. The balance between serving and caring can be delicate but must be maintained. Medication aides who pass medications in long term care/skilled nursing facilities should not be confused with medication aides who pass medications in adult care settings (including assisted living facilities). Medication aides who pass medications in adult care settings (informally referred to as medication technicians [med techs]) are listed on a separate Medication Aide Registry maintained by the NC Division of Health Service Regulation’s Adult Care Licensure Section. No high school diploma or GED required. No formal training required. Successfully pass training administered by the N.C. Division of Health Service Regulation, Adult Care Licensure Section with a score of at least 90% within 90 days after successful completion of the clinical skills validation portion of a competency evaluation
How is assisted living regulated? Licensing and other assisted living regulations vary from state to state contributing to the wide range of senior housing models considered assisted living. Most providers and their staff have special training as a result of either state requirements or company policy. Some states require special staff certification and training. Residences must comply with local building codes and fire safety regulations. Regulation of assisted living has been hit or miss at best. It has grown sporadically. Although nursing facilities have been heavily regulated for decades, it is only in the past few years that ALFs have been regulated to any significant degree. However, state licensing agencies have been working diligently to make up for lost time. The National Academy for State Health Policy, an agency with experience chronicling state health regulations, reported in 2002 that 32 states and the District of Columbia had a licensing category or statute that included the term “assisted living.” But even as more states become involved in licensing ALFs, there is still little commonality in the specifics of their regulations. Some states use a specific model of assisted living: a consumer-centered philosophy, apartment settings, a residential environment, and a broad array of services that support aging in place. Others have consolidated separate categories so that such services as assisted living, board and care, multilevel unit elderly housing, congregate housing, and adult family or foster care are all covered under a single set of regulations. Gerontological nurses are challenged to ensure that appropriate standards of care are developed and practiced in this setting to avoid the scandalous conditions that plagued the early development of nursing homes, and to advocate for payment options for assisted living for those individuals who lack private funds to afford this care. The Assisted Living Workgroup issued a report to Congress in April 2003. In that report they made several recommendations concerning regulation of ALFs. Among them was a recommendation that a national Center for Excellence in Assisted Living be formed and funded to continue the work of the ALW and serve as an ongoing source of information and guidance to states regulating assisted living. Assisted living facility does not fall under OBRA guidelines. There is very little regulation or conformity. Often there are no licensed staff onsite, although some type of staff must be present 24/7 to oversee the residents.
The North Carolina General Assembly has defined assisted living residence to mean “any group housing and services program for two or more unrelated adults, by whatever name it is called, that makes available, at a minimum, one meal a day and housekeeping services and provides personal care services directly or through a formal written agreement with one or more licensed home care or hospice agencies. The Department of Human Resources may allow nursing service exceptions on a case-by-case basis. Settings in which services are delivered may include self-contained apartment units or single or shared room units with private or area baths.” North Carolina recognizes three types of assisted living residences: adult care homes, group homes for developmentally disabled adults, and multi-unit assisted housing with services. Adult care homes are residences for aged and disabled adults who may require 24-hour supervision and assistance with personal care needs. People in adult care homes typically need a place to live, some help with personal care (such as dressing, grooming and keeping up with medications), and some limited supervision. Medical care may be provided on occasion but is not routinely needed. Medication may be given by designated, trained staff. These homes vary in size from family care homes of two to six residents to adult care homes of more than 100 residents. These homes were previously called "domiciliary homes." Some people refer to them as "rest homes." The smaller homes, with 2 to 6 residents, are still referred to as family care homes . In addition, there are Group Homes for Developmentally Disabled Adults, which are licensed to house two to nine developmentally disabled adult residents. Adult care homes are different from nursing homes in the level of care and qualifications of staff. There are over 1,400 adult care homes in North Carolina. They are licensed by the state Division of Health Service Regulation (Group Care Section) under State regulations and are monitored by Adult Home Specialists within county departments of social services. Facilities that violate licensure rules can be subject to sanctions, including fines. In addition, homes must also respect the rights of residents as outlined in the North Carolina General Statutes. While the Division of Health Service Regulation Group Care Section and the Department of Social Services' Adult Home Specialists are responsible for assuring the homes' compliance with these rights and the state Licensure law, North Carolina also enjoys a well-established Long Term Care Ombudsman Program. The Ombudsman Program advocates on behalf of adult care home residents and provides a variety of services and assistance to adult care home residents, families, and providers. Multi-unit assisted housing with services is a category of apartments or other independent living residential arrangements where services are offered to enable residents with special needs to live in an independent, multi-unit setting. At a minimum, one meal a day, housekeeping services and personal care services are available. Hands-on personal care and nursing care, which are arranged by housing management, are provided by a licensed home care provider, through a written care plan. Residents must not be in need of 24-hour supervision.
Broad definition: Improvement of functional capacity to promote coping; Maximal independence; Sense of well-being Functional status rather than diagnosis directs rehabilitative care What is subacute care? It is a phase of inpatient restorative or rehabilitative health care that occurs immediately following a physically debilitating illness, surgery or injury. Who is a candidate for sub acute care? Determining whether an individual, who has had a debilitating health threatening event, is a candidate for subacute care is guided by general criteria for admission to subacute care services. General criteria include: stabilization of some acute health care problem, the need for rehabilitative services to restore physical function, ability to participate in daily rehabilitative therapy, anticipated discharge from inpatient to community residence or a specialty rehabilitation facility for more intensive rehabilitation within approximately 3 weeks. What are functional goals? In subacute settings, care planning is 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. Functional status can change within an individual depending on the symptoms, progression of the disease or disability, and mood Functional Assessment: Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Assessment over time is essential to determine the needs and goals for patient care
As the acute care hospital has become the site of surgical, emergency, and intensive care, the traditional nursing hoe has been transformed into a center for the coordination of the continuum of care. After spending a few days in an acute care hospital, the elder is often moved to either a rehabilitation hospital for specific therapies expected to increase the elder’s function or to a subacute (sometimes called postacute) care unit that functions much like the general medical-surgical hospital units of the past, although they are presently most often located in nursing homes. Subacute care is a relatively new and rapidly growing medical care service in America – the newest entry into the continuum of care. It merges the sophisticated technology of a hospital and the efficient operation of a skilled nursing facility to reduce the cost of services while maintaining the high quality of care. Subacute care is more intensive than traditional nursing facility care and several times more costly, but it is far less costly than similar care in an acute care hospital. Mediare usually covers most of the cost for subacute care if the person has skilled needs. The expectation is that the patient will be discharged home or to a less intensive setting. The stay in a subacute care unit is likely to be less than 1 month and is largely reimbursed by Medicare. Subacute care has emerged as one of the key solutions to reforming the American health care delivery system. It is also the fastest growing segment of the healthcare delivery system. As a result, nursing facilities are dedicating entire wings, even entire facilities, to provide high-tech, hospital-like medical care to seriously ill patients of all ages at half the cost of hospital-based facilities. Subacute care is given as part of a specifically defined program, regardless of the site. Subacute care is generally more intensive than traditional nursing facility care and less than acute care. It is comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process. It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization to one or more technically complex treatments, in the context of a person’s underlying long-term conditions and overall situation. Generally, the condition of the individual is such that the care does not depend heavily on high-technology monitoring or complex diagnostic procedures. Subacute care requires the coordinated services of an interdisciplinary team including physicians, nurses, and other relevant professional disciplines, such as physical therapy, occupational therapy, or speech therapy. It requires frequent (daily to weekly) recurrent patient assessment and review of the clinical course and treatment plan for a limited (several days to several months) time period, until the condition is stabilized or a predetermined treatment course is completed.
