1. Long-Term Care Chapter 14 McGraw-Hill/Irwin © 2013 McGraw-Hill Companies. All Rights Reserved.

2. 14-2 The Need for Long-Term Care Who needs long-term care? Those over 75 Those with Alzheimer’s Those without a caregiver (spouse, family) Elders who cannot perform ADLs or IADLs Frail elders

3. 14-3 The Need for Long-Term Care Ethnic elders are less likely to use long-term care Elders have moved away from family-care to formal care, or independent living Increased life expectancy of baby boomers

4. 14-4 Funding Sources for Long- Term Care Medicare Very limited for long-term care Medicaid (MediCal) The largest public funding source for LTC Private insurance Medigap or long-term care insurance Other sources Social Security, community support, Veterans Affairs

5. 14-5 Home Care: Family Providers of Home Care The single-most-important consideration to determine if a frail elder can live at home is if a family member or close friend can be a caregiver Adult children or spouses are caregivers Cultural differences in family care Physically, emotionally and financially taxing

6. 14-6 Home Care: Formal Support for Caregivers Education programs Support groups Financial support Legal support Case management Respite care Temporary, infrequent relief for caregivers

7. 14-7 Domestic Elder Abuse Includes physical, psychological or sexual abuse, financial exploitation and neglect It is very difficult define and collect data on abuse Most abuse happens to women and those over 80 Abuse happens because of long-term habits of behavior it is not based on the stress of care giving alone Signs of abuse can be attributed to aging

8. 14-8 Home Care: Self-Neglect Elders’ right to live as they please vs. Society’s obligation to ensure safety If elders are rational, there is little to be done about self-neglect A conservator can be assigned if the elder cannot manage his or her own affairs – it is difficult and serious to do this

9. 14-9 Home Care: In-home Services Includes skilled services and personal care services Medicare encourages home health services Home care can be less expensive than institutionalization There are no quality or training standards for home care

10. 14-10 Home Care Home health services Homemaker aides Help with light housekeeping, shopping Not reimbursed by Medicare Home health aides Help with personal care such as bathing Skilled nursing services Nurses come to the home to provide direct patient care, monitor treatment, refer the patient to other resources and give education and home care techniques

11. 14-11 Home Care Physician services Doctors rarely make house calls anymore A PA or NP can make home visits to treat the patient under the supervision of a doctor Physical, speech and occupational therapists In general, better and quicker results come from home visits The therapist develops a plan, teaches the patient and caregiver and then monitors with home visits

12. 14-12 Home Care Emergency response services Electronic response The elder has a button they can use for emergencies Personal response A friend calls at a prearranged time each day to check on the elder Telephone and visiting programs Help with isolation issues of homebound elders The visitors are trained to notice health problems or environmental dangers

13. 14-13 Home Care Home-delivered meals Meals on Wheels provides homebound elders one meal a day five days a week Hospice care Can be provided in hospitals, but usually are in the home Must be diagnosed with 6 or less months to live to qualify Medicare will reimburse for hospice services

14. 14-14 Community-Based Services Congregate meal services Funding comes from Administration on Aging Allows elders a social meal and includes transportation. Can be prepared with special dietary needs Adult day care centers and adult day health centers Many include specialized programs for Alzheimer’s Can be paid for through Medicaid Many communities do not have centers

15. 14-15 Community-Based Services Multipurpose senior centers Recreation/education Should meet the community’s needs Activities will be varied Service Includes congregate meals Information and referrals Transportation services Necessary for many elders to attend social and cultural events Public transportation does not always serve wheelchairs or frail elders Can be part of other community-based programs

16. 14-16 Community-Based Services Case management services Helps negotiate the services offered to assist elders with long-term care Can keep elders out of nursing homes by using other options Hospitals and private companies offer case management services Comprehensive community-based care Program of All-Inclusive Care of the Elderly (PACE) Helps elders who have been certified as eligible for nursing home admission to enter a long-term care program and remain at home Must be dual-eligibility seniors (Medi-Medi)

