Long-Term Care

The setting in which long-term care is provided is best determined by the patient's wishes and medical, social, emotional, and financial needs; by the family's ability to meet the patient's needs; and by the provider's ability to achieve the goals established for the patient by the referring physician. The availability, accessibility, and affordability of community-based long-term care services (see Table 11-5) often determine whether placement in a nursing home is necessary.

Nursing Homes

A general term covering a wide variety of short- and long-term care facilities that provide medical and nursing care and other services.

A skilled nursing facility (SNF) is a term defined by the Health Care Financing Administration as an institution that provides persons >= 65 years (and younger disabled persons) with daily skilled nursing care, skilled rehabilitation services, and other medical services. Many also provide additional community-based services (eg, day care, respite care). For patients with functional disabilities resulting from injury or illness, many SNFs provide short-term postacute care services, including skilled nursing care and intensive physical, occupational, respiratory, and speech therapy. SNF beds may be located in hospitals (including rural hospitals with swing-beds) or in freestanding facilities that may or may not be affiliated with a hospital.

To be able to receive reimbursement from Medicare for skilled care, SNFs must be certified. To be certified, SNFs must have the following: a licensed charge nurse on site 24 hours/day, certified nurse assistants, a full-time social worker if the facility has > 120 beds, a medical director and licensed nursing home administrator, a qualified recreational therapist, a rehabilitative therapist, and a dietitian. Although not required to be on site, the following must be available as needed: physicians, pharmacists, dentists, and pastoral services.

To qualify for Medicare coverage of services in an SNF, beneficiaries must need daily skilled nursing care or daily rehabilitation therapy and must be admitted to the SNF or rehabilitation service within 30 days after a minimum 3-day hospital stay.

The number of nursing home beds continues to increase but is not keeping pace with the increase in the elderly population. In 1996, the USA had about 16,800 certified nursing homes with about 1.8 million beds. The number of beds per 1000 persons >= 65 ranged from 80.9 in Kansas to 26.1 in Nevada. Average occupancy was 87.4%, ranging from 98% in New York to 77% in Texas.

The probability of nursing home placement within a person's lifetime is closely related to age; for persons aged 65 to 74, the probability is 17%, but for those > 85, it is 60%. Projections indicate that 43% of persons who turned 65 in 1990 will spend some time in a nursing home before they die, and > 50% of those admitted will spend at least 1 year. Other risk factors for nursing home placement are living alone, loss of ability for self-care, impaired mental status, lack of social or informal supports, poverty, and female sex.

Services

The types of medical, nursing, and social services vary considerably among nursing homes. In addition to the basic services described above for certification, ophthalmologic, otolaryngologic, neurologic, psychiatric, psychologic, and other medical specialty services are provided by consultants but may require transport of patients to other facilities. Some nursing homes provide IV therapy, enteral nutrition through feeding tubes, and long-term oxygen treatment or ventilator support.

Recreational services are required in nursing homes, including weekend and evening programs. High-quality activity programs include scheduled group events and provide choices of leisure-time activities for patients, especially those who are cognitively impaired or bedridden. Some homes provide personal services (eg, hairdressing, makeup), which are usually paid for by patients' personal funds.

Social services also vary. Social workers assist patients and family members to improve the quality of care. They can help alleviate transfer trauma for patients and family members, identify social withdrawal and isolation, and actively assist in maintaining the patients' psychosocial well-being. Social workers can also ensure ongoing communication among the patient, family members, and care team, provide assistance when the patient applies for Medicare or Medicaid coverage, plan an appropriate discharge, and inform the patient and family members about other services.

Some nursing homes have special care units that provide services designed to meet specific problems (eg, Alzheimer's disease, ventilator dependence, cancer). Special care units must specify programs and admissions criteria, train staff specifically for the unit, meet regulations and reimbursement requirements, and have an identifiable area or discrete physical space.

Role of Nursing Home Staff

Some states set minimum nurse-to-patient ratios that are more stringent than federal rules, but the ratio of other staff members to patients varies considerably. When too few staff members are employed, they rarely have time to adequately care for the sicker or needier patients, particularly those with dementia; substandard care may result.

Physicians must see patients as often as medically necessary but not less than every 30 days for the first 90 days and at least once every 60 days thereafter. During routine visits, patients should be examined, drug status assessed, and laboratory tests ordered as needed. Findings must be documented in the patient's chart to keep other staff members informed. If possible, the physician who cares for a patient in the nursing home should treat that patient if hospitalization becomes necessary.

