1. Long-Term Care
NURS 4100 Care of the Older Adult
Spring 2014
Joy A. Shepard, PhD(c), MSN, RN, CNE
1

2. Objectives
Describe the long-term care continuum
Describe various long-term care practice
settings and roles for gerontological nurses
Describe the principles of rehabilitative
nursing
Compare and contrast community-based
versus institutional long-term care
2

3. “There’s No Place Like Home”
3

4. Long-Term Care Continuum
Long-Term Care:
“Care of those
persons requiring
health care, personal
care, social, and
supportive services
over a sustained
period of time”
4

5. Components of the Long-Term
Care System
Consumers:
 Elderly users of
long-term care



The elderly as a
political force
Nonelderly longterm care users
Physically disabled

Mentally ill,
developmentally disabled

Baby boomers: future
long-term care consumers
5

6. Seniors Account for Half of the
Total Population with Long-Term
Care Needs
6

7. Components of the Long-Term
Care System
Providers:
Providers:
Nursing
Adult Day Care
Facilities
Home Health
Assisted Living/
Care
Residential Care
Hospice Care
Subacute Care
7

8. Institutional vs. Non-Institutional
(Community-Based) Care
Institutional:
Non-Institutional:
• Nursing Facilities
• Adult Day Care
• Assisted Living
• Subacute Care
• Home Health
• Hospice Care
8

9. Institutional vs. Non-Institutional
(Community-Based) Care
9

10. Impact of the Large Number of
Boomers on LTC…
Will grow over the next 2 decades and beyond…
10

11. Looming Shortage
US will need to recruit
200,000 new directcare workers each
year to meet future
demand among the
Baby Boomers as
they age
http://www.reuters.com/article/pressRelease/idUS155188+29-Apr-2008+BW20080429
11

12. Major Sources Financing Longterm Care Expenditures
12

13. Nursing Facilities (Homes)
13

14. Nursing Facilities (Homes)
1.5-2 million residents
(4-5% older US
population)

5.3 million by 2030
Resident characteristics
Predominantly women,
age 80+, white, widowed,
dependent in ADLs &
IADLs
 More than 60%
cognitively impaired

16,100 Nursing homes
(US)
Costs of care
Vary by geographical
location, ownership,
amenities
 Average annual cost:
 $83,585 (US)


$7,000 month
 $66,830
(NC)
14

15. Getting Admitted into a Nursing Home…
Often a crisis makes it necessary…
15

16. Responsibilities of Nurses in LTC
Box 37-4, p. 503
Administrative & management
Direct care provider
Guardian of care/ advocacy
Care coordinator
Numerous other roles
MDS
16

17. Activities of Daily Living (ADLs)
Bathing
•
•
Eating
•
•
Dressing
Toileting
Transferring
(Average resident needs help with 4 ADLs)
17

18. Financing Nursing Facilities
Reimbursement
sources:
 Medicaid
- 65%
 Medicare - 13%
 Private pay and
other sources –
the remainder
Medicaid
Medicare
Private, other
18

19. Medicare Coverage
Restrictions:
Covers only skilled nursing care
Must follow 3-day hospital stay
 Limited to 100 days per “benefit period”
Requires co-payment days 21-100
19

20. Nursing Facilities (Homes)
Regulations and
quality of care
Highly regulated
 Omnibus
Budget
Reconciliation Act
(OBRA) of 1987 has
had positive impact
 MDS – Federal
database
Nursing homes must have
licensed nurse on duty 24
hrs/day
During one 8-hr shift each
day, one of these nurses
must be RN
20

21. Nursing Staffing Ratios in NC
“Daily direct patient care nursing staff, licensed
and unlicensed, shall equal or exceed 2.1
nursing hours per patient per day”
Also referred to as nursing hours per patient day
( NHPPD or NH/PD)
http://www.hpm.umn.edu/nhregsPlus/state_regulation_attachments/north_carolina_regulation_attachments/nort
Typical staffing ratio (area nursing homes):
 20-30:1
(RN or LPN)
 10:1 CNA
21