Like most other aspects of subacute care, staffing requirements fall somewhere between acute care staffing and nursing facility staffing. There are some basic elements, however, that must be included. As defined by JCAHO, subacute care “requires the services of an interdisciplinary team whose members are trained to assess and manage specific conditions to perform necessary procedures.” An interdisciplinary team – philosophy of care; organizational structure. Team will vary somewhat but would include a program administrator, a medical director, case managers, physicians, nursing social services, psychology, physical and occupational therapy, therapy for speech-language pathologies, respiratory therapy, recreation therapy, and dietary/ nutrition. Program administrator – person in charge administratively. Might be called program manager, program director, administrator, or some variation of those titles. Has clear responsibility and authority for operation of the subacute care unit or facility. May have related clinical background or may be trained in healthcare administration. Regardless of background, the person responsible for running the unit or facility must have good management skills. Physicians – critical to success of the subacute care program. Should be a medical director with designated responsibility for clinical oversight of the program, ensuring its integrity. Other duties – direct care of some patients, trained in care of the types of patients to be treated (such as specialist in internal medicine or geriatrician). Physicians need to visit more often than in the traditional nursing facility, although generally not as often as in an acute hospital. Nursing – critical importance. Must be 24-hour coverage by registered nurses. Patients in transitional medical programs will usually require more than some other rehabilitation patients. Some highly specialized subacute care, such as pulmonary rehabilitation or neurobehavioral programs, may require considerably more, even approaching acute staffing levels. Other professional staff – therapists, psychologists, social workers, dieticians, and others. Services obtained through direct hire, consulting, and contracting through an independent company. Non-licensed staff – Committed, well-trained cadre of nonlicensed workers, including nursing assistants and staff in housekeeping, maintenance, the business office, and medical records. They must be in tune with the overall philosophy of the subacute program.
Different categories of subacute care: Short-term transitional – short-term, serving as a means of transferring patients from highly-intensive, more expensive hospital units while maintaining the availability of acute care if needed. Such transitional units are usually located at or near hospitals and are operated by those hospitals. Most of these patients are recuperating from major illness or surgery, have complex health monitoring needs, or require palliative care with pain and symptom control. These patients may be head injured or on ventilators, require aggressive rehabilitation after injury or surgery, or require the services and intensive treatments from specialists such as physical therapists, occupational therapists, dietitians, and other specialties. Diagnostic and support services of the acute care facility support the care given on transitional care units as needed. Usually rehabilitation in these facilities is covered by the patient’s private insurance or Medicare. Long-term transitional – usually hospital-based care for patients with more complex medical problems who need more intensive (but still not acute) care over a longer time before transitioning to home or another level of care. Chronic – care for patients with serious chronic conditions requiring services such as ventilator or intravenous therapy. The average stay in longer than those in the transitional or general subacute care units, but most patients stay only about 60 to 90 days before they die or are able to be transferred to a lower level of care. Thus, subacute care, as a portion of the continuum, is best defined in terms of the type, amount, and duration of care given. There is emphasis on staff with skills in assessment of patients’ conditions and the ability to adjust treatment plans as needed. They must also be skillful at managing specific conditions, such as strokes or post cardiac surgery care, and in performing specific procedures such as ventilator therapy or pain management. For skilled nursing facilities, if short stay, is Medicare reimbursed. If chronic, the reimbursement is private pay or Medicaid.
Services provided in subacute care units vary depending on the nature of the population served, but might include any of the following.
This is the terminology nursing homes use – They divide nursing home care into SNF and NF. A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services. Skilled nursing care - Care such as intravenous injections that can only be given by a registered nurse or doctor. Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
Intermediate care facilty = nursing facility (not skilled) = regular nursing home Most nursing homes have both intermediate and skilled sections (certified by Medicaid and Medicare respectively). The intermediate section services residents who just need "custodial" care - incapable of living alone due to dementia/ stroke/ bedbound, etc. These residents have multiple chronic comorbid conditions leaving them with severe functional deficits. They will not be getting any better and they, unfortunately, are not candidates for rehab or skilled care. They need 24/7 help with ADLs, but very little skilled nursing help. They are considered a "stable" patient population overall, even though the vast majority are very old and frail. Because of federal law (OBRA), there must be a minimal amount of licensed nurses in intermediate nursing facilities (nursing homes) - one RN present 8 hours per day and a LPN available on site 24 hours per day. An example is the 94-year-old man who has been treated for his pneumonia in an acute care facility but is now completely dependent in all ADLs. If the physician or primary care provider deems that he will not improve, that he is just too old and frail, then he is not a candidate for rehab or skilled care. (To be a candidate for rehab, there has to be some hope for rehabilitation. The patient also has to be strong enough to endure 3 hours worth of tough therapies daily [OT, PT, Speech - if necessary]. He will be placed in a nursing home for an indefinite period of time. Medicare will not pay for his expenses. Medicaid might, if he is poor enough. If not, he will need to "spend down" his assets to cover his nursing home expenses. Only after he has spent down everything will Medicaid begin to pick up the nursing home tab. Skilled sections are similar to rehabilitation units.Skilled nursing facility = subacute = rehabilitation unit - All very similar and financed by Medicare, but only for a limited period of time per benefit period (first 20 days full pay, days 21-100 with copay, after day 100, no pay). An example is the fully alert and oriented 84-year-old woman who fell and broke her hip, then had an ORIF, is a candidate for rehab. The interdisciplinary health care team on the skilled unit will help her get her independence back. And, she will only be there for a short time (usually 20 days or less). Medicare will pay for her expenses. Nurses on the skilled unit often perform highly skilled tasks, such as complicated dressing changes, Wound Vacs, chemotherapy, IV antibiotics, accessing ports/ CVLs/ PICC lines, tracheostomy care and suctioning, CPM machines, etc.
The largest source of reimbursement for subacute care is Medicare. There is no single payer for subacute services, nor any standardized payment mechanism. Most reimbursement comes from Medicare, Medicaid, and MCOs, with a small amount from other insurance. One survey indicated the following proportions: Medicare paid 68%, managed care 14%, Medicaid 10%, indemnity insurance 6%, and 2% came from other sources, mostly private pay. Has to have “rehabilitative potential” in order for Medicare to pay. Medicare has moved from a retrospective, cost-based payment system to a prospective payment system (PPS) for both acute care and subacute care (result of Balanced Budget Act of 1997). Under the PPS, providers receive payment based on preestablished rates for specific services instead of receiving direct reimbursement for their costs. Managed care – increased influence; growing very rapidly in subacute care. Not only private MCOs, but government programs. MCOs are freer to create new and innovative payment mechanisms than are government programs such as Medicare and Medicaid. Some of the most common payment arrangements between MCOs and subacute care providers are discounts from the provider’s standard charges, payment per day of treatment (per diem), payment per episode of patient treatment (per case), payment per enrollee for a given time period (capitation), and payment as a percentage of the premiums paid by MCO enrollees. One study indicated that both hospital-based and free-standing subacute care providers had an average of 11 managed care contracts.
