Module 1. Nursing Homes, the Basics

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  • Notes:
    70% of for-profit NHs are group or chain affiliated
    NH occupancy rate is 86% (2008-9) Go to: www.medicare.gov/NHCompare to obtain NH-specific information: number of beds, Medicare/Medicaid status; resident characteristics (e.g., % with pressure ulcer, UTI), last inspection/survey findings; number of RNs, LPN/LVNs, CNAs
  • Notes:
    African-American residents: 9%; increasing slowly
    Mobility assistance needed: 65%
    Toileting assistance (includes transfer, hygiene) needed: 80%
    Long-term memory loss, disorientation: >50%
    Depression most common among 65-84 y/o
    Socially inappropriate behavior: 13% (e.g., sexual acting out; disrobing; smearing food)
    Younger NH residents tend to be in hospital-based NHs & VA facilities
    Go To: www.medicare.gov/NHCompare to obtain NH-specific information: number of beds, Medicare/Medicaid status; resident characteristics (e.g., % with pressure ulcer, UTI), last inspection/survey findings; number of RNs, LPN/LVNs, CNAs
  • Notes:
    Issues in Dementia SCUs: inadequate staff training and numbers; outcomes regarding effectiveness are mixed
    Sub-acute Care Units more common in larger and not-for-profit NHs
    Many states regulate Sub-acute Care Units as to: admission and discharge criteria, specially trained staff, special programs, resident and family education, process to evaluate care.
    Many assisted living communities (ALCs) provide special dementia care services or units. Some ALCs are dementia-care only; variety of names, eg, memory enhancement.
  • Notes:
    The licensed nurse requirement can be waived if a NH shows, in good faith, inability to hire a licensed nurse to meet this requirement; there must, however, be a licensed nurse on call.
    Most NH staff are full-time employees
    Advanced practice nurses typically not employees of the NH
    NH physicians can be in a group practice; private practice; full or part-time employee of the NH.
    SW, Activities, Nutritionist: number varies with bed size of facility
  • Notes
    Podiatric, ophthalmology, dental, pharmacy etc services can be on site or resident is transported to provider’s office.
    All reasonable consultative services must be provided/arranged, eg, neuro, ortho
    Rehabilitation services (PT, OT, ST): service can be skilled (Medicare reimbursed), or maintenance (not Medicare reimbursed)
    75% of nursing homes use certified hospice agency for consultation or as full provider of end of life care.
    Psychiatry consultant required but not necessarily on staff; very few gero-psychiatric nurses
    Ethics Committee or rounds: not required.
    Family Councils are not mandated. 50% have them.
  • Notes:
    State Health Departments conduct un-announced Quality of Care and Quality of Life inspection (i.e., survey) every 12-15 months on behalf of CMS
    State surveys can last up to 5 days. Survey team: predominantly nurses; likely to include environmentalist, nutritionist, social worker
    Quality of care problems or “deficiencies” are classified by “scope” (number of residents potentially or actually affected) and “severity” (extent of possible harm).
    Most frequently cited deficiency: comprehensive care planning followed by food sanitation, pressure sores, dignity, accidents.
  • Notes:
    Some NH provider associations and clinicians question the validity of some aspects of the 5-Star rating system
    Changes (positive and negative) in the NH can affect quality within a time period; it is important to look at other factors that can influence quality and at consistency of ratings from period to period.
    For implications of a NH’s rating on selection as a clinical site, see Modules 4.
  • Notes:
    Health Inspection Domain NH rating based on scope and severity of care deficiencies.
  • Notes:
  • Notes:
    MDS:
    MDS (2.0) collects data on: cognition, memory, communication, hearing, vision, mood, behavior, ADL, physical functioning, continence, disease and health conditions, skin condition, oral and nutritional status, activity interests and pursuits, treatments, medications, and discharge potential.
    Data is collected at specific intervals: within 14 days after admission; quarterly; when there is a “significant” change of condition (positive or negative); annually
    MDS is part of medical record or can be maintained in separate file
    Many NHs have an “MDS Coordinator” – usually an RN
    MDS 3.0 (Oct 2010) will have improved reliability, accuracy and usefulness, require less time to complete, and will include resident interview as part of assessment process regarding quality of life
    Some researchers question the validity and reliability of MDS data
  • 30%* of NH resident care is reimbursed by Medicare only.
    70% of NH resident care is reimbursed by Medicaid
    28% of residents are private pay
    The Medicare daily rate is generally higher than Medicaid rate, but less than private pay rate.
    Note: These numbers are not mutually exclusive. Many post-acute care NH residents start on Medicare and then revert to private pay and/or Medicaid when Medicare coverage stops. Other residents start as private pay and then revert to Medicaid when they no longer have sufficient assets.
