Skilled Nursing Facilities (Nursing Home)

1
Skilled Nursing Facilities (Nursing Home)

• Steven Tam, MD
• Assistant Clinical Professor
• UCI Internal Medicine/Geriatrics

2
Educational Objectives

• Become familiar with Nursing Homes and other
  facilities
• Understand who are candidates for Nursing Homes
  and other facilities
• Define the services provided.
• Identify important issues at Nursing Homes

3
The Stats!

• Approximately 1.5 million Americans (4.2)gt65
  have spent time in a skilled nursing facility
  2004 National Nursing Home Survey
• Jones AL, et al. 2009 Vital Health Stat
  1671-155.
• Expected to be 3 million in 2030 if continues at
  this rate.
• 50 of those 95 and older live in nursing homes.
  
• 51 of nursing home residents require assistance
  with all ADLs

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Skilled Nursing Facilities (Nursing Homes)

• Skilled Nursing Facility part of a Nursing Home
  or Hospital that provides skilled nursing care.
• Registered Nurses who provide skilled nursing
  care to people, along with interdisciplinary
  staff/team
• Licensed practical and vocational nurses
• Physical Therapy, Occupation Therapy
• Speech Therapy
• Social Worker/Case Manager
• Skilled care usually a short period
• Custodial Care may be required for longer period

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Skilled Nursing Facilities (Nursing Homes)

• A licensed physician supervises each patients
  care and a nurse or other medical professional is
  almost always on the premises.
• gt80 of nursing homes use community physicians to
  provide care
• Average family physician supervises 9.6 nursing
  home residents and conducts 2.3 nursing home
  visits per week
• 2008 AAFP survey

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Skilled Medical Care

• Skilled Services
• RN doing wound care or administering and
  monitoring IV antibiotics
• A physical therapist working to improve strength
  and balance in a patient with difficulty walking
• A speech therapist helping a patient speak and
  swallow after a stroke.
• An occupational therapist helping a patient
  relearn dressing, grooming and eating.
• Skilled care may also involve managing
  injections, ostomy management and tracheotomy
  care amongst other needs.

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Custodial Care

• Need assistance with ADLS
• Bathing
• Dressing
• Eating
• Grooming
• Getting in and out of bed, or walking around
• Toileting (incontinence care)
• Often provided at a Nursing Home
• May also be temporary

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Who May Need a Nursing Home?

• Skilled Nursing facility is for Patients who
• Require a short stay for skilled services prior
  to returning to previous residence
• Can no longer care for their own personal needs,
  such as feeding, bathing, toileting (custodial
  care) because of medical, physical, behavioral
  problems
• Need more care than can be provided at home
• Has extensive medical needs requiring daily
  attention, or monitoring

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Who May Need a Nursing Home?

• Special Needs in Skilled Nursing Facility
• Dialysis, Dementia care, Respiratory Care,
  Parkinsons Care
• Hospice care, Chronic Psychiatric Care

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Nursing Home Costs

• Medicare coverage for skilled care
• Medicare Part A (Hospital Insurance)
• Qualifying 3 day hospital stay 30 days prior to
  Nursing home admission
• 100 day benefit period (renewable if not
  hospitalized, or in SNF for 60 consecutive days)
• 1st 20 days, Medicare covers full cost
• Between Day 21 and 100 there is a copay
• After Day 100, Medicare covers nothing.

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Nursing Home Costs

• Medigap may cover deductibles/other charges
• Medicaid for Custodial care, Long Term Care
  Insurance

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Nursing Home Costs

• 2004 MetLife Market Survey of Nursing Home and
  Home Care costs, 192/day, or 70,080 a year
  Private room
• Shared room 169/day, or 61,685 a year.
• Costs can vary with location
• Alaska, highest rates for private room
  204,765/yr, or 561/day
• Shreveport, Louisiana, lowest 36,135/yr, or
  99/day

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Whats the Alternative?

• Assisted Living facility
• Subsidized senior housing
• Board and care homes
• Continuing care retirement communities
• Program of All-Inclusive Care for the Elderly and
  the Social Managed Care Plan

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Whats the alternative? ALF

• In 2002, 1 million people lived in assisted
  living.
• McCormick JC, et al. 2003 Health Care Finance Rev
  24143-150
• Transition period?
• Offers help with ADLS, but none or limited
  medical care.
• gt80 require help with ADLS
• 40 describe their health as poor

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Whats the Alternative? ALF

• Greater emphasis on personal privacy and
  autonomy.
• No onsite RN
• ALF provide only personal assistance that can be
  performed by someone with little or no medical
  training.
• Patients may visit MD if onsite clinic
  available, at MD office, or if there is a
  Housecall MD.

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Whats the Alternative? Continuing Care
Retirement Communities

• Continuing Care Retirement Communities provides
  independent living, housing-with-services, and
  Nursing home care in one location
• Enables seniors to remain in a familiar setting
  as they grow older
• Many enter while they are healthy and active,
  knowing they will be able to stay in the same
  community
• May be able to move within the different levels
  of care.

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Important Issues in Skilled Nursing Facilities

• Transitions of Care
• To and From Acute Care settings
• To Home and or other Long Term Care options
• End of Life Care
• 1/3 rd of nursing home residents die within one
  year of admission
• Estimated by 2020, 40 of all deaths will occur
  in nursing homes.
• Oliver DP, et al. 2004 J Am Med Dir Assoc 5(3)
  147-155
• End of life care similar to that in the community
  setting, and hospice and palliative care can be
  provided in the skilled nursing facility

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Important Issues in Skilled Nursing Facilities

• Infections
• Similar nosocomial infection rates to acute care
  hospitals?
• MRSA 10-30 prevalent in nursing homes.
• Pacio GA, et al. 2003 Infect Control Hosp Epid
  24(4) 246-250
• C. Difficile Colitis
• Scabies
• Influenza, Tuberculosis
• Infection control programs

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Important Issues in Skilled Nursing Facilities

• Abuse and Neglect
• Surveys of nursing home residents suggest abuse,
  neglect common?
• Frailty
• Fatigue
• Inactivity
• Slowness
• Weakness
• Weight loss

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Important Issues in Skilled Nursing Facilities

• Nutrition and weight loss
• Various strategies
• Liberating diet
• Frequent meals
• Supplements between meals
• Resistance strength training
• Family presence and socialization
• Assess feeding disability and need for assistance
• Appetite stimulants?
• Artificial Nutrition (maybe a limited role).

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Important Issues in Skilled