A. Functional status of individuals describes the capacity and performance of safe ADLs and IADLs. 1 , 2 , 3 , 4 and is a sensitive indicator of health or illness in elders and therefore a critical nursing assessment. 5 , 6 , 7 , 8 B. Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, toileting schedules, enhanced communication, adaptive equipment, and attention to medications and dosages). 9 , 10 , 11 , 12 C. Some functional decline may occur progressively and is not reversible. This decline often accompanies chronic and terminal disease states such as degenerative joint disease, Parkinson’s disease, dementia, heart failure, and cancer. 13 D. Functional status is influenced by physiological aging changes, acute and chronic illness, and adaptation to the physical environment. Functional decline is often the initial symptom of acute illness such as infections (e.g., pneumonia and urinary tract infection). These declines are usually reversible and require medical evaluation. 1 , 14 Functional status is contingent on motivation, cognition, and sensory capacity, including vision and hearing. 15 E. Risk factors for functional decline include injuries, acute illness, medication side effects, pain, depression, malnutrition, decreased mobility, prolonged bedrest (including the use of physical restraints), prolonged use of foley catheters,and changes in environment or routines. 10 , 11 , 16 F. Additional complications of functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, and increased risk for long-term institutionalization and depression. 11 , 16 , 17 G. Recovery of function can also be a measure of return to health, such as for those individuals recovering from exacerbations of cardiovascular or respiratory diseases and acute infections, recovering from joint replacement surgery, or new strokes. 3 H. Functional status evaluation assists in planning future care needs post-hospitalization, such as short-term skilled care and home care. 11 , 18 . I. Physical environments of care with attention to the special needs of older adults serve to maintain and enhance function (i.e., chairs with arms, elevated toilet seat, levers versus door knobs, enhanced lighting). 7 , 11
The goal of nursing care is to maximize the physical functioning, prevent or minimize decline in ADL function, and plan for future care needs. Guidelines for Rehabilitative Nursing Know the unique capacities and limitations of the individual Emphasize function rather than dysfunction Provide time and flexibility Recognize and praise accomplishments EXPECTED OUTCOMES Patients will: 1. Maintain safe level of ADL and ambulation. 2. Make necessary adaptations to maintain safety and independence, including assistive devices and environmental adaptations. Act for or do for when the person is unable to take action for himself or herself. 3. Strive to attain highest quality of life despite functional level. Increase self-care capacity. Eliminate or minimize self-care limitations. 4. Improving functional capacity can promote well-being and quality of life
Prevent complications Care coordinator Multidisciplinary team effort Teaching: Bowel and bladder training, regimens; proper use of mobility aids
Adult day-care programs have been a growing component of community-based, long-term care. There are currently over 3500 centers that provide adult day care in the Unites States. The programs maximize the existing self-care capacity of participants while preventing further limitations. Adult day-care programs are sponsored by public agencies, religious organizations, and private groups, with one-third being freestanding and the remaining ones affiliated with a larger parent organization; each varies in schedule, activities, costs, and program focus. Medical insurance does not cover charges and most are private pay. Adult Day Health Care: First year research findings indicate the average annual cost for five days a week in an adult day health care facility is $15,236 nationally. The comparable cost in Charlotte is $11,661 and $11,817 throughout the rest of the state. The Creative Living Center in Greenville (been there for 20 years) is private pay and also supported by grant money from the Mid East Commission. Sliding-scale pay based on level of care and income - $22 to $44 per day.
Adult day care serves people who fall between needing institutional long-term care and being able to function on their own. Adult day care is a form of long-term care that provides interim (less than 24-hour) supervision for individuals who cannot be without supervision or assistance. They do not need the more complete services of a nursing care facility, nor can their needs be met by periodic home care. The National Adult Day Services Association (NADSA) defines adult day services as “community-based group programs designed to meet the needs of functionally and/or cognitively impaired adults through an individual plan of care. These structured, comprehensive programs provide a variety of health, social, and other related support services in a protective setting during any part of a day, but less than 24-hour care.” Adult day centers generally operate programs during normal business hours 5 days a week. Some programs offer services in the evening and on weekends. These centers provide health and social services to persons with moderate physical or mental disabilities and give respite to their caregivers. Adult day care allows elderly or frail individuals to remain at home with family members when they would otherwise have to move to a long-term care facility. The programs attempt to maximize the existing self-care capacity of participants while preventing further limitations. Adult day care developed from the concept of respite – providing a short reprieve from the responsibilities of care giving for those who have a family member living with them who needs constant care and supervision. Society has moved from a more inclusive nuclear family to families that are separated by distance and/ or where both husband and wife must work. Individuals attending day centers often include persons with Alzheimer’s disease or related dementia, mental retardation, heart disease, diabetes, Parkinson’s disease and those recovering from strokes. Adult day care provides a mix of social, recreational and health activities and services in a group setting - along with the following benefits: • Helps cognitively- and physically-impaired adults maintain or improve their level of functioning. The goal is for them to remain in a community setting, enjoying their sense of dignity and self-worth. • Offers opportunities for socialization and peer support. • Offers nursing and social services in a stimulating environment. • Promotes improvement in mental and physical health. • Provides assistance to families and/or caregivers who have an adult who cannot be left alone during the day, yet does not need 24 hour care in a nursing home. • Helps functionally impaired individuals who live alone and need support services to improve or maintain their level of independence. • Prevents social isolation and the mental deterioration that often accompanies it.
Adult day care operates on a philosophy of providing needed services for both the person receiving the care and those responsible for that care. In this sense, it is somewhat different from other forms of long-term care. True, in all of long-term care, from nursing facilities to home care, family members are involved with care and are considered “extended consumers.” The difference with adult day care is a matter of degree. As service beneficiaries, the caregivers are nearly as important as the care recipients themselves. Adult day care centers approach their care of consumers in a holistic manner, seeking to maintain and improve their quality of life while protecting them from injuries or neglect that might result from their inability to look after themselves. Independence is promoted, and self-confidence is improved. Social interaction with other consumers and the staff of the day care center helps them achieve a way of life that is as close to normal as is possible given their physical or cognitive impairments. It has been shown that the improvements in functional independence carry over to their lives at home, making it better for them and their caregivers. An adult day care center offers numerous benefits to those who use them, including: The chance to live with their families and not be a full-time burden Opportunities for social interaction with peers A program of stimulating activities Physical or speech therapy in a nonmedical environment Help with activities of daily living with dignity
As with most long-term care providers, the specific services provided vary depending on the nature of the consumers served and the interests of the providers. Participants attend the program for a portion of the day and enjoy a safe, pleasant, therapeutic environment under the supervision of qualified personnel. Although the primary focus is social and recreational, there usually is some health screening, supervision of medication administration, and monitoring of health conditions. Rest periods and meals accompany the planned therapeutic activities. Adult day care centers are generally grouped into two categories: Social day care and Health day care. Social Model The social model of adult day care is the original form and has been around since the 1970s. Its primary purpose is providing a safe and secure environment for people without significant health care needs but who may have some minor limitation in the activities of daily living (ADLs). The social model provides consumers with relief from boredom and loneliness, conditions that can lead to feelings of isolation and depression. It allows seniors and others with some mild cognitive impairment to interact with others in a sheltered setting. Individuals with Alzheimer’s disease are often candidates for social adult day care. They cannot be left alone because of memory loss or a tendency to wander, but in an adult day care center they can be supervised appropriately. Services focus on socialization and recreation and may range from group singing and bingo to more challenging activities, depending on the cognitive levels of those participating. Communal meals and other group activities such as field trips add to the social interaction and sense of belonging. Senior citizens centers provide most of the services typical of a social adult day care center, although many are not called such. Their users need less in the way of supervision or assistance, but the socialization benefits are similar. Health Care Model Over time, many adult day care centers have found themselves caring for more and more people with medical or other significant health problems who need more than purely social day care centers could offer. For example, most would assist their consumers to remember to take self-administered medications. However, the medicines available to help the elderly became more complex, and the staff began seeing a need to actually administer the medications (e.g., insulin for diabetics). They began adding limited nursing care and eventually expanded to include other health services, including administration of medication, blood pressure monitoring and other clinical measures, and medical evaluation. Today, most adult day health centers provide health screening and a variety of therapies, including physical, occupational, speech, and recreational. Nutrition counseling and other health education are popular as are social services, With the added health services available, consumers needing assistance with several ADLs can participate.