Some physicians limit their practice to nursing homes. They are available to participate in team activities and to consult with other staff members, thus promoting better care than that given in hurried bimonthly visits. Such full-time practice is enhanced when physicians also can monitor their patients' hospital care and when they can teach medical students and house staff members. House staff members learn more about geriatric care and that not all nursing home patients are obtunded, dehydrated, and febrile--a misconception commonly held by practitioners whose only contact with such patients is in a hospital emergency department.

Some nurse practitioners and physicians collaborate to manage patients' disorders. By administering antibiotics and monitoring IV lines, suctioning equipment, and sometimes ventilators, nurse practitioners may help prevent patients from being hospitalized.

Financial Aspects

Nursing home care is expensive, averaging $46,000 per year in 1995 according to estimates by the Health Care Financing Administration. About 50% of the cost is paid by Medicaid, 37% by the patient, 8% by Medicare, and 5% by private insurance.

Critics claim that prospective case-mix systems reimburse nursing homes at too low a rate and limit patient access to rehabilitation and services that enhance quality of life, especially for patients with dementia. Other criticisms are that these systems offer insufficient financial incentives to provide restorative care and rehabilitation for low-functioning patients and that they may encourage nursing homes to foster dependence or to maintain the need for high-level care to maximize reimbursement.

Determining the Need for Nursing Home Placement

A patient's preferences and needs can be determined most effectively through comprehensive geriatric assessment.

All disorders are identified and evaluated before a patient is institutionalized. Disabling disorders may be the trigger for considering nursing home placement. However, even modest improvement of a disorder may forestall the need for a nursing home. For example, if a patient who depends on family members for care develops urinary incontinence, the family may be overwhelmed. However, if the causes of incontinence can be treated, the patient may be able to remain at home.

Physical Function

Evaluating a patient's ability to perform the activities of daily living and instrumental activities of daily living is crucial in deciding whether nursing home placement is necessary. Severely impaired mobility may make living at home impossible, but patients with other functional impairments may be able to remain at home with the assistance of adaptive devices and durable medical equipment. Physical and occupational therapists and home health nurses can assess patients in their homes and help determine whether placement in a nursing home or in an assisted-living facility is necessary.

Cognitive Function

Dementia commonly leads to nursing home placement, but supportive family members may be taught ways to deal with frustrating or disruptive behavior. For example, using monitoring devices--purchased or rented--can help with behaviors such as nocturnal wandering.

Social Support

Strongly motivated family members usually can perform elaborate and detailed care; however, without support and respite services, they may become resentful or worn out. Physicians can help by listening while caregivers discuss the burdens and by providing information about community caregiving support groups and about options for paid respite care. All practitioners delivering services to the elderly should be familiar with signs of abuse or neglect and be ready to intervene if elder abuse is suspected.

Selection of a Nursing Home

When matching the needs of a patient with the services of a nursing home, physicians should consider which clinical care practice model the nursing home uses. Models range from private single-physician practices to large networks of primary care practitioners who routinely visit a certain set of nursing homes. Physicians considering an SNF may compare services available on site with those requiring transfers to other facilities. Cognitively impaired patients are easily disoriented and frightened by the shuffling from one facility to another, and severely deconditioned patients may be exhausted by travel for dental care or blood work. Also, physicians should be familiar with the hospitals that have transfer agreements with the nursing home and with the availability of special therapeutic services, palliative care, hospice, and other services. Differences in services and the employment of full-time vs. part-time staff members may help determine the appropriateness of a home and the quality of its care. Patients' medical coverage, particularly if they are in a Medicare capitated program, must be considered when selecting a nursing home. Medicare covers certain aspects of ongoing medical care, although it does not cover long-term custodial care.

Monitoring quality of care in nursing homes is the responsibility of federal and state regulators. The government is legally responsible for ensuring that a facility is providing good care, not merely that it is capable of doing so; therefore, outcome measures are playing an increasing role in quality assessment. Through observation of care, interviews with patients and staff members, and review of clinical records, surveyors attempt to assess a facility's performance and to detect deficiencies (see Table 11-6).