17. 14-17 Community-Based Services Community-based sheltered living Helps elders who need assistance, but not 24-hour nursing care Levels of care, licensing and costs vary Boarding houses Adult foster care Assisted living Continuing care retirement communities

18. 14-18 Nursing Homes 24-hour care, short-term or long-term Similar to hospitals Offer activities, assistance, therapy Each facility varies in price, care, size, etc. Nursing assistants are the majority of staff, LVNs and RNs assist with medical care and contact doctors when needed

19. 14-19 Nursing Homes: The Nursing Home Population 1.5 million residents are housed in nursing homes 90% are 65 and older ¾ are women, most are unmarried Cannot perform the tasks of daily living and have no help (family) to take care of them Ethnic groups are underrepresented in nursing homes

20. 14-20 Nursing Homes: Nursing Home Costs Average cost of $90,155 yearly Many elders enter with Medicare as their primary funding, then pay cash when no longer eligibly; they move to Medicaid when their assets are depleted Medicaid pays less per day than the costs, so facilities with Medicaid patients lose $ Non-Medicaid patients pay more

21. 14-21 Nursing Homes: Nursing Home Regulations Address the physical, medical and psychological well-being of the residents – they focus on actual performance Nursing homes cannot receive payment from Medicare or Medicaid without being subjected to these regulations and inspections States can make their own regulations as well Safety regulations must also be followed

22. 14-22 Nursing Homes: The Minimum Data Set (MDS) MDSs are assessments of each resident submitted to the federal government and completed by staff who works closely with the patient MDSs help determine the Medicare reimbursement rate Includes information on health, well-being, function, risk factors, care plan, etc. They are extensive reports

23. 14-23 Nursing Homes: Individual Care Plans The data from the MDS help determine the care plan for each resident The care plan takes information from the entire interdisciplinary team as well as the resident and the resident’s family Care plans must be updated frequently with any new conditions

24. 14-24 Nursing Homes: Selected Areas of Concern Physical restraints Restraints cannot be used for convenience or discipline – they must have a medical use Restraints use must be monitored and there must be efforts to discontinue the use There are no regulations on restraints at home Chemical restraints Psychoactive drugs and sedatives can only be used for certain diagnoses in certain doses The dose must be reduced every few months unless there is a medical reason not to reduce Must be monitored

25. 14-25 Nursing homes: Selected Areas of Concern Pressure ulcers Most common reason for lawsuits There are ample regulations for treatment and prevention Those at risk need to have it in their care plan Institutional elder abuse Healthcare providers must report any suspected elder abuse Careful screening of employees can help eliminate elder abuse Nursing homes should have many visitors

26. 14-26 Nursing Homes: Benefits and Limitations of Nursing Home Care Benefits 24-hour medical supervision Centralized, coordinated care Social interaction Federally regulated Safe, secure place for frail elders Limitations Keeping qualified staff – especially nurse’s aides Atmosphere may feel like a hospital instead of a home – impersonal Too much care Loss of individuality Privacy and personal choice are rare

27. 14-27 Nursing Homes New directions in nursing homes Person-directed care – making the institution fit the elder Focus on relationships One example is the Eden Alternative Nursing home advocacy Nursing Home Reform Act of 1987 mandates certain rights to those who use Medicare and Medicaid Each Area Agency on Aging has an ombudsman program

28. 14-28 Nursing Homes: Assessing Nursing Home Quality Federal government measures quality based on the MDS – this information is published on CMS’s website for consumers Staffing ratios or “hours per patient day” help determine quality The same website compares health deficiencies and citations

29. 14-29 Planning for Long-Term Care Must look at options including financing before the need arises A reverse mortgage can help with financing Visit all potential nursing homes in the area Visit during a meal and talk to the residents Visit websites for comparison information

30. Long-Term Care Chapter 14