Adult day care centers are staffed by a combination of professional and nonprofessional employees, with the proportion of each determined by the nature of the center (social or health model) and the particular services offered. Both social model and health model day care centers have staff trained in personal care, activities, and/ or recreation, and nutrition. They may also have positions such as activity coordinator, recreation assistant, drivers, and cooks. Adult day health care centers have more health care professionals available, either part-time or full-time, including physicians; nurses; physical, occupational, speech, and recreation therapists; nutritionists; and social workers. There is also usually a category comparable to the certified nursing assistants found in nursing facilities or the home health aides found in home health agencies. They are often called program aides or health aides. The ratio of staff to consumers may be defined in those states that license adult day care centers. A review of both state regulations and the literature suggests that the average direct care staffing ratio varies from 1:6 to 1:4 for adult day health care centers. Adult social day care centers are more likely to have a ratio around 1:8.
The distinction between social adult day care and adult day health care is not all that clearly drawn, but most often it is a matter of degree. The one factor that does separate them, however, is who pays. Only those providing health services are eligible for funding by Medicaid vouchers or by grants. Even with the health centers, most are private pay. However there are certain basic services that are provided by most centers, whether social or health care oriented (safe, secure environment; social & recreational activities; assistance with ADLs; at least one meal & additional snacks; transportation to and from the center; consumers – and caregivers – both served). Transportation to the site is provided, usually by vehicles equipped to accommodate wheelchairs and persons with other special needs.
In the Greenville Creative Living Center (Adult Day Health Care), there is one RN on duty 4 hours per day. She monitors participants’ health, medications, blood pressure, vital signs, finger stick blood sugars. Keeps an eye on medical condition.
Consumers of the services of adult day care are those individuals who fall between needing institutional long-term care, such as nursing facilities, and being able to function on their own. Most live at home with family members or other informal caregivers. Some do live alone but could not do so without family or neighbors nearby to help them. They may need assistance because of medical conditions, cognitive or functional impairment, or inability to handle the day-to-day tasks they previously took for granted, such as personal care, cooking meals, or taking medication. Many take advantage of adult day care to provide the mental and intellectual stimulation of interacting with others. Most are elderly, with several studies showing an average of 70 to 75 years, although some adult day care centers serve younger clients who need them because of mental or physical conditions limiting their ability to function without help. Far more women than mean make use of adult day care, reflecting the disproportionate number of women living into their 70’s and 80’s.
The caregivers of adult day care consumers are spouses, children, friends, and volunteers. To distinguish them from those who give care as part of their jobs, they will be referred to as “informal caregivers.” Formal caregivers are the staff members of healthcare organizations: nursing and assisted living facilities, hospitals, subacute care units, home care agencies, and hospice programs. Informal caregivers are not unique to adult day care, although they are critical to it. Many people receiving any form of noninstitutional care, including home care and some forms of hospice, rely on informal caregivers for much of the care they receive outside of the formal system. Others, whose only formal care is an occasional visit to a physician’s office or outpatient department, also rely on informal caregivers. Without that support, they might well need more services, even admission to a long-term care facility. *Nearly one of every four US households (23% or 22.4 million) provides care to a relative or friend aged 50 years or older. *Approximately 15% of US adults care for a seriously ill or disabled family member. Some 13.3 million people – 7% of US adults – are spouses or adult children of disabled older people and have the potential responsibility for their care. Of these, about 85% (11.4 million) are adult children. Approximately 7.3 million people are informal caregivers, providing unpaid help to disabled older people living in the community. Of these, about 60% (or 4.2 million) are spouses and adult children, and remaining 40% (3.1 million) are other relatives, friends, and neighbors. The majority of caregivers are female (72%) , mostly wives and adult daughters. The average age of a caregiver is 57 years. More than one in three, however, are older themselves (65 years or more). Informal caregivers play a huge role in providing care to long-term care consumers. Adult day care services provide much-needed relief for those caregivers. It may also make it possible for them to go shopping or hold down a job, bringing in needed income for the family. Caregivers sacrifice much to care for their loved ones, often placing their own health in jeopardy. Caregivers feel an obligation to do as much as they can and resist asking for outside assistance. Services such as those provided in adult day care centers can give these family members valuable assistance and do it without taking away independence or breaking any of the bonds that exist. This helps them avoid the feelings of guilt. It stops short of taking a beloved family member away to a nursing facility or other institutional setting, and that means a great deal to them.
Adult day care provides an organized program of services during the day in a community group setting for the purpose of supporting the personal independence of older adults and promoting their social, physical, and emotional well-being. Programs must offer a variety of activities designed to meet the individual needs and interests of the participants, including referral to and assistance in using other community resources. Also included in the service, when supported by funding from the Division of Aging and Adult Services, are medical examinations required for individual participants for admission to day care services and thereafter when not otherwise available without cost. Food and services to provide a nutritional meal and snacks, as appropriate are also expected. Providers of adult day care must meet NC State Standards for Certification, which are administrative rules (10A NCAC 06R) set by the Social Services Commission. These standards are enforced by the State Division of Aging and Adult Services. Routine monitoring of compliance is performed by Adult Day Care Coordinators located at county departments of social services. Costs to consumers vary, and there is limited funding for adult day care from state and federal sources. Adult day health services are similar programs to adult day care in that they provide an organized program of services during the day in a community group setting to support the personal independence of older adults and promote their social, physical, and emotional well-being. In addition, providers of adult day health services, as the name implies, offer health care services to meet the needs of individual participants. Programs must also offer referral to and assistance in using other community resources, and transportation to and from the program may be provided or arranged when needed and not otherwise available. Also included in the service, when supported by funding from the Division of Aging and Adult Services, are medical examinations required for individual participants for admission to day health care services and thereafter when not otherwise available without cost. Food and services to provide a nutritional meal and snacks as appropriate are expected as well. Providers of adult day health services must meet North Carolina State Standards for Certification, which are administrative rules (10A NCAC 06R) set by the Social Services Commission and enforced by the State Division of Aging and Adult Services. Routine monitoring of compliance is performed by Adult Day Care Coordinators located at county departments of social services. Centers may be certified to provide both adult day care and adult day health services. Many centers are members of the NC Association of Adult Day Services.
When working with community-based older adults, nurses focus on maintaining independence, preventing risks to health and well-being, establishing risks to health and well-being, establishing meaningful lifestyles, and developing self-care strategies for health and medical needs.
Home health began in the latter part of the 1800s as a service of city health departments called visiting nurse services. They often supplemented the work of physicians at a time when doctors regularly made house calls. In time, these visiting nurse associations sometimes separated from the municipal government and became free-standing. They still relied heavily on funds contributed by the cities and private sources of philanthropy. As third party reimbursement became more available, home health agencies became even more independent. In the 1980s and 1990s, as reimbursement sources, particularly Medicare and Medicaid, looked for ways to reduce their ever-increasing costs, there was a concerted move to divert long-term care residents from institutional care to home-based care.
Home health care is based on the concept of taking the services to the consumer. The philosophy of home health care is quite simple – to take health services to the consumer rather than requiring the consumer to go to where the services are delivered. There are several qualifiers defining who receives home health care. They are included in the Medicare eligibility requirements and are a good guide for defining home health care in general. Physician ordered care – Home health care must be ordered by a physician. Nonhealth services such as homemaking and other supportive services may be provided without a physician’s order, but without that order they are usually not provided by a home health agency. There are organizations that provide only such services. The physician ordering home health care services also participates in developing a plan of care for the patient. Intermittent care – Full-time care is not needed. Medicare defines intermittent care as care that is given fewer than 7 days per week or less than 8 hours per day. In most cases, home health care is provided for a few (3-4) hours at a time, several times a week. Different health care professionals (e.g., nurses, therapists, social workers) may visit on different days. To recap, Medicare defines intermittent care as care that is delivered less than 7 days per week, and less than 8 hours per day. Homebound consumers - The recipient of home health care must be essentially homebound, meaning unable to leave home without a major effort. The only exceptions are infrequent, short trips to get medical care or attend religious services. Home health care may be short-term or long-term. Short-term care usually provides a transition from an acute episode of care to self-reliance. Patients can be released from a hospital or rehabilitation facility sooner if they can get the care they need at home. Follow-up nursing care and therapies are commonly used in this way. Long-term home health care is for people who need ongoing care because of an illness or a diminution of functional capability. They need the services over a period of time but only on an intermittent basis.