22. Delegation & Accountability/Responsibility
Delegation: Transferring to a competent
individual the authority to perform a selected
nursing activity in a selected situation. The
nurse retains accountability for the delegation.
Accountability/ Responsibility: Answerable for
actions or inactions of self in the context of
assignment or delegation.
http://www.ncbon.com/content.aspx?id=682&terms=delegation
22

23. 5 Rights of Delegation for RNs
Right task
Right circumstances
Right person
Right direction/ communication
Right supervision/ evaluation
https://www.ncsbn.org/fiverights.pdf
23

24. (NC) Medication Aide –
ICF/Skilled Nursing Facilities
CNA I
Complete 24-hour NC Medication Aide training program
Pass NC Medication Aide certification exam (NCBON)
“Before allowing a medication aide to administer medications, the nursing
home employer must conduct a clinical skills validation for those
medication tasks to be performed in the facility. The validation must be
conducted by a registered nurse”
Registry – NC Division of Health Service Regulation Medication Aide
“The licensed nurse maintains accountability and responsibility for the
delivery of safe and competent care”
https://www.ncnar.org/matcep.html
http://www.ncbon.com/content.aspx?id=826
24

25. Question
Which question by the nurse would be the most
appropriate to ask the unlicensed assistive
personnel (UAP) after discussing the care the
UAP is to give to a client?
 A.
"Do you understand what you are to do for this client?"
 B. "Will you be able to complete this assignment before
you leave the unit today?"
 C. "Can you repeat the main points of what we just
discussed with regard to your assignment?"
 D. “Do you have any questions?"
25

26. Question
The registered nurse monitors the performance of each
unlicensed assistive personnel (UAP) and intervenes as
necessary, obtains and provides feedback, and ensures
proper documentation. Which right of delegation is the
registered nurse demonstrating?
A. Right task
B. Right circumstances
C. Right person
D. Right direction/ communication
E. Right supervision/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+
26

27. Question
The registered nurse matches the complexity of the
activity with the unlicensed assistive personnel (UAP)
competency and with the level of supervision available.
Which right of delegation is the registered nurse
demonstrating?
A. Right task
B. Right circumstances
C. Right person
D. Right direction/ communication
E. Right supervision/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+
27

28. Question
The registered nurse instructs and/or assesses, verifies
and identifies the UAP's competency on an individual,
task and patient-specific basis. Which right of delegation
is the registered nurse demonstrating?
A. Right task
B. Right circumstances
C. Right person
D. Right direction/ communication
E. Right supervision/ evaluation
http://www.mass.gov/?pageID=eohhs2terminal&L=8&L0=Home&L1=Provider&L2=Certification%2c+Licensure%2c+and+Registration&L3=Occupational+and+Professional&L4=Nursing&L5=Nursing+Practice&L6=Advisory+Rulings+
28

29. NC Nursing Homes - Regulations
NC Division of Health Service Regulation
(formerly Division of Facility Services)
 Nursing
Home Licensure & Certification Section
 Licenses
nursing homes in NC
Certificate of Need (CON)
Centers for Medicare & Medicaid Services –
95% of nursing homes
Surveys – every 9-15 months
29

30. NC Regulations
Office of Long-Term Services & Supports
Nursing homes
List of Nursing Homes
NC Nurse Aide I & Health Care Personnel Registry
Nursing Home Residents' Bill of Rights
Long Term Care Ombudsman Program
Mental Illness in Long-Term Care Facilities Study (2008)
Long-Term Services and Supports Action Plan
A Long-Term Care Plan for North Carolina: Final Report
NC State Board of Examiners for Nursing Home Administrators
30

31. How Nurses Can Help Families
Choose a Nursing Home
Nursing Home Compare
 http://www.medicare.gov/NHCompare
 CMS’s
Online Survey Certification and Reporting
(OSCAR) database
 Minimum Data Set (MDS) Repository
Issues to consider: safe physical environment,
dementia health, overall health, knowledgeable
and available staff, quality of life, support,
interdisciplinary team (Box 37-2, pp. 500-501)
31

32. Assisted Living Facilities
32

33. Assisted Living Facility (ALF)
“Special combination of housing, personalized
supportive services, and health care designed to meet
the needs, both scheduled and unscheduled, of those
who need help with activities of daily living”
Long-term care residential alternative
More assistance than retirement community
 Less medical & nursing care than nursing facility

