1. Long-Term Care
NURS 4100 Care of the Older Adult
Spring 2013
Joy A. Shepard, PhD(c), MSN, RN, CNE
1

2. Objectives
Describe the long-term care continuum
Describe various long-term care practice
settings and roles for gerontological nurses
Describe the principles of rehabilitative
nursing
Compare and contrast community-based
versus institutional long-term care
2

3. “There’s No Place Like Home”
3

4. Long-Term Care Continuum
Long-Term Care:
“Care of those
persons requiring
health care, personal
care, social, and
supportive services
over a sustained
period of time”
4

5. Components of the Long-Term
Care System
Consumers:
 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

6. Components of the Long-Term
Care System
Providers: Providers:
Nursing Adult Day Care
Facilities
Home Health
Assisted Living/
Residential Care Care
Subacute Care Hospice Care
6

7. Institutional vs. Non-Institutional
(Community-Based) Care
Institutional: Non-Institutional:
• Nursing Facilities • Adult Day Care
• Assisted Living • Home Health
• Subacute Care • Hospice Care
7

8. Institutional vs. Non-Institutional
(Community-Based) Care
8

9. Impact of the Large Number of
Boomers on LTC…
Will grow over the next 2 decades and beyond…
9

10. Looming Shortage
US will need to recruit
200,000 new direct-
care workers each
year to meet future
demand among the
Baby Boomers as
they age
http://www.reuters.com/article/pressRelease/idUS155188+29-Apr-2008+BW20080429
10

11. Major Sources Financing Long-
term Care Expenditures
11

12. Nursing Facilities (Homes)
12

13. 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 geographical
Resident 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

14. Getting Admitted into a Nursing Home…
Often a crisis makes it necessary…
14

15. 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

16. Activities of Daily Living (ADLs)
Bathing
• Dressing
• Eating
• Toileting
• Transferring
(Average resident needs help with 4 ADLs)
16

17. Financing Nursing Facilities
Reimbursement
sources:
 Medicaid - 65%
Medicaid
 Medicare - 13% Medicare
Private, other
 Private pay and
other sources –
the remainder
17

18. Medicare Coverage
Restrictions:
Covers only skilled nursing care
Must follow 3-day hospital stay
 Limited to 100 days per “benefit period”
Requires co-payment days 21-100
18

19. Nursing Facilities (Homes)
Regulations and Nursing homes must
quality of care have licensed nurse
Highly 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

20. Nursing Staffing Ratios in NC
“Daily direct patient care nursing staff, licensed
and unlicensed, shall equal or exceed 2.1
nursing hours per patient per day”
Also referred to as nursing hours per patient day
( NHPPD or NH/PD)
http://www.hpm.umn.edu/nhregsPlus/state_regulation_attachments/north_carolina_regulation_attachments/nort
Typical staffing ratio (area nursing homes):
 20-30:1(RN or LPN)
 10:1 CNA
20

21. 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

22. 5 Rights of Delegation for RNs
Right task
Right circumstances
Right person
Right direction/ communication
Right supervision/ evaluation
https://www.ncsbn.org/fiverights.pdf
22

23. (NC) Medication Aide –
ICF/Skilled Nursing Facilities
CNA I
Complete 24-hour NC Medication Aide training program
Pass NC Medication Aide certification exam (NCBON)
“Before allowing a medication aide to administer medications, the nursing
home employer must conduct a clinical skills validation for those
medication tasks to be performed in the facility. The validation must be
conducted by a registered nurse”
Registry – NC Division of Health Service Regulation Medication Aide
“The licensed nurse maintains accountability and responsibility for the
delivery of safe and competent care”
https://www.ncnar.org/matcep.html
http://www.ncbon.com/content.aspx?id=826
23