Yes, being bedridden is NOT a requirement of being homebound.
The different types of home care providers include home health agencies, hospices, homemaker and home care aide agencies, and staffing and private-duty agencies. Some types of home health care (medical equipment and supplies, pharmaceuticals, and drug infusion therapy) are provided by companies specializing in those services. Home Health Agencies & Hospice – First, there are those agencies that are Medicare certified. This is the group usually meant by the term “home health agency.” They provide skilled nursing care and other health care-related services such as therapies, social services, and counseling. Hospice is a form of home care providing care for people who are terminally ill. Homemaker and home care aide agencies – Home care aides, or homemakers, help people with support services such as ADLs, transportation, and meal preparation. Homemaker and home care agencies specialize in providing these services, and, in general, these agencies do not provide their services to individuals needing health care services. Those services are provided by a home health agency. Staffing and private-duty agencies – These agencies also specialize in providing staff members to assist homebound individuals, but they supply both nursing and personal care supportive services. Like homemaker/ health care aide agencies, they do not provide a full range of home health services. One form of staffing and private-duty agency is a registry, which simply means that the agency matches consumers and individuals providers.
Home health care is a personnel-intensive industry, that is, payroll for staff is the largest portion of the budget. Home health agencies rely on a mix of professional and nonprofessional staff working as a care team. The team includes nurses (both RNs and LPNs), home health aides, therapists (physical, occupational, speech), social workers, and numerous other specialties. Nurses – Both RNs (professional) and LPNS (vocational), are the largest group of employees in home health care. One study showed them accounting for 45% of the total staff, with RNs at 31% and LPNs at 14%. Skilled nursing services are provided under the supervision of an RN. An RN makes the initial evaluation visit to the patient’s home and initiates the plan of care for that patient. In addition to directly providing skilled nursing services, the nurse ascertains what other clinical services are needed, such as therapies, and coordinates those services. During the course of treatment, the nurse regularly reevaluates the nursing care needs of each patient and adjusts the care plan accordingly. As the coordinator of the care plan, the RN keeps the supervising physician and other members of the care team informed about the condition of the patient, any changes in that condition, and the progress of the patient. The nurse is also instrumental in providing the patient and family with the education they need to optimize their contribution to the care plan. LPNs assist the RNs, providing many of the nursing services needed. They are allowed to perform many treatments and nursing procedures under the supervision of an RN. Home Health Aides – seen by many as the backbone of home health care because they provide such a large number of the routine services to patients – nearly 40%. They work under the broad supervision of professional nurses and therapists and provide most of the personal care. That care includes assistance with ADLs and some homemaker services such as meal preparation. Home health aides in Medicare-certified home health agencies must complete a training program covering specified competency areas. H ome health aides are not licensed, but must be certified for Medicare to cover their services. Therapists – Physical and occupational therapy may be provided either by registered therapists or by certified therapy assistants under the supervision of the therapists. Therapists evaluate the patient’s therapy needs, develop the plan of care, and oversee the work of therapy assistants when they are involved. Social Workers – Medical social workers assist the team with assessing social and emotional factors affecting the patient’s treatment plan. They also assist the patient and family in accessing community resources, resolving financial issues, and interacting with other providers. Other Staff – Home health care uses other specialists to provide other services needed by individual patients, including nutritionists, dentists or dental assistants, and specialty physicians. Such services are usually obtained on a contract basis, although some large agencies may have such persons on staff. The staff members providing home health care must work at a team, even though they do not all see the patient at the same time. They rely heavily on team conferences and detailed documentation to keep each other informed.
Services provided by home health care agencies include skilled services (nursing, physical, occupational, and speech/ language therapy; dental care; nutritional counseling; laboratory services; and social work coordination) and supportive services (personal care, homemaking, chores, and transportation). Nursing – Nursing is the primary skilled service provided and is at the heart of home health care. Nursing care includes assessment, monitoring, dressing changes, administration of medications, and education of the patient and the family caregivers. It is provided by both registered nurses (RNs) and licensed practical nurses (LPNs). Therapy – Several types of therapy are provided to home care consumers in their own residences, including physical therapy, occupational therapy, and therapy for speech/ language pathologies. Physical therapy involves restoring or maintaining the mobility and strength of patients who are limited by physical injuries, using techniques such as exercise and massage. Occupational therapists assist them in overcoming limitations with the use of assistive devices and techniques. Speech language pathologists are therapists who work with patients to improve or restore their ability to communicate, as well as the ability to eat and swallow. Other services – Some minor dental procedures, such as cleaning, checkups, and small fillings, can be done in the patient’s home by dentists and/ or dental assistants. Nutritional assessment and counseling assist the patient and his/ her family or caregiver to provide the proper nutrition and learn how to plan diets appropriate to the patient’s illness. Also, routine and special lab tests can be performed, with the specimens (blood, urine, etc.) being collected in the patient’s home. Social workers coordinate much of the care and arrange other services as needed. For personal care, home care staff help patients who may have limitations in their ADLs, particularly with personal care, including bathing, grooming, and dressing. Homemakers perform light housekeeping and other chores, which include some meal preparation when the family or other caregiver is unable to do so. Agency staff may also transport the patient to medical appointments and shop for the patient if needed. Another very important services is education of the patient and family. Patients are taught who to do as much for themselves as possible and how to change their way of doing things, if necessary, to achieve more independence and less reliance on formal caregivers.
Medicare is the single largest payer of home health services, paying for 28% of national expenditures in 2000. However, private health insurance was close behind at 24%, followed by Medicaid at 19%. Out-of-pocket payments by consumers and other private funding sources paid for 24%. The remaining 5% came from other public funds. Medicare – Medicare funding for home health care has been very volatile since its inception. As new groups of beneficiaries have been added, payment methods have changed, and as Medicare rates have fluctuated up and down, the impact on home health care has been considerable. For example, from the time Medicare first began covering home health care in 1965, through the mid-1980s, the number of home health care agencies grew steadily and dramatically. In the mid-1980s, the number of home health care providers leveled off, largely because of increasing Medicare paperwork and unreliable payment policies. Then, in 1987, a lawsuit caused changes in payment policies, and the number of home health agencies again grew. In 1997, however, portions of the Balanced Budget Act (BBA) again reduced Medicare reimbursement, and the number of providers declined. The BBA changed not only the amount of Medicare reimbursement but also the method. It mandated that the former retrospective, cost-based payment system be replaced with a prospective payment system (PPS). With the PPS, Medicare pays home health providers for each 60-day “episode of care.” The amount paid for that 60-day period is a set amount based on a standard rate, adjusted for the type and intensity of care provided, in what is known as a case-mix formula. The patient must be homebound, and the services must be provided by a Medicare-certified agency. The care must be medically ordered, be intermittent, and include nursing care or therapy. Medicare does not cover all home health care, even when these criteria are met. It does not cover 24-hour care, prescription drugs, meals delivered to the home (e.g., Meals-on-Wheels), homemaker services, and personal care if that is the only care needed. Medicaid – designed to cover health care for people who are medically indigent, meaning that their incomes are too low for them to afford to pay for care, and for those who have no health insurance. It is operated by the states under national guidelines, and the cost is split between the states and the national government. States must provide services but have the option of choosing whether to provide others. They must provide nursing services, home care aide services, and medical equipment and supplies, but they are not required to provide other services, including some that would be provided under Medicare. Therapies and social services are among those that the states may or may not provide. Hospice care is also optional. Medicaid coverage of home health care is growing, largely because state governments are seeking ways to reduce their costs, and home health care is one way to do that. However, the rates paid by some state Medicaid programs are lower than those for other programs, and some home health agencies do not accept patients with Medicaid coverage only. Other Government Payers – Some other government programs also provide home health care coverage. One such program is Tricare (formerly known as CHAMPUS), a federal program that covers dependents of active military personnel, military retirees, and their dependents and survivors. Other government programs providing home health coverage include, in some instances, worker’s compensation and state social programs.