Hospitalization of Nursing Home Patients

Hospitalization is avoided whenever possible because patients often return from the hospital with urinary catheters and pressure sores. Hospitalization often causes patients to become confused or severely deconditioned, and they are often given psychoactive drugs in hospitals. Many patients also prefer to avoid hospitalization because treatment in hospitals can be dehumanizing and impersonal.

When patients are transferred to a hospital, their medical records should accompany them. A phone call from a nursing home nurse to a hospital nurse is useful to explain the diagnosis and reason for transfer and to describe the patient's baseline functional and mental status, drugs, and advance directives. When patients are discharged to a nursing home from the hospital, communication among hospital nurses and nursing home nurses is critical.

Abuse and Neglect of Nursing Home Patients

Patients are vulnerable and unable to leave the facility, they may have infrequent visitors, and their complaints may not be believed. Subtle types of abuse (eg, using drugs and physical restraints inappropriately) to manage disruptive behavior are still too common. Pinching, slapping, or yanking may be hard to prove, because ecchymosis and skin tears occur easily in the elderly, even without abuse. Detecting, stopping, and preventing abuse is a primary function of physicians, nurses, and other health care practitioners. A public advocacy system exists, and nursing homes can be cited by regulatory agencies.

Board-and-Care Facilities

(Adult Care Homes; Domiciliaries; Rest Homes)

Facilities for elderly persons who cannot live independently but who do not need the constant supervision provided in nursing homes.

Board-and-care facilities typically provide shelter, meals, minimal assistance with personal care, and sometimes supervision of drug administration (see Table 11-5). The program costs >= $8 billion annually. The number of facilities is increasing because they offer an economic, federally funded means of accommodating the increasing number of elderly persons who would otherwise require nursing home care paid for with state Medicaid funds.

Minimally regulated and sometimes unlicensed, the facilities principally serve two groups, often cared for together--the elderly and the deinstitutionalized mentally ill. Although excellent homes exist, many facilities tend to warehouse the disabled in substandard buildings and to employ few skilled staff members. At least one study uncovered widespread misuse of drugs in board-and-care facilities.

Physicians should try to ensure that their patients in board-and-care facilities are safe and are receiving appropriate care. Physicians may need to visit the facility or send a nurse or social worker to evaluate it.

Assisted-Living Programs

(Supportive Housing; Enriched Housing; Congregate Care)

Programs that enable residents with deficits in activities of daily living to maintain their independence in personalized settings by providing or arranging for the provision of daily meals, personal and other supportive services, health care, and 24-hour oversight as needed.

In some states (eg, New York), assisted-living programs are implemented in existing board-and-care facilities (with supplemental care provided by a home health agency), because supplying services to a group of patients in one location costs less than supplying services to persons throughout the community.

Life-Care Communities

(Continuing Care Retirement Communities)

Organizations that offer a contract intended to remain in effect for the resident's lifetime and, at a minimum, guarantee shelter and access to various health care services.

Life-care communities offer different levels of care: for persons who can live independently, for those who need assistance, and for those who need skilled nursing care. Generally, persons pay a substantial entrance fee ($50,000 to $500,000) when moving to the community and monthly fees thereafter. In some communities, residents pay only a monthly fee for rent plus service or health packages. In others, residents can purchase a condominium, cooperative, or membership; service or health packages are purchased separately.

Three types of life-care retirement communities are generally recognized: those covered by an all-inclusive contract, those covered by a modified contract limiting the amount of long-term care provided before the monthly fee is increased, and those covered by a fee-for-service contract with billing for health services as they are used.

The number of life-care communities increased by 50% in the 1980s and continues to increase; > 40% of these communities are in five states (Pennsylvania, California, Florida, Illinois, and Ohio). Resident profiles indicate that the average resident is a wealthy, widowed female aged 81.

If well financed and managed, life-care communities provide a broad range of housing, social, supportive, and health services that enable their residents to live comfortably. However, some are not well regulated and, because of unscrupulous real estate dealers or well-intentioned but inept management, the assets of the residents have been wiped out.

Communities may be housed in a single building or may be spread across multiacre campuses with housing options ranging from efficiency apartments to cottages with several rooms. Many have community buildings for organized social events, dining rooms, clubs, sports facilities, planned outings, and vacation options. Life-care communities are usually affiliated with various home care services, adult homes, day care programs, and nursing homes. Access to physicians is usually provided, and most programs are affiliated with local acute care facilities.