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Geriatrics > Nursing Home Care > Flashcards

Nursing Home Care Flashcards

1
Q

2 MC kinds of institutional long term care?

A
  • nursing homes

- assisted living

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2
Q

What is a skilled nursing facility?

A
  • house persons requring care and supervision of a skilled nurse
  • licensed and regulated by state agencies with considerable federal control through medicare and medicaid guidelines
  • admission is based on case by case basis
  • mostly staffed w/ CNAs
  • few licensed nurses are present to conduct assessments, distribute meds, supervise CNAs, communicate w/ providers, and admin tx
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3
Q

What are assisted living facilities?

A
  • diverse
  • can include small “mom and pop” homes caring for as few as 2 residents
  • clusters of small homes w/ central admin
  • larger freestanding facilities that look a lot like nursing homes
  • buildings or wings w/in multilevel campus
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4
Q

Characteristics of long term care residents?

A
  • tend to be old, sick, poor and alone
  • mean age: 78-85
  • alzheimers
  • multi-infarct dementia
  • severe chronic heart disease
  • amputation
  • COPD
  • widows
  • no kids
  • low income
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5
Q

Diff in short and long stay care?

A
  • short stay: for terminal care or rehab
  • ## long stay: primarily medical problems, dementia
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6
Q

Who pays for nursing homes?

A
  • after medicare runs out:
    47% medicaid
    45% private pay
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7
Q

Who pays for assisted living?

A
  • neither medicare nor medicaid pays for most assisted living
  • ends up private pay
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8
Q

Job of the medical director?

A
  • reqd for all SNFs
  • ensures provider care, addresses legal and medical needs
  • quality improvement
  • committees susch as infection control, pharm, and utilization review
  • reviews incident reports
  • assists w/ development of policies and procedures for residents and staff
  • oversees health program for employees
  • conducts educational programs for employees, residents and families
  • acts as spokesperson for facility in community and w/ regulatory and other health care agencies
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9
Q

What does function oriented care mean?

A
  • maximize what each pt can do independently
  • rehab mind set
  • assessment and care plan for fxnl status, establish prognosis, identify specific fxnl objectives and time frame to accomplish these
  • monitor fxnl status improvement, preventing iatrogenic consequences
  • plan a d/c date if possible - when not likely, strategies to maintain fxnl status should be developed
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10
Q

Are use of restraints helpful?

A

Not really
- increase agitation
- rarely prevent falls or injuries
- constitute an unjustified infringement on resident autonomy
- types of restraints:
vest, wrist, ankle, chairs w/ locking lap trays, wrist restraints, safety belts, bed rails

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11
Q

Alternatives to restraints?

A
  • increased involvement for residents in structured activities
  • assisted daily ambulation, regular toileting
  • active listening
  • therapeutic touch
  • behavior modification
  • search for physiologic causes of agitation: pain, constipation, infection
  • recliner chairs
  • carpeted floors
  • lower beds
  • motion detectors and position monitors
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12
Q

Why are long term care residents considered medically underserved pop?

A
  • lack personal relationships and individualized attention that characterize the best primary medical care
  • logistics of traveling to long term care facility
  • decisions are made via telephone
  • medicare and medicaid reimbursements are low
  • high resident and staff turnover
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13
Q

Upside of having a resident w/ an involved family?

A
  • tend to receive more staff attention and have medical problems detected earlier
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14
Q

Provider’s role in taking care of pt in longterm care and dealing w/ the family?

A

-take time to meet w/ family
- anticipate future events and discuss in advance w/ family
- learn as much as possible about family dynamics, anticipate conflicts - on admission, when there is a major status change
- advanced directives
- don’t resucitate
- end of life measures
- withholding txs:
feeding tubes, abx for fever, whether to hosp. or not

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15
Q

PA reimbursement in skilled nursing facility and nursing facility?

A
  • all services PA is legally authorized to provide that would have been covered if provided personally by a physician
  • reimbursement rate:
    85% of physician’s fee schedule
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16
Q

What are common infections in long term care settings?

A
  • pneumonia

- urosepsis

17
Q

What is a common musculoskeletal disease in long term care settings?

A
  • arthritis - manage w/ mobilization and acetaminophen (not NSAIDs)
18
Q

Why do falls and pressure sores occur? What should be assessed? Tx for pressure sores?

A
  • reduced mobility leads to both falls and pressure sores
  • assess cognitive status:
    risk assessment, skin care, frequent turning and positioning, special beds, and mattresses
  • early tx for pressure sores:
    protection from further pressure, shear and friction, debridement of necrotic tissue, maintenance of moist wound environment, protection from secondary infection, adequate nutrition
19
Q

Causes of constipation in long term care settings?