Consumers of home health care are largely the elderly. Studies have shown that nearly 75% are over the age of 65 years, with the remaining 25% almost evenly split between those aged 45 to 64 years and those under 45. These consumers may be receiving the care to avoid or delay the need for full-time care, or they may need temporary assistance following discharge from a hospital. In 2000, 38% of Medicare beneficiaries beginning use of home care came directly from the community, 48% had been in a hospital within 15 days of receiving home health care, and 14% had come from nursing homes. Those requiring only home care (nonhealth) may be doing so to improve their independence and ability to function at home.
Home Health is skilled health care prescribed by a physician that is provided in the home of an older adult in need of medical care. Allowable services include: skilled nursing; physical, occupational, and/or speech therapy; medical social services; and nutrition care. In-Home Aide services are intended to assist individuals who have functional/physical or mental impairments with essential daily activities in the areas of home management and personal care tasks, enabling them to be maintained in their home settings for as long as possible. The service also may give needed assistance and respite to many families who are involved daily with care giving responsibilities. Over the years, this service has been known as Chore, Homemaker, and Homemaker-Home Health Aide, among others. Currently, the term In-Home Aide is the most inclusive title for a paraprofessional service involving assistance with various levels of home management tasks and/or simple, assistive personal care tasks to more extensive and complex personal care tasks that require the provider to be listed or classified as a Nurse Aide. Agencies that provide any level of personal care must be licensed for Home Care through the Division of Health Service Regulation. The Division of Health Service Regulation (formerly known as the Division of Facility Services) regulates medical, mental health and group care facilities, emergency medical services, and local jails. We ensure that people in the care of these facilities are safe and receive appropriate care. We make certain that medical facilities are built only when there is a need for them. A “home health agency” means a home care agency which is certified to receive Medicare and Medicaid reimbursement for providing nursing care, therapy, medical social services, and home health aide services on a part-time, intermittent basis as set out in G.S. 131-176(12). Each site providing home health services must have a separate certificate of need and a separate license. The North Carolina Medical Care Commission has rulemaking authority for home health services.
Hospice was founded in England in 1967 by a nurse who later became a physician (Cicely Saunders). Hospice movement began in US in the 1970s. Since 1974, over 7 million pts and families have received EOL care at home or other settings through hospice programs. Although hospice care is listed here under partial and intermittent care services, it can also be included under complete and continuous care services. This is because the nature of the patient’s needs determines the level at which this service is provided. Rather than a site of care, hospice is a philosophy of caring for dying individuals. Hospice provides support and palliative care to patients and their families. Although hospice programs can exist within an institutional setting, most hospice care is provided in the home. The focus is on the quality of remaining life rather than life extension. Hospice neither speeds up nor slows down the dying process. It provides a specialized environment where a dying patient may receive medical care in addition to emotional and spiritual support during the dying process. One of the real advantages of hospice is that personnel are trained to treat pain aggressively. The patient should be as pain free as possible, while at the same time remaining as alert as possible. Survivor support is also an important component of hospice care. Hospice care includes an interdisciplinary team – a registered nurse, a social worker, a home health aide, a chaplain, and trained volunteers. The interdisciplinary team helps aptients and families meet physical, emotional, social, and spiritual needs. Hospice is reimbursed by Medicare in all states and by Medicaid in 42 states.
Hospice care supports and cares for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible. The Medicare hospice benefit was designed to support dying patients with less than 6 months to live. In order to qualify for Medicare reimbursement, there must be certification by a PHYSICIAN of terminal prognosis of 6 months or less. Coverage can extend beyond that period if necessary. There also must be a signed acknowledgement that treatment (including medications) directed at curing the terminal disease cannot be carried out. The hospice movement began in the US in the 1970s. Since 1974, over 7 million patients and families have received end-of-life care at home as well as in nursing homes and hospitals through hospice programs, with escalating use in recent years. Hospice care can be defined as the support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible. Hospice care focuses on the whole person by caring for the body, mind, and spirit. Since end-of-life care deeply affects the family, support is also provided to family and caregivers. Hospice care is centered on the patient living the last days as fully as possible.
A multidisciplinary team of physicians, nurses, therapists, home health aides, pharmacists, pastoral counselors, social workers, and trained lay volunteers assist the family in providing care at home. The hospice nurse assumes the role of specialist in the management of pain and the control of symptoms. Hospice care may be provided at home if someone is available to safely provide care. The hospice nurse assesses the patient’s and family’s coping mechanisms, the available resources to care for the patient, the patient’s wishes, and the support systems in place.
Hospice care may be provided at home if someone is available to safely provide care. Almost all hospice care (96%) is provided as routine care in the home. There are also freestanding hospices that provide a homelike atmosphere in which care is provided by trained staff at the facility. Hospitals may have affiliated hospices, or some home health agencies may also promote their home care hospices. Reimbursement for hospice services is provided by Medicare, Medicaid, private health insurances, and some health maintenance organizations. Some hospices accept donations for care, some have a sliding scale, and some may have access to foundations to help with payment. Hospice personnel may work with staff and patients in nursing homes, other long-term care settings, and hospitals. All hospices encourage family involvement and promote death with dignity. Supportive care continues for the family after the death of the loved one.