  • Module 1. Nursing Homes, the Basics

    1. 1. Nursing Homes: The Basics Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Mathy Mezey, EdD, RN, FAAN Hartford Institute for Geriatric Nursing, New York University College of Nursing Module 1 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
    2. 2. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Acknowledgments This is a joint project of With support from Grant to the University of Minnesota Schoo
    3. 3. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing This project is endorsed by: Project Steering Committee View List of Members
    4. 4. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing About Module 1- Nursing Homes: The Basics  Evaluate attributes of nursing homes that can affect the educational experience of students  Compare and contrast quality of care in nursing homes using objective criteria  Explain how nursing homes are regulated and reimbursed  Evaluate the potential for a nursing home to serve as a clinical training site for nursing students Objectives/Purpose: At the end of this module you will be able to:
    5. 5. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Nursing Home Characteristics and Services 16,000+ Nursing Homes 1.7 Million Medicare and/or Medicaid certified beds Most Nursing Homes (67%) are for-profit Average Nursing Home Size: 104 beds 1.5 million+ people (6%+ of people >65 years old) are in Nursing Homes
    6. 6. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Resident Characteristics Most residents are white (86%), female (62%), married (17%) and live alone Assistance needed with 3-4 ADLs: 95% Incontinent of bladder or bowel: 50% Age range: 75-84: 30%, >85 y/o: 45%, <65 y/o: 12% Dementia of some kind: 65% Depressed (at least one clinical symptom): 20% Physical restraint use: 6% (some NHs: 0%) Receiving psychotropic medication: 63% 46% of residents are admitted from acute care
    7. 7. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Resident Length of Stay Short-Term (typically Medicare covered) Long-Term (typically Medicaid covered) 50%+ 2.5 years (mean) 50% + 14-32 days (mean)
    8. 8. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Hospitalization of Residents  Between 25%-50% of residents are hospitalized during any one year  Some residents can be hospitalized as many as 4 times in one year (e.g. with diagnosis of COPD, CHF)
    9. 9. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Reasons for Hospitalization  Physician practice pattern and hospital vacancy rate  Resident’s Medicare eligibility  Nursing Home resources (staffing; IV administration; diagnostic services)  Family pressure Reasons for hospitalization include:
    10. 10. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing 3000 Nursing Homes (19+%) have designated a Special Care Unit (SCU) Special Care Units (SCU) Dementia SCUs are the most common type (22%) (Originally for residents with mild/moderate stage dementia) Sub-acute Care Units provide short-term intensive rehab and continuous medical monitoring Types of Sub-acute Care Units include ventilator dependent, traumatic brain injury, oncology, pressure ulcer care, AIDS, skilled rehab, palliative care and hospice units
    11. 11. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Nursing Home Regulations: The Nursing Home Reform Act 1987 (NHRA [OBRA’87]) (PL 100-203) Most federal regulation of Nursing Homes stems from The Nursing Home Reform Act 1987. Components of the Act include the following:  Nursing homes are certified as a Medicare and/or Medicaid skilled nursing facility by the federal government (Centers for Medicare and Medicaid [CMS]).  “Conditions of Participation”: Spells out the mandates that a nursing home is obliged to meet in order to remain Medicare/Medicaid certified and eligible for reimbursement  Specifies that people living in a nursing home are “residents” – not patients.  Requires that every facility is “to care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of quality of life of each resident” and to “provide services and activities to attain or maintain, for each resident, the highest, practicable physical, mental and psychological well-being.”
    12. 12. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Staffing in Medicare and Medicaid Skilled Nursing Homes  On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN must be on duty 8 hrs/day, 7 days/wk. -Nursing: 66%+ of Nursing Home staff (RN, LPN, Certified Nurse Assistant or CNA) See Module 2: An Overview of Nursing homes Generally  Full-time licensed administrator  Therapeutic staff: social worker, activities therapist, nutritionist, and rehab therapy staff (full or part time required)  Medical director (at least 20% time)  Physician for every resident
    13. 13. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing CMS Mandated Services and Committees in Medicare and Medicaid Skilled Nursing Homes Podiatric, ophthalmology and dental services Rehabilitation services (PT, OT, ST) intensity can vary) Pharmacy, clinical lab, radiology End of Life (EOL) Care Psychiatry consultation Resident and Family Council (to express concerns & interests, and receive information and updates). Committees: Pharmacy & Therapeutics (P&T), Infection Control, Quality Assurance, Safety (Risk Management), Utilization Review
    14. 14. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing CMS Mandate for Interdisciplinary Team in Medicare and Medicaid NHs Physicians are the legal head of the team and the team includes nursing, social worker, activities therapist, nutritionist, rehabilitation, and others (e.g. psych) on ad hoc basis CNAs can (and should) be a member of the interdisciplinary team Resident, family, health proxy/surrogate, if resident wishes, are also part of the team
    15. 15. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Oversight and Monitoring of Nursing Homes The following are used in monitoring Nursing Homes:  State Departments of Health: Conducts surveys on behalf of CMS  CMS 5-Star Quality Rating System  Long Term Care Ombudsman: State office (federally funded) investigates and resolve complaints regarding resident rights, quality of care (in most but not all nursing homes).  Joint Commission: optional except for Nursing Homes seeking managed care contracts or that are hospital-based