A 
- polypharm:
antacids
anticholinergics
TCAs
CCBs
NSAIDs
benzos
neuroleptics 
- decreased physical activity
- immobility
- decreased oral intake
- decreased dietary fiber intake
- dehydration
- loss of fxnl status
- normal aging changes involving decrease gastric motility and peristalsis
20
Q

Tx for constipation?

A
  • exercise
  • hydration
  • stool softeners
  • bulk laxatives
  • drug changes
21
Q

Why is there usually sig wt loss in longt term care settings?

A
  • depression
  • meds
  • cancer
  • swallowing disorders
  • poor fitting or absent dentures
  • advanced dementia
22
Q

Tx for wt loss?

A
  • monitor food and fluid intake
  • weigh pts at least once a month
  • look for reversible causes
  • simple form of diet:
    soft diet, pureed, adequate staff time to assist pt w/ eating
23
Q

Impt health maintenance in pts in long term care settings?

A
  • all new and prospective residents need to be screened for TB: 2 step (rules out booster phenomenon in the future)
  • all pts should get flu vaccine, medical eval: hx, physical, and lab tests based on eval, routine lab assessment isn’t recommended
24
Q

What is the booster phenomenon?

A
  • in PPD testing: occurs when person’s immune system has forgotten about an infection by mycobacterium tb until yrs later when the person is tested again for TB - PPD test reminds the immune system about the infection
  • although initial TB test was negative, a 2nd TB test performed yrs later, may boost the immune system’s inability to react to tuberculin
  • therefore no way of knowing if positive TB test result was due to recent TB infection or due to TB booster phenomenon
25
Q

Why is home care so impt?

A
  • bc overall goal of good geriatric medical practice is to maintain older persons in the familiarity, comfort and dignity of their own homes for as long as possible
26
Q

What are the reasons for home care?

A
  • aging society
  • family caregivers provide 80% of care
  • pressure to contain overall health care costs
  • DRGs: shortening the period of an inpt convalescence
  • managed care and health maintenance organizations have encouraged the use of home care as an alt to hospitalization
27
Q

Why did home care decrease in 1997?

A
  • concerns about growing medicare budget
  • misuse of home care
  • marked regional variation in utilization
  • insufficient datat regarding return on investment
  • medicare reset home care payments to 1994 stds - lower reimbursement
  • restricted the avg number of reimbursable visits per pt
28
Q

What techniques are available for better home care if families are willing to help provide care?

A
  • infusion pumps
  • dialysis units
  • ventilators
  • O2 concentrators
  • monitoring systems
  • it is expected that home care will continue to grow
29
Q

What is the criteria for selecting pts for home care?

A
  • clinical stability
  • caregiver support
  • appropriate enviro
  • availability of professional services
  • financial support: poorly covered at present by medicare and other insurers, self pay costs need to be est b/f initiating home care
30
Q

Health care involvement w/ home care?

A
  • physician must sign initial plan and any subsequent orders in timely manner
  • physician must exercise medical judgement and supervision of care
  • nurse clinicians and other home care professional, in consultation w/ provider, provide much of the in home assessment and hands on care of pts
  • if possible, provider also personally performs assessment periodically at home
31
Q

PA reimbursment for home care?

A
  • all services PA is legally authorized to provide that would have been covered if provided personally by a physician
  • reimbursement rate: 85% of physician’s fee schedule
32
Q

What does a provider perform during the “house call”?

A
  • H and P
  • counsel to pt and family
  • med review
  • nutritional screening
  • assessment of enviro
  • assessment of caregivers
  • home support devices (safety)
  • obtain specimens
33
Q

Benefits of home care?

A
  • improve desired outcomes of care
  • medical legal actions involved in home care visits are almost non-existent
  • still must be aware of medical liability
  • appropriate risk management
  • informed consent
  • good communication
  • documentation of care in medical record
34
Q

Regulatory and coverage issues w/ home care?

A

basic entry criteria for medicare home health care:
- pt must be homebound
- leaving home must reqr assistance and considerable effort
- pt must reqr intermittent skilled care ordered by provider:
nurse visits
PT
ST
home health aide

35
Q

Medicaid coverage of home care?

A
  • varies b/t states
  • all states provide some level of both skilled and custodial community services to pts who meet the medical and income criteria
  • for geriatrics who have both medicare and medicaid, skilled services are covered by medicare, personal or custodial care is covered by medicaid
  • both medicare and medicaid pay for certain types of home medical equipment

Geriatrics (16 decks)

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