Patients receiving hospice care must give up any treatments that may be curative or life sustaining; they must be determined to be within the last 6 months of life Palliative care usually consists of a multidisciplinary team whose goal is to provide patient comfort and relief of suffering while not requiring patient to give up the fight for a cure. Many do not understand allowing aggressive treatment in palliative care, knowing that such care is futile. Treatments and medicines aimed at relieving symptoms are provided by hospice
B, D, E
Long-Term CareNURS 4100 Care of the Older AdultSpring 2013Joy A. Shepard, PhD(c), MSN, RN, CNE 1
ObjectivesDescribe the long-term care continuumDescribe various long-term care practicesettings and roles for gerontological nursesDescribe the principles of rehabilitativenursingCompare and contrast community-basedversus institutional long-term care 2
Long-Term Care Continuum Long-Term Care: “Care of thosepersons requiringhealth care, personalcare, social, andsupportive servicesover a sustainedperiod of time” 4
Components of the Long-Term Care SystemConsumers: Elderly users of long-term care The elderly as a political force Mentally ill, Nonelderly long- developmentally disabled term care users Baby boomers: future Physically disabled long-term care consumers 5
Components of the Long-Term Care System Providers: Providers:Nursing Adult Day Care Facilities Home HealthAssisted Living/ Residential Care CareSubacute Care Hospice Care 6
Institutional vs. Non-Institutional (Community-Based) Care Institutional: Non-Institutional: • Nursing Facilities • Adult Day Care • Assisted Living • Home Health • Subacute Care • Hospice Care 7
Institutional vs. Non-Institutional (Community-Based) Care 8
Impact of the Large Number of Boomers on LTC…Will grow over the next 2 decades and beyond… 9
Looming ShortageUS will need to recruit200,000 new direct-care workers eachyear to meet futuredemand among theBaby Boomers asthey agehttp://www.reuters.com/article/pressRelease/idUS155188+29-Apr-2008+BW20080429 10
Major Sources Financing Long- term Care Expenditures 11
Nursing Facilities (Homes)1.5-2 million residents 16,100 Nursing homes(4-5% older US (US)population) Costs of care 5.3 million by 2030 Vary by geographicalResident characteristics location, ownership, Predominantly women, amenities Average annual cost: age 80+, white, widowed, dependent in ADLs & $76,460 (US) IADLs $6,370 month More than 60% $66,830 (NC) cognitively impaired 13
Getting Admitted into a Nursing Home… Often a crisis makes it necessary… 14
Responsibilities of Nurses in LTC Box 37-4, p. 472 Administrative & management Direct care provider Guardian of care/ advocacy Care coordinator Numerous other roles MDS 15
Activities of Daily Living (ADLs) Bathing • Dressing • Eating • Toileting • Transferring(Average resident needs help with 4 ADLs) 16
Financing Nursing FacilitiesReimbursementsources: Medicaid - 65% Medicaid Medicare - 13% Medicare Private, other Private pay and other sources – the remainder 17
Medicare Coverage Restrictions:Covers only skilled nursing careMust follow 3-day hospital stay Limited to 100 days per “benefit period”Requires co-payment days 21-100 18
Nursing Facilities (Homes)Regulations and Nursing homes mustquality of care have licensed nurseHighly regulated on duty 24 hrs/day Omnibus Budget Reconciliation Act During one 8-hr shift (OBRA) of 1987 has each day, one of had positive impact these nurses must MDS – Federal be RN database 19
Nursing Staffing Ratios in NC“Daily direct patient care nursing staff, licensedand unlicensed, shall equal or exceed 2.1nursing 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/nortTypical staffing ratio (area nursing homes): 20-30:1(RN or LPN) 10:1 CNA 20
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 21
5 Rights of Delegation for RNs Right task Right circumstances Right person Right direction/ communication Right supervision/ evaluationhttps://www.ncsbn.org/fiverights.pdf 22
(NC) Medication Aide – ICF/Skilled Nursing FacilitiesCNA IComplete 24-hour NC Medication Aide training programPass NC Medication Aide certification exam (NCBON)“Before allowing a medication aide to administer medications, the nursinghome employer must conduct a clinical skills validation for thosemedication tasks to be performed in the facility. The validation must beconducted by a registered nurse”Registry – NC Division of Health Service Regulation Medication Aide“The licensed nurse maintains accountability and responsibility for thedelivery of safe and competent care”https://www.ncnar.org/matcep.htmlhttp://www.ncbon.com/content.aspx?id=826 23
QuestionWhich question by the nurse would be the mostappropriate to ask the unlicensed assistivepersonnel (UAP) after discussing the care theUAP 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?" 24
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 task B. Right circumstances C. Right person D. Right direction/ communication E. Right supervision/ evaluationhttp://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&si d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2 25
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 task B. Right circumstances C. Right person D. Right direction/ communication E. Right supervision/ evaluationhttp://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&si d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2 26
Question The registered nurse instructs and/or assesses, verifies and identifies the UAPs competency on an individual, task and patient-specific basis. Which right of delegation is the registered nurse demonstrating? A. Right task B. Right circumstances C. Right person D. Right direction/ communication E. Right supervision/ evaluationhttp://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&si d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2 27
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 homes Surveys – every 9-15 months 28
NC RegulationsOffice of Long-Term Services & SupportsNursing homes List of Nursing Homes NC Nurse Aide I & Health Care Personnel Registry Nursing Home Residents Bill of RightsLong 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 29
How Nurses Can Help Families Choose a Nursing HomeNursing Home Compare http://www.medicare.gov/NHCompare CMS’s Online Survey Certification and Reporting (OSCAR) database Minimum Data Set (MDS) RepositoryIssues to consider: safe physical environment,dementia health, overall health, knowledgeableand available staff, quality of life, support,interdisciplinary team (Box 37-2, p. 469) 30
Assisted Living Facility (ALF)“Special combination of housing, personalizedsupportive services, and health care designed to meetthe needs, both scheduled and unscheduled, of thosewho need help with activities of daily living”Long-term care residential alternative More assistance than retirement community Less medical & nursing care than nursing facility24-hr/day on-site support and assistance39,500 ALFs (US)900,000 residents 32
Profile of Resident of Assisted Living Facility80 years old (mean age) Needs help with IADLsFemale (69%) Housework: 91%Needs help with at least Medications: 86%two ADLs Length of stay: 27 Bathing: 68% months Dressing: 47% 34% move to nursing Toileting: 34% facility Transferring: 25% 30% die while resident Eating: 22% 33
Services Provided Personal care Exercise & Health care educational activities Supervision Transportation Social services Laundry & linen Social & religious Housekeeping & activities maintenance 35
Staffing/Work ForceLargely non-clinical (unlicensed personnel)Customer service focusFew staffing regulations – mostly based onnursing facility modelTraining staff to recognize residents’ privacy &independenceMedication Aide (Tech) – Adult Care Setting Registry – NC Division of Health Service Regulation’s Adult Care Licensure Section 38
RegulationsFew regulations until recentlyIncreasing number of states nowregulating assisted livingVery little commonality oruniformity 39
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 ServicesCounty Departments of Social ServicesRights of ResidentsElder Housing InformationMedication Aide (Tech) – Adult Care Homes 40
What is Subacute Care?Inpatient restorative or rehabilitative healthImmediately following debilitating illness, surgery, or injury General criteria for admission include: stabilization of someacute health care problem, need for rehabilitative services torestore physical function, ability to participate in dailyrehabilitative therapy, anticipated discharge withinapproximately 3 weeksCare planning based on functional goals such as being able towalk around the house, climb stairs, assist or be independent inself care, perform exercises or be able to participate in moreintensive rehabilitation once discharge for the inpatient settinghttp://www.subacutecare.info/consumer.html 42
What Is Subacute Care?Comprehensive Usually for definedinpatient care period of timeComes after, or Developed for cost-instead of, acute care savingsBetween acute & Fastest-growinglong-term care segment of health- care delivery system 43
Reimbursement: Short-Stay vs ChronicSubacute care (Medicare reimbursed, short stay)Chronic care (private pay or Medicaid) for frail, elderlyresidents requiring help with the activities of daily livingA 3-day qualifying stay in a hospital is required forskilled nursing care to receive Medicarereimbursement 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” 46
UHS Regional Rehabilitation CenterPatients admitted to the Center must meet thefollowing general criteria Must 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=5284&linkidentifier=id&itemid=5284 http://whiteshoal.uhseast.com/rehab/video/rehab tour.wmv 47
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 49