24. Question
Which question by the nurse would be the most
appropriate to ask the unlicensed assistive
personnel (UAP) after discussing the care the
UAP is to give to a client?
 A. "Do you understand what you are to do for this client?"
 B. "Will you be able to complete this assignment before
you leave the unit today?"
 C. "Can you repeat the main points of what we just
discussed with regard to your assignment?"
 D. “Do you have any questions?"
24

25. 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/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure
%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+on+Nursing+Practice&L7=Delegation+to+Unlicensed+Assistive+Personnel&si
d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2
25

26. 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/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure
%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+on+Nursing+Practice&L7=Delegation+to+Unlicensed+Assistive+Personnel&si
d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2
26

27. Question
The registered nurse instructs and/or assesses, verifies
and identifies the UAP's competency on an individual,
task and patient-specific basis. Which right of delegation
is the registered nurse demonstrating?
A. Right task
B. Right circumstances
C. Right person
D. Right direction/ communication
E. Right supervision/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure
%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+on+Nursing+Practice&L7=Delegation+to+Unlicensed+Assistive+Personnel&si
d=Eeohhs2&b=terminalcontent&f=dph_quality_boards_nursing_p_five_rights&csid=Eeohhs2
27

28. 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

29. NC Regulations
Office of Long-Term Services & Supports
Nursing homes
List of Nursing Homes
NC Nurse Aide I & Health Care Personnel Registry
Nursing Home Residents' Bill of Rights
Long Term Care Ombudsman Program
Mental Illness in Long-Term Care Facilities Study (2008)
Long-Term Services and Supports Action Plan
A Long-Term Care Plan for North Carolina: Final Report
NC State Board of Examiners for Nursing Home Administrators
29

30. How Nurses Can Help Families
Choose a Nursing Home
Nursing Home Compare
 http://www.medicare.gov/NHCompare
 CMS’s Online Survey Certification and Reporting
(OSCAR) database
 Minimum Data Set (MDS) Repository
Issues to consider: safe physical environment,
dementia health, overall health, knowledgeable
and available staff, quality of life, support,
interdisciplinary team (Box 37-2, p. 469)
30

31. Assisted Living Facilities
31

32. Assisted Living Facility (ALF)
“Special combination of housing, personalized
supportive services, and health care designed to meet
the needs, both scheduled and unscheduled, of those
who need help with activities of daily living”
Long-term care residential alternative
 More assistance than retirement community
 Less medical & nursing care than nursing facility
24-hr/day on-site support and assistance
39,500 ALFs (US)
900,000 residents
32

33. Profile of Resident of
Assisted Living Facility
80 years old (mean age) Needs help with IADLs
Female (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

34. Assisted Living Facility (ALF)
34

35. Services Provided
 Personal care Exercise &
 Health care educational activities
 Supervision Transportation
 Social services Laundry & linen
 Social & religious Housekeeping &
activities maintenance
35

36. ALF Living Accommodations
36

37. Financing Assisted Living
Reimbursement
Sources:
 Mostly self-pay
 Medicaid – small, but
growing
Average annual cost:
 $36,090 (US)
 $3000 month
 $28,734 (NC)
37

38. Staffing/Work Force
Largely non-clinical (unlicensed personnel)
Customer service focus
Few staffing regulations – mostly based on
nursing facility model
Training staff to recognize residents’ privacy &
independence
Medication Aide (Tech) – Adult Care Setting
 Registry – NC Division of Health Service
Regulation’s Adult Care Licensure Section
38

39. Regulations
Few regulations until recently
Increasing number of states now
regulating assisted living
Very little commonality or
uniformity
39

40. NC Regulations
Assisted Living
Adult Care Homes
Licensed by State Division of Health Service Regulation (Group Care Section)
Group Homes (Developmentally Disabled)
Multi-Unit Assisted Housing With Services
County Departments of Social Services
Rights of Residents
Elder Housing Information
Medication Aide (Tech) – Adult Care Homes
40