24-hr/day on-site support and assistance
39,500 ALFs (US)
900,000 residents
33

34. Profile of Resident of
Assisted Living Facility
80 years old (mean age)
Female (69%)
Needs help with at least
two ADLs
Bathing: 68%
 Dressing: 47%
 Toileting: 34%
 Transferring: 25%
 Eating: 22%

Needs help with IADLs
Housework: 91%
 Medications: 86%

Length of stay: 27
months
34% move to nursing
facility
 30% die while resident

34

35. Assisted Living Facility (ALF)
35

36. Services Provided
 Personal care
Exercise &
 Health care
educational activities
Transportation
Laundry & linen
Housekeeping &
maintenance
 Supervision
 Social services
 Social & religious
activities
36

37. ALF Living Accommodations
37

38. Financing Assisted Living
Reimbursement
Sources:
Mostly self-pay
 Medicaid – small, but
growing

Average annual cost:

$39,516 (US)


$3300 month
$28,734 (NC)
38

39. Staffing/Work Force
Largely non-clinical (unlicensed personnel)
Customer service focus
Few staffing regulations – mostly based on
nursing facility model
Training staff to recognize residents’ privacy &
independence
Medication Aide (Tech) – Adult Care Setting
 Registry
– NC Division of Health Service
Regulation’s Adult Care Licensure Section
39

40. Regulations
Few regulations until recently
Increasing number of states now
regulating assisted living
Very little commonality or uniformity
40

41. Tragic Case of GlenCare (ALF)
in Mount Olive
Example poor quality ALF
5 residents died of
hepatitis B; 3 others
diagnosed
State says facility failed to
train medication techs for
blood glucose monitoring
http://www.witn.com/localnews/headlines/Two_More_Hepatitis_B_Cases_Confirmed_At_Mt_Olive_Facility_106777234.html
41

42. Cypress Glen (ALF) in Greenville
Example highquality ALF
Many amenities
Expensive
facility
http://www.cypressglenretirementcommunity.com/CypressGlenAssistedLiving.htm
42

43. NC Regulations
Assisted Living
Adult Care Homes
Licensed by State Division of Health Service Regulation (Group Care Section)
Group Homes (Developmentally Disabled)
Multi-Unit Assisted Housing With Services
County Departments of Social Services
Rights of Residents
Elder Housing Information
Medication Aide (Tech) – Adult Care Homes
43

44. Subacute Care & Rehabilitation
Units
44

45. What is Subacute Care?
Inpatient restorative or rehabilitative health
Immediately following debilitating illness, surgery, or injury
General criteria for admission include: stabilization of some
acute health care problem, need for rehabilitative services to
restore physical function, ability to participate in daily
rehabilitative therapy, anticipated discharge within
approximately 3 weeks
Care planning based on functional goals such as being able to
walk around the house, climb stairs, assist or be independent in
self care, perform exercises or be able to participate in more
intensive rehabilitation once discharge for the inpatient setting
http://www.subacutecare.info/consumer.html
45

46. What Is Subacute Care?
Comprehensive
inpatient care
Comes after, or
instead of, acute care
Between acute &
long-term care
Usually for defined
period of time
Developed for costsavings
Fastest-growing
segment of healthcare delivery system
46

47. Staffing
Interdisciplinary Team:
Physicians
or mid-level
providers
Nurses
Physical therapists,
occupational therapists,
speech pathologists,
recreational therapists,
nutritionists, social workers
Non-licensed staff
47

48. 48

49. Reimbursement:
Short-Stay vs Chronic
Subacute care (Medicare reimbursed, short stay)
Chronic care (private pay or Medicaid) for frail, elderly
residents requiring help with the activities of daily living
A 3-day qualifying stay in a hospital is required for
skilled nursing care to receive Medicare
reimbursement in a subacute care facility
Must be a candidate for rehabilitation
 Periodic recertification – continued need for skilled care
 Resident’s progress toward established goals
 One hundred days of skilled care can be reimbursed per
“benefit period”