Skilled Nursing Facility (SNF) vs Nursing Facility (NF or ICF)?Skilled nursing facility (SNF) – Skilled medical or nursing care, rehabilitationGenerally, Medicare doesnt pay for long-termcare Medicare pays only for medically necessary skilled nursing facility or home health care Skilled nursing care and home health aide services only covered on part-time or "intermittent" basishttp://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3433 50
Skilled Nursing Facility vs Regular Nursing HomeNursing homes (or nursing facilities) are defined as health care institutions thatprovide onsite 24-hour supervision, nursing services, and personal care.The two basic types of nursing homes are skilled nursing facilities andintermediate care facilities.A skilled nursing facility is an institution that provides inpatient 24-hour skillednursing services, as prescribed by the client’s primary care provider. Theemphasis 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 mainreimburser.An intermediate care facility is an institution that provides basic custodial ornonskilled personal care, but not skilled nursing care. Custodial care isassistance with ADLs such as transferring from the bed to the chair, putting onclothes, bathing, and eating. The care provided by registered nurses andlicensed practical nurses is less intense, but still vital for quality of care andpositive resident outcomes. Medicaid and private pay are the main sources ofpayment. 51
Financing Subacute Care ReimbursementSources: Medicare – 2/3 - Pays as Skilled Nursing Facility (SNF) Other 1/3: - Managed care - Medicaid - Private pay & other 52
Definitions Used in Rehabilitation Functional status Capacity & performance of safe ADLs & IADLs Sensitive indicator of health or illness in elders Critical nursing assessment Impairment Disturbance in structure or function resulting from physiologic or psychologic abnormalities Disability Degree of observable and measurable impairment 53
Principles of Rehabilitative NursingGoal of nursing care: maximize physicalfunctioning, prevent or minimize decline in ADLfunction, & plan for future care needsPromote living to one’s maximum potential Unique set of strengths & abilities Acute & chronic illnessesAttain highest QOL despite functional levelImproving functional capacity: well-being & QOL 54
Rehabilitation Nursing Care InterventionsPreventing infectionMaintaining correct body alignment, position, & ROMPreventing skin breakdownProviding adequate nutrition & fluidsProviding care: achieve realistic level of independenceTeachingMaking referrals to community agencies 55
Adult Day CareOption 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 57
What Is Adult Day Care?Interim (less than 24 hour) careProvides a structured environmentGives family caregivers a break, orchance to hold a jobMix of social & health services 58
Philosophy & BenefitsServes both consumers Can live with family& caregivers without being a burdenHolistic approach to care Social interaction with peersMaintains or improves Program of stimulatingquality of life activitiesProvides safe, Therapy in a non-supervised setting medical setting ADL assistance with dignity 59
Types of Adult Day CareTwo categories of adult day care: Social Day Care Adult Day Health Care 60
Services ProvidedBasic services providedby all types: Safe, secure environment Social & recreational activities Assistance with ADLs Transportation to & from the center At least one meal, plus snacks 62
Adult Day Health ServicesIn NC, licensed nursemust be present part ofthe dayRatio staff to participants1:6Health care services: Assessment Medications Monitoring Nutrition counseling Health education 63
Consumers of Adult Day CareBetween needing Must be continentinstitutional care & being Able to communicateindependent needs (mild toMost live with family moderate dementia)Unable to handle day-to- No wanderingday tasks behaviorsMost are elderly Nurse screensMore women than men admissions 64
CaregiversThree-fifths are spousesor adult childrenOther two-fifths are otherrelatives, friends, orneighborsMostly female (3/4’s)Average age: 57One-third over 65themselves 65
NC RegulationsAdult Day Care/ Health ProgramsAdult Day Health CareNC State Standards for CertificationList of Certified Adult Day Care/ Adult Day HealthProgramsAdult Day Care FormsNC Association of Adult Day ServicesFamily Caregiver Support 66
JCAHO DefinitionHome health services are provided by healthcareprofessionals to patients in their place of residenceThis includes, but is not limited to, performing assessments,provision of care, treatment, counseling, and/ or monitoringof the patient’s clinical status by nurses, occupationaltherapists, physical therapists, speech-languagepathologists, audiologists, social workers, dieticians,dentists, physicians and other licensed healthcareprofessionals in the patient’s homeIt includes the extension or follow-up of healthcare services providedby hospital professional staff in the patient’s home 68
How Home Health Care DevelopedPublic healthdepartment visitingnursesFreestanding visitingnurse associationsGrowth based onbetter reimbursement 69
QuestionThe home health agency’s medical chart ofyour 78-year-old client claims that she ishomebound. However, she is notbedridden. So, could the “homebound”status still be correct? 71
Home Health AgenciesOfficial or public agenciesVoluntary or private not-for-profit agenciesPrivate, proprietary agenciesInstitution-based agencies20,000 providers deliver home health careservices to 7.6 million people 72
Types of Home Health CareHome healthagenciesHospice agenciesHomemaker & homecare aide agenciesStaffing & privateduty agencies 73
StaffingCombination ofprofessional & non-professional staff Nurses Home Health Aides Therapists Social Workers Other specialists 74
Components of Home Health CareCare of clients in the home Observe family dynamics Identify caregiver burdenReferrals for home care Discuss fundingReimbursement sources for home care Medicare, Medicaid, insurance, public funding, self- pay 76
Financing Home Health Care Medicare – single largest payer (28%) Medicaid – 19% Private funding sources (insurance, private-pay) – 24% Other government programs – 5% 77
QuestionWhat agency is the largest singlereimbursement source for home healthcare?A. MedicareB. MedicaidC. Private insuranceD. Self-pay 78
Consumers of Home Health CareLargely elderlySome need on-goingcareOthers need onlytemporary carefollowing a hospitalstay 79
Nursing Process in Home Health Assessing Planning Conduct careful and Set priorities, establish complete data collection goals, decide on initially and on an interventions ongoing basis Implementing Diagnosing Carry out interventions Identify actual or Evaluating potential problems— LPN/ LVNs contribute to Compare plan of care this process with goals and review client’s progress 80
Home Health Care NursesGuidelines Roles ANA Standards for Home Provider of care Health Nursing Practice Teacher ANA Standards of Community Health Advocate Nursing National Association for Home Care Bill of Rights 81
Concerns for the Home Health NurseSafety Assessment of, documentation of, and teaching of safety measuresInfection Control Effective hand washing Use of gloves Disposal of wastes and soiled dressings Handling of linens Practice Standard Precautions 83
Legal Issues in Home HealthPrivacy and confidentialityClient access to health informationFreedom from unreasonable restraintWitnessing of documentsInformed consentNegligence or malpractice 84
NC RegulationsHome HealthIn-Home AideSenior CompanionDivision of Health Service RegulationAcute and Home Care Certification SectionProcedure for Establishing a Certified HomeHealth Agency 85
Home Health Review QuestionReferral 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 86
QuestionA 94-year-old man has been hospitalized and treated forpneumonia. At the end of his hospitalization, his familydecides that they can no longer care for him because heis completely dependent in all activities of daily living andhas become incontinent. His long-term prognosis is poor.To meet this client’s needs, the nurse discharge plannerwill apply for:A. Assisted living facilityB. 24-hour/day home careC. Intermediate nursing careD. Skilled nursing care 87
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 dyingprocess as well as providing bereavementsupport to surviving family 89
Hospice CareFocus whole person Last phase (6 months) of Mind incurable disease Body Medicare coverage can Spirit extend beyond that period if necessarySupport & care Live as fully & comfortably Pts as possible Family & caregivers Continues after death of loved one 90
Hospice Care: InterdisciplinaryTeam of Professional Caregivers Nurse Physician Pain & symptom control Assesses pt & family’s Pharmacist ability to cope Social worker Identifies resources for care of pt Chaplain Recognizes pt’s wishes Others (volunteers) Assures support systems in place Bereaved family services 93
QuestionWhich of the following statements is trueconcerning 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 97
Palliative Care vs HospiceHospice & palliative: both focus on helping a person becomfortable by addressing issues causing physical oremotional pain, or sufferingPalliative: does not require pt to give up fight for a curePalliative: may be given at any time during a person’sillness, from diagnosis onHospice: pts with a life expectancy of mos not yrs(usually 6 mos)Hospice: set of defined services, team members, rules& regulations 98
QuestionThe gerontological nurse understands thatpalliative care is different from hospice in which ofthe following ways? Palliative care (Select all thatapply):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 99