41. Subacute Care & Rehabilitation
Units
41

42. What is Subacute Care?
Inpatient restorative or rehabilitative health
Immediately following debilitating illness, surgery, or injury
General criteria for admission include: stabilization of some
acute health care problem, need for rehabilitative services to
restore physical function, ability to participate in daily
rehabilitative therapy, anticipated discharge within
approximately 3 weeks
Care planning based on functional goals such as being able to
walk around the house, climb stairs, assist or be independent in
self care, perform exercises or be able to participate in more
intensive rehabilitation once discharge for the inpatient setting
http://www.subacutecare.info/consumer.html
42

43. What Is Subacute Care?
Comprehensive Usually for defined
inpatient care period of time
Comes after, or Developed for cost-
instead of, acute care savings
Between acute & Fastest-growing
long-term care segment of health-
care delivery system
43

44. Staffing
Interdisciplinary Team:
Physicians or mid-level
providers
Nurses
Physical therapists,
occupational therapists,
speech pathologists,
recreational therapists,
nutritionists, social workers
Non-licensed staff
44

45. 45

46. Reimbursement:
Short-Stay vs Chronic
Subacute care (Medicare reimbursed, short stay)
Chronic care (private pay or Medicaid) for frail, elderly
residents requiring help with the activities of daily living
A 3-day qualifying stay in a hospital is required for
skilled nursing care to receive Medicare
reimbursement in a subacute care facility
 Must be a candidate for rehabilitation
 Periodic recertification – continued need for skilled care
 Resident’s progress toward established goals
 One hundred days of skilled care can be reimbursed per
“benefit period”
46

47. UHS Regional Rehabilitation
Center
Patients admitted to the Center must meet the
following 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

48. Services Provided
• Rehabilitation • Pain Management
• Chemotherapy • Cardiac Rehab
• Physical Therapy • Complex Medical
• Parenteral Nutrition • Speech Therapy
• Occupational Therapy • Wound Management
• Dialysis • Postsurgical Care
• Respiratory therapy • Ventilation Care
48

49. 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
required
Nursing 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

50. Skilled Nursing Facility (SNF) vs
Nursing Facility (NF or ICF)?
Skilled nursing facility (SNF) –
 Skilled medical or nursing care, rehabilitation
Generally, Medicare doesn't pay for long-term
care
 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" basis
http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3433
50

51. Skilled Nursing Facility vs
Regular Nursing Home
Nursing homes (or nursing facilities) are defined as health care institutions that
provide onsite 24-hour supervision, nursing services, and personal care.
The two basic types of nursing homes are skilled nursing facilities and
intermediate care facilities.
A skilled nursing facility is an institution that provides inpatient 24-hour skilled
nursing services, as prescribed by the client’s primary care provider. The
emphasis is on the restorative and rehabilitative potential of the client. Only 5 %
of nursing home residents require a skilled level of care. Medicare is the main
reimburser.
An intermediate care facility is an institution that provides basic custodial or
nonskilled personal care, but not skilled nursing care. Custodial care is
assistance with ADLs such as transferring from the bed to the chair, putting on
clothes, bathing, and eating. The care provided by registered nurses and
licensed practical nurses is less intense, but still vital for quality of care and
positive resident outcomes. Medicaid and private pay are the main sources of
payment.
51

52. Financing Subacute Care
Reimbursement
Sources:
Medicare – 2/3
- Pays as Skilled Nursing
Facility (SNF)
Other 1/3:
- Managed care
- Medicaid
- Private pay & other
52

53. 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

54. Principles of Rehabilitative
Nursing
Goal of nursing care: maximize physical
functioning, prevent or minimize decline in ADL
function, & plan for future care needs
Promote living to one’s maximum potential
 Unique set of strengths & abilities
 Acute & chronic illnesses
Attain highest QOL despite functional level
Improving functional capacity: well-being & QOL
54

55. Rehabilitation Nursing Care
Interventions
Preventing infection
Maintaining correct body alignment, position, & ROM
Preventing skin breakdown
Providing adequate nutrition & fluids
Providing care: achieve realistic level of independence
Teaching
Making referrals to community agencies
55