49

50. Vidant Regional Rehabilitation
Center
Patients admitted to the Center must meet the
following general criteria
 Must
be able to participate in therapy 3 hours a day
 Must be medically appropriate
 Must have functional & cognitive recovery potential
 Must have support & involvement of family
http://www.uhseast.com/uhseast/ServicesDetail.aspx?id=5284&linki
 http://whiteshoal.uhseast.com/rehab/video/rehab tour.wmv

50

51. Services Provided
• Rehabilitation
• Chemotherapy
• Physical Therapy
• Parenteral Nutrition
• Occupational Therapy
• Dialysis
• Respiratory therapy
• Pain Management
• Cardiac Rehab
• Complex Medical
• Speech Therapy
• Wound Management
• Postsurgical Care
• Ventilation Care
51

52. Skilled Nursing Facility (SNF) vs
Nursing Facility (NF or ICF)?
Distinction based on:
Whether skilled care or custodial care is provided
 Whether skilled medical or nursing care or rehabilitation is
required

Nursing facility (NF)/ nursing home
Provides room, meals, and help with activities of daily living
& recreation (custodial care)
 Residents have physical or mental problems that keep them
from living on their own
 Require daily assistance with ADLs & IADLs

52

53. Skilled Nursing Facility (SNF) vs
Nursing Facility (NF or ICF)?
Skilled nursing facility (SNF) –
 Skilled
medical or nursing care, rehabilitation
Generally, Medicare doesn't pay for long-term
care
 Medicare
pays only for medically necessary skilled
nursing facility or home health care
 Skilled nursing care and home health aide services
only covered on part-time or "intermittent" basis
http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3433
53

54. Skilled Nursing Facility vs
Regular Nursing Home
Nursing homes (or nursing facilities) are defined as health care institutions that
provide onsite 24-hour supervision, nursing services, and personal care.
The two basic types of nursing homes are skilled nursing facilities and intermediate
care facilities.
A skilled nursing facility is an institution that provides inpatient 24-hour skilled nursing
services, as prescribed by the client’s primary care provider. The emphasis is on the
restorative and rehabilitative potential of the client. Only 5 % of nursing home
residents require a skilled level of care. Medicare is the main reimburser.
An intermediate care facility is an institution that provides basic custodial or nonskilled
personal care, but not skilled nursing care. Custodial care is assistance with ADLs
such as transferring from the bed to the chair, putting on clothes, bathing, and eating.
The care provided by registered nurses and licensed practical nurses is less intense,
but still vital for quality of care and positive resident outcomes. Medicaid and private
pay are the main sources of payment.
54

55. Financing Subacute Care
Reimbursement
Sources:
Medicare
– 2/3
- Pays as Skilled Nursing
Facility (SNF)
Other
1/3:
- Managed care
- Medicaid
- Private pay & other
55

56. Definitions Used in Rehabilitation
Functional status
 Capacity
& performance of safe ADLs & IADLs
 Sensitive indicator of health or illness in elders
 Critical nursing assessment
Impairment
 Disturbance
in structure or function resulting from
physiologic or psychologic abnormalities
Disability
 Degree
of observable and measurable impairment
56

57. Principles of Rehabilitative
Nursing
Goal of nursing care: maximize physical
functioning, prevent or minimize decline in ADL
function, & plan for future care needs
Promote living to one’s maximum potential
 Unique
set of strengths & abilities
 Acute & chronic illnesses
Attain highest QOL despite functional level
Improving functional capacity: well-being & QOL
57

58. Rehabilitation Nursing Care
Interventions
Preventing infection
Maintaining correct body alignment, position, & ROM
Preventing skin breakdown
Providing adequate nutrition & fluids
Providing care: achieve realistic level of
independence
Teaching
Making referrals to community agencies
58

59. Adult Day Care
59

60. Adult Day Care
Option for frail elders requiring daytime supervision
Many services are optional to meet needs
 Medical
insurance usually does not cover charges
 Mostly private pay
 Average annual cost (adult day health care):
 $15,236
(US)
 $11,817 (NC)
 Center
in Greenville:
 $22-$44
per day
60

61. 61

62. What Is Adult Day Care?
Interim (less than 24 hour) care
Provides a structured environment
Gives family caregivers a break, or
chance to hold a job
Mix of social & health services
62

