1. Long Term Care in Geriatrics Seki Balogun, MD, FACP

2. Case 1. Ms. TJ is an 85year old woman with paraplegia from a spinal cord injury. She has severe neuropathic pain and is wheelchair dependent. Ms. TJ is an 85year old woman with paraplegia from a spinal cord injury. She has severe neuropathic pain and is wheelchair dependent. She lives alone, has no relatives in VA. She lives alone, has no relatives in VA. She had a paid caregiver, 6hrs/day, who helped her with self care (bathing, toileting) and her instrumental ADLs (cooking, cleaning and shopping). She had a paid caregiver, 6hrs/day, who helped her with self care (bathing, toileting) and her instrumental ADLs (cooking, cleaning and shopping). She can no longer afford to pay her caregiver She can no longer afford to pay her caregiver

3. You are her physician, what would be your advice? You are her physician, what would be your advice? 1. Tell her to go to the emergency room 2. Advise her to go to a nursing facility 3. Offer to pay her caregiver 4. Advise her to go to an assisted living facility

4. Nursing homes 1.5 million Americans (most aged 65 years and older) reside in 17,000 nursing facilities nationwide 1.5 million Americans (most aged 65 years and older) reside in 17,000 nursing facilities nationwide 43% of adults 65 years and older will stay in a nursing home at some time before they die 43% of adults 65 years and older will stay in a nursing home at some time before they die 55% have a lifetime use of at least 1 year 55% have a lifetime use of at least 1 year 21% have a total lifetime use of 5 years or more 21% have a total lifetime use of 5 years or more

5. LTC: Historical background Twelfth century “Gerocomeia” in ancient Greece “Gerocomeia” in ancient Greece Early 1900 Europe: special care units for the chronically ill elderly Europe: special care units for the chronically ill elderly United States: chronically ill and disabled United States: chronically ill and disabled Poorhouses Poorhouses

6. Historical background 1920s 1920s State licensure programsState licensure programs Standards and oversight were minimalStandards and oversight were minimal Mid – 1900s Mid – 1900s Social Security ActSocial Security Act Private nursing homesPrivate nursing homes Run by nursesRun by nurses Custodial careCustodial care Post- world war II: modeled after hospitals Post- world war II: modeled after hospitals Minimum standard of careMinimum standard of care

7. Historical background 1980s 1980s Nursing Home Reform Act (OBRA ’87) Nursing Home Reform Act (OBRA ’87) State regulations State regulations Quality of care for the cognitively and functionally impaired Quality of care for the cognitively and functionally impaired

8. Long Term Care Facility Nursing Homes Nursing Homes Assisted living facilities Assisted living facilities Focus of care is to achieve and maintain an optimal level of functioningFocus of care is to achieve and maintain an optimal level of functioning Interdisciplinary careInterdisciplinary care

9. Case 2. Mr. TB is a 90 year old man with multiple medical problems, who was admitted to the hospital last week with community acquired pneumonia. Mr. TB is a 90 year old man with multiple medical problems, who was admitted to the hospital last week with community acquired pneumonia. He is now ready for discharge He is now ready for discharge He is deconditioned and is unable to ambulate He is deconditioned and is unable to ambulate He lives with and is the caregiver for his wife, who has advanced dementia He lives with and is the caregiver for his wife, who has advanced dementia

10. You are the resident: Do you 1. Discharge him home: he did well at home before 2. Discharge him to a skilled nursing facility for rehabilitation 3. Discharge him home with home physical therapy 4. Not discharge him: it would be heartless to do so

11. Nursing Homes Skilled nursing care Typically for those discharged from an inpt setting with functional deficits and often medically complex Typically for those discharged from an inpt setting with functional deficits and often medically complex Require one or more form of therapy (PT, OT, speech) Require one or more form of therapy (PT, OT, speech) High degree of nursing care: IV, wound care High degree of nursing care: IV, wound care Length of stay usually less than 6 months (few days to months) Length of stay usually less than 6 months (few days to months)

12. Nursing Homes Long term nursing care For those who can no longer live independently For those who can no longer live independently Require assistance for self care and IADLsRequire assistance for self care and IADLs Significant functional, cognitive or psychosocial deficits Significant functional, cognitive or psychosocial deficits

13. Nursing Homes Hospice care Terminal conditions with less than 6 months to live Terminal conditions with less than 6 months to live Usually in conjunction with an independent hospice organization Usually in conjunction with an independent hospice organization Team provides a network of services: physicians, nurses, social workers, chaplain Team provides a network of services: physicians, nurses, social workers, chaplain

14. So what should happen to seniors who need some help, but do not require 24 hr nursing care? 1. They should be admitted to the nursing home: better safe than sorry. 2. Their family should care for them: it is their responsibility 3. They could live in an assisted living facility 4. They should pay for a caregiver

15. Assisted Living facility Residents require some supervision or physical assistance due to functional or cognitive deficits Residents require some supervision or physical assistance due to functional or cognitive deficits Usually owned by private organizations Usually owned by private organizations Provision of individual care needs vary with facility Provision of individual care needs vary with facility Provides 3 meals and medication administrationProvides 3 meals and medication administration Costs about $2-3K/monthCosts about $2-3K/month

16. Assisted living facility Better received by seniors Better received by seniors More home - likeMore home - like Less institutionalized settingLess institutionalized setting Paid by individuals or long term care insurance Paid by individuals or long term care insurance There are rare “Auxiliary Grants” for low income people. A few beds in our area at Mountainside in Crozet. There are rare “Auxiliary Grants” for low income people. A few beds in our area at Mountainside in Crozet.

17. HealthCare Financing in LTC Medicare Medicare Medicaid Medicaid Long term care insurance Long term care insurance Private pay Private pay

19. Medicare Federal insurance program run by Centers for Medicare and Medicaid Services (CMS) Federal insurance program run by Centers for Medicare and Medicaid Services (CMS) Covers acute health care for: Covers acute health care for: Adults 65 years and over Adults 65 years and over The disabled The disabled Persons with End Stage Renal disease Persons with End Stage Renal disease Covers skilled nursing care Covers skilled nursing care Does not cover care in assisted living facilities Does not cover care in assisted living facilities

20. Medicaid Joint federal and State Program People of all ages who have low income People of all ages who have low income Eligibility vary from state to state Eligibility vary from state to stateCovers Medicare part B premiums Medicare part B premiums Deductibles and co-insurance costs Deductibles and co-insurance costs Long term care (some assisted living facilities) Long term care (some assisted living facilities) Home care Home care Medications Medications

22. Long Term Care Insurance Premiums vary with plan Premiums vary with plan Can be expensive Can be expensive

23. Where would you like to spend your golden years? 1. Nursing facility 2. Assisted living facility 3. Home 4. I’d rather die than go to a nursing home