    16. 16. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing State Departments of Health Surveys on Behalf of CMS Surveys assess 17 different Categories, including:  Resident rights  Admission and discharge rights  Resident behavior and facility practices  Quality of life  Resident assessment  Quality of care  Nursing services  Dietary services  Infection control Survey assessment of individual residents includes:  Use of physical restraints  Psychotropic medication  Staff training & supervision  Staffing  Care planning  Specific outcomes of care and others…
    17. 17. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing The CMS 5 Star Quality Rating System is a nationally recognized standard against which to assess nursing homes. Star rating reflects a Nursing Home’s quality status for the past 12-15 month period. Higher star ratings reflect better quality:  5 Stars: top 10% of nursing homes within the state  2, 3, 4 Stars: middle 70% of nursing homes within the state  1 Star: bottom 20% of nursing homes within the state CMS 5 Star Quality Rating System
    18. 18. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Sample Nursing Home Rating View the Nursing Home Compare web site
    19. 19. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing There are 3 performance measures of the CMS 5 Star Quality Rating System:  Staffing (Nursing) Domain  Quality Measures Domain  Health Inspection Domain CMS 5 Star Quality Rating System: 3 Domains (Performance Measures)
    20. 20. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing * Nurse staffing data provided by Nursing Homes is available in the annual federal On-line Survey, Certification and Staffing (Nursing) Domain of CMS 5 Star Quality Rating System The Staffing (Nursing) Domain, consists of the following characteristics:  Nurse staffing includes RNs, LPNs, and Certified Nursing Assistants (CNAs)  Nurse staffing typically reported as hours per resident day (HPRD). HPRD computed for RNs only and for total nursing staffing. *  Relationship of staffing to quality. CMS studies show a clear association between nursing staffing and quality of care outcomes  Staff-to-resident ratios indicate when NH residents are at high risk for quality problems (CMS data).
    21. 21. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Quality Domain of the CMS 5 Star Quality Rating System  Assessment of Quality based on data in the Minimum Data Set  Quality Measures (QMs) are issued by the NHQI Quality Initiative*  All QMs are validated, reliable and endorsed by the quality measure rating agency: National Quality Forum The Quality Domain, consists of the following characteristics: For comparison of quality measures across homes go to www.medicare.gov/NHCompare Quality Measures (QMs) are believed to be within the NHs ability to influence and control Seven Long-stay QMs: The percent of residents (1) whose need for ADL assistance increased; (2) whose in-room mobility decreased; (3) are “high-risk” and have pressure ulcers; (4) have an indwelling urinary catheter; (5) are physically restrained; (6) have a UTI; (7) have moderate to severe pain. Four Short-stay QMs: The percent of residents with (1) pressure ulcers; (2) delirium; (3) moderate to severe pain.
    22. 22. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Health Inspection Domain of the CMS 5 Star Quality Rating System The Health Inspection Domain carries the strongest weight. It uses annual health survey and complaint data and also indicates the relative performance of a nursing home within the state.
    23. 23. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing  The Minimum Data Set (MDS) is:  a functional assessment instrument; required by NHRA [OBRA ’87]  provided by the interdisciplinary team members according to their specialty.  the basis for interdisciplinary assessment, care planning, reimbursement, and quality monitoring. Resident Assessment: The Minimum Data Set (MDS) Click here for more information about MDS
    24. 24. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing NH Costs and Reimbursement  The mean national cost for a nursing home stay is $ 62,000+/year. A two-bed shared room is $169/day  62%+ of residents are dually Medicare and Medicaid eligible.  Medicare is primary payer for residents in a Nursing Home for post-hospital skilled nursing and/or rehab (100 days maximum).  Medicaid is primary payer for residents in a Nursing Home for an entire year (or longer).  Other residents are “private pay,” i.e. they pay for Nursing Home care “out of pocket.”
    25. 25. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Resource Utilization Groups III (RUGs)  Resource Utilization Groups III (RUGs) is a method of assigning payment for care in NHs (achieving a similar aim as DRGs in hospitals)  It is a case-mixed reimbursement system in which ADL data is essential. It also reflects the amount of resources (human and other) needed to provide care Click here for more information about RUGs
    26. 26. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Recap: Key Points about Nursing Homes: The Basics  Knowing the characteristics of residents in nursing homes is helpful in creating strong clinical assignments for students  Objective criteria exist for comparing and contrasting quality of care in nursing homes  Understanding regulation and reimbursement in nursing homes can help students meet learning objectives related to the health care system We present the following key points to consider:
    27. 27. © 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing Please Proceed to the following modules of the Series Nursing Homes as Clinical Placement Sites for Nursing Students Overview of the Project Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes Module 3: Content on resident directed care and culture change Module 4: Selecting and structuring clinical placements in nursing homes Module 5: A case study to help faculty introduce resident directed care and cu Module 6: Strategies to help nursing homes position themselves as clinical placement

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