63. Philosophy & Benefits
Serves both consumers
& caregivers
Holistic approach to care
Maintains or improves
quality of life
Provides safe,
supervised setting
Can live with family
without being a burden
Social interaction with
peers
Program of stimulating
activities
Therapy in a nonmedical setting
ADL assistance with
dignity
63

64. Types of Adult Day Care
Two categories
of adult day care:
Social Day Care
Adult Day
Health Care
64

65. Staffing
Combination of
professional &
non-professional
staff
Mix depends on
focus (social or
health)
65

66. Services Provided
Basic services provided
by all types:
Safe, secure
environment
 Social & recreational
activities
 Assistance with ADLs
 Transportation to & from
the center
 At least one meal, plus
snacks

66

67. Adult Day Health Services
In NC, licensed nurse
must be present part of
the day
Ratio staff to participants
1:6
Health care services:
Assessment
 Medications
 Monitoring
 Nutrition counseling
 Health education

67

68. Consumers of Adult Day Care
Between needing
institutional care & being
independent
Most live with family
Unable to handle day-today tasks
Most are elderly
More women than men
Must be continent
Able to communicate
needs (mild to
moderate dementia)
No wandering
behaviors
Nurse screens
admissions
68

69. Consumers of Adult Day Care
69

70. Caregivers
Three-fifths are spouses
or adult children
Other two-fifths are other
relatives, friends, or
neighbors
Mostly female (3/4’s)
Average age: 57
One-third over 65
themselves
70

71. NC Regulations
Adult Day Care/ Health Programs
Adult Day Health Care
NC State Standards for Certification
List of Certified Adult Day Care/ Adult Day Health
Programs
Adult Day Care Forms
NC Association of Adult Day Services
Family Caregiver Support
71

72. Home Health
72

73. JCAHO Definition
Home health services are provided by healthcare
professionals to patients in their place of residence
This includes, but is not limited to, performing assessments,
provision of care, treatment, counseling, and/ or monitoring
of the patient’s clinical status by nurses, occupational
therapists, physical therapists, speech-language
pathologists, audiologists, social workers, dieticians,
dentists, physicians and other licensed healthcare
professionals in the patient’s home
It includes the extension or follow-up of healthcare services provided
by hospital professional staff in the patient’s home
73

74. How Home Health Care
Developed
Public health
department visiting
nurses
Freestanding visiting
nurse associations
Growth based on
better reimbursement
74

75. Philosophy of Care
Takes services to
consumers’ homes
Eligibility
requirements (based
on Medicare regs):
 Physician-ordered
 Intermittent
 Homebound
75

76. Question
The home health agency’s medical chart of
your 78-year-old client claims that she is
homebound. However, she is not
bedridden. So, could the “homebound”
status still be correct?
76

77. Home Health Agencies
Official or public agencies
Voluntary or private not-for-profit agencies
Private, proprietary agencies
Institution-based agencies
20,000 providers deliver home health care
services to 7.6 million people
77

78. Types of Home Health Care
Home health
agencies
Hospice agencies
Homemaker & home
care aide agencies
Staffing & private
duty agencies
78

79. Staffing
Combination of
professional & nonprofessional staff
 Nurses
 Home
Health Aides
 Therapists
 Social Workers
 Other specialists
79

80. Services Provided
Skilled services,
therapies

Nursing, PT, OT, speech
therapy, social work,
nutritionist)
Supportive services
 Personal
care
 Homemaking
 Transportation
Dental care
Laboratory
Education
80

81. Components of Home Health
Care
Care of clients in the home
Observe family dynamics
 Identify caregiver burden

Referrals for home care

Discuss funding
Reimbursement sources for home care

Medicare, Medicaid, insurance, public funding, selfpay
81

82. Financing Home Health Care
 Medicare
– single
largest payer (28%)
 Medicaid – 19%
 Private funding
sources (insurance,
private-pay) – 24%
 Other government
programs – 5%
82

83. Question
What agency is the largest single
reimbursement source for home health
care?
A. Medicare
B. Medicaid
C. Private insurance
D. Self-pay
83

84. Consumers of
Home Health Care
Largely elderly
Some need on-going
care
Others need only
temporary care
following a hospital
stay
84