56. Adult Day Care
56

57. Adult Day Care
Option for frail elders requiring daytime supervision
Many 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

58. What Is Adult Day Care?
Interim (less than 24 hour) care
Provides a structured environment
Gives family caregivers a break, or
chance to hold a job
Mix of social & health services
58

59. Philosophy & Benefits
Serves both consumers Can live with family
& caregivers without being a burden
Holistic approach to care Social interaction with
peers
Maintains or improves
Program of stimulating
quality of life activities
Provides safe, Therapy in a non-
supervised setting medical setting
ADL assistance with
dignity
59

60. Types of Adult Day Care
Two categories
of adult day care:
Social Day Care
Adult Day
Health Care
60

61. Staffing
Combination of
professional &
non-professional
staff
Mix depends on
focus (social or
health)
61

62. Services Provided
Basic services provided
by all types:
 Safe, secure
environment
 Social & recreational
activities
 Assistance with ADLs
 Transportation to & from
the center
 At least one meal, plus
snacks
62

63. Adult Day Health Services
In NC, licensed nurse
must be present part of
the day
Ratio staff to participants
1:6
Health care services:
 Assessment
 Medications
 Monitoring
 Nutrition counseling
 Health education
63

64. Consumers of Adult Day Care
Between needing Must be continent
institutional care & being Able to communicate
independent needs (mild to
Most live with family moderate dementia)
Unable to handle day-to- No wandering
day tasks behaviors
Most are elderly Nurse screens
More women than men admissions
64

65. Caregivers
Three-fifths are spouses
or adult children
Other two-fifths are other
relatives, friends, or
neighbors
Mostly female (3/4’s)
Average age: 57
One-third over 65
themselves
65

66. NC Regulations
Adult Day Care/ Health Programs
Adult Day Health Care
NC State Standards for Certification
List of Certified Adult Day Care/ Adult Day Health
Programs
Adult Day Care Forms
NC Association of Adult Day Services
Family Caregiver Support
66

67. Home Health
67

68. JCAHO Definition
Home health services are provided by healthcare
professionals to patients in their place of residence
This includes, but is not limited to, performing assessments,
provision of care, treatment, counseling, and/ or monitoring
of the patient’s clinical status by nurses, occupational
therapists, physical therapists, speech-language
pathologists, audiologists, social workers, dieticians,
dentists, physicians and other licensed healthcare
professionals in the patient’s home
It includes the extension or follow-up of healthcare services provided
by hospital professional staff in the patient’s home
68

69. How Home Health Care
Developed
Public health
department visiting
nurses
Freestanding visiting
nurse associations
Growth based on
better reimbursement
69

70. Philosophy of Care
Takes services to
consumers’ homes
Eligibility
requirements (based
on Medicare regs):
 Physician-ordered
 Intermittent
 Homebound
70

71. Question
The home health agency’s medical chart of
your 78-year-old client claims that she is
homebound. However, she is not
bedridden. So, could the “homebound”
status still be correct?
71

72. Home Health Agencies
Official or public agencies
Voluntary or private not-for-profit agencies
Private, proprietary agencies
Institution-based agencies
20,000 providers deliver home health care
services to 7.6 million people
72

73. Types of Home Health Care
Home health
agencies
Hospice agencies
Homemaker & home
care aide agencies
Staffing & private
duty agencies
73

74. Staffing
Combination of
professional & non-
professional staff
 Nurses
 Home Health Aides
 Therapists
 Social Workers
 Other specialists
74

75. Services Provided
Skilled services, Supportive services
therapies  Personal care
 Nursing, PT, OT, speech  Homemaking
therapy, social work,
nutritionist)  Transportation
Dental care
Laboratory
Education
75

76. Components of Home Health
Care
Care of clients in the home
 Observe family dynamics
 Identify caregiver burden
Referrals for home care
 Discuss funding
Reimbursement sources for home care
 Medicare, Medicaid, insurance, public funding, self-
pay
76

77. Financing Home Health Care
 Medicare – single
largest payer (28%)
 Medicaid – 19%
 Private funding
sources (insurance,
private-pay) – 24%
 Other government
programs – 5%
77

78. Question
What agency is the largest single
reimbursement source for home health
care?
A. Medicare
B. Medicaid
C. Private insurance
D. Self-pay
78

79. Consumers of
Home Health Care
Largely elderly
Some need on-going
care
Others need only
temporary care
following a hospital
stay
79

80. 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

81. Home Health Care Nurses
Guidelines 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

82. 82

83. Concerns for the Home Health
Nurse
Safety
 Assessment of, documentation of, and teaching of safety
measures
Infection Control
 Effective hand washing
 Use of gloves
 Disposal of wastes and soiled dressings
 Handling of linens
 Practice Standard Precautions
83

84. Legal Issues in Home Health
Privacy and confidentiality
Client access to health information
Freedom from unreasonable restraint
Witnessing of documents
Informed consent
Negligence or malpractice
84

85. NC Regulations
Home Health
In-Home Aide
Senior Companion
Division of Health Service Regulation
Acute and Home Care Certification Section
Procedure for Establishing a Certified Home
Health Agency
85

86. Home Health Review Question
Referral to a home care agency requires:
A. A physician’s order
B. A client need for skilled nursing or therapy
C. Unable to leave home without major effort
(homebound)
D. Full time care not needed (intermittent)
E. Consent of the client
F. All of the above
86

87. Question
A 94-year-old man has been hospitalized and treated for
pneumonia. At the end of his hospitalization, his family
decides that they can no longer care for him because he
is completely dependent in all activities of daily living and
has become incontinent. His long-term prognosis is poor.
To meet this client’s needs, the nurse discharge planner
will apply for:
A. Assisted living facility
B. 24-hour/day home care
C. Intermediate nursing care
D. Skilled nursing care
87

88. Hospice
88

89. Hospice
“Not a place but a philosophy”
Dying is a normal part of life cycle
Promotes the idea of “living until you die”
Care is provided in multiple settings &
supports the pt/family through dying
process as well as providing bereavement
support to surviving family
89

90. Hospice Care
Focus whole person Last phase (6 months) of
 Mind incurable disease
 Body  Medicare coverage can
 Spirit extend beyond that
period if necessary
Support & care
Live as fully & comfortably
 Pts
as possible
 Family & caregivers
 Continues after death of
loved one
90

91. 91

92. 92

93. Hospice Care: Interdisciplinary
Team 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

94. 94

95. Hospice Settings
Home
Freestanding
Hospital
Home health
agencies with home
care hospice
Nursing home or
other LTC settings
95

96. 96

97. Question
Which of the following statements is true
concerning hospice?
A. Hospice is a special place of care
B. Hospice care is a lifelong type of care
C. Hospice is a model of care rather than a
place of care
D. Hospice is designed for clients with
serious chronic illness
97

98. Palliative Care vs Hospice
Hospice & palliative: both focus on helping a person be
comfortable by addressing issues causing physical or
emotional pain, or suffering
Palliative: does not require pt to give up fight for a cure
Palliative: may be given at any time during a person’s
illness, from diagnosis on
Hospice: pts with a life expectancy of mos not yrs
(usually 6 mos)
Hospice: set of defined services, team members, rules
& regulations
98

99. Question
The gerontological nurse understands that
palliative care is different from hospice in which of
the following ways? Palliative care (Select all that
apply):
A. People no longer seek treatments for a cure
B. May be provided at any time during a person`s illness,
even from the time of diagnosis
C. Focused exclusively on terminally ill patients
D. Can take place at the same time as curative treatment
E. Typically, provided in the hospital
99