85. Nursing Process in Home Health
Assessing

Conduct careful and
complete data collection
initially and on an
ongoing basis
Diagnosing

Identify actual or
potential problems—
LPN/ LVNs contribute to
this process
Planning

Set priorities, establish
goals, decide on
interventions
Implementing

Carry out interventions
Evaluating

Compare plan of care
with goals and review
client’s progress
85

86. Home Health Care Nurses
Guidelines
ANA Standards for Home
Health Nursing Practice
 ANA Standards of
Community Health
Nursing
 National Association for
Home Care Bill of Rights

Roles
 Provider
of care
 Teacher
 Advocate
86

87. 87

88. Concerns for the Home Health
Nurse
Safety

Assessment of, documentation of, and teaching of safety
measures
Infection Control





Effective hand washing
Use of gloves
Disposal of wastes and soiled dressings
Handling of linens
Practice Standard Precautions
88

89. Legal Issues in Home Health
Privacy and confidentiality
Client access to health information
Freedom from unreasonable restraint
Witnessing of documents
Informed consent
Negligence or malpractice
89

90. NC Regulations
Home Health
In-Home Aide
Senior Companion
Division of Health Service Regulation
Acute and Home Care Certification Section
Procedure for Establishing a Certified Home
Health Agency
90

91. Home Health Review Question
Referral to a home care agency requires:
A. A physician’s order
B. A client need for skilled nursing or therapy
C. Unable to leave home without major effort
(homebound)
D. Full time care not needed (intermittent)
E. Consent of the client
F. All of the above
91

92. Question
A 94-year-old man has been hospitalized and treated for
pneumonia. At the end of his hospitalization, his family
decides that they can no longer care for him because he
is completely dependent in all activities of daily living and
has become incontinent. His long-term prognosis is poor.
To meet this client’s needs, the nurse discharge planner
will apply for:
A.
B.
C.
D.
Assisted living facility
24-hour/day home care
Intermediate nursing care
Skilled nursing care
92

93. Hospice
93

94. Hospice
“Not a place but a philosophy”
Dying is a normal part of life cycle
Promotes the idea of “living until you die”
Care is provided in multiple settings &
supports the pt/family through dying
process as well as providing bereavement
support to surviving family
94

95. Hospice Care
Focus whole person
Mind
 Body
 Spirit

Support & care
Pts
 Family & caregivers


Last phase (6 months) of
incurable disease

Medicare coverage can
extend beyond that
period if necessary
Live as fully & comfortably
as possible
Continues after death of
loved one
95

96. 96

97. 97

98. Hospice Care: Interdisciplinary
Team of Professional Caregivers
Nurse
 Pain
& symptom control
 Assesses pt & family’s
ability to cope
 Identifies resources for
care of pt
 Recognizes pt’s wishes
 Assures support
systems in place
 Bereaved family
services
Physician
Pharmacist
Social worker
Chaplain
Others (volunteers)
98

99. Hospice Team
99

100. 100

101. Hospice Settings
Home
Freestanding
Hospital
Home health
agencies with home
care hospice
Nursing home or
other LTC settings
101

102. 102

103. Question
Which of the following statements is true
concerning hospice?
A.
Hospice is a special place of care
B. Hospice care is a lifelong type of care
C. Hospice is a model of care rather than a
place of care
D. Hospice is designed for clients with
serious chronic illness
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104. Palliative Care vs Hospice
Hospice & palliative: both focus on helping a person be
comfortable by addressing issues causing physical or
emotional pain, or suffering
Palliative: does not require pt to give up fight for a cure
Palliative: may be given at any time during a person’s
illness, from diagnosis on
Hospice: pts with a life expectancy of mos not yrs
(usually 6 mos)
Hospice: set of defined services, team members, rules
& regulations
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105. Question
The gerontological nurse understands that
palliative care is different from hospice in which of
the following ways? Palliative care (Select all that
apply):
A. People no longer seek treatments for a cure
B. May be provided at any time during a person`s illness,
even from the time of diagnosis
C. Focused exclusively on terminally ill patients
D. Can take place at the same time as curative treatment
E. Typically, provided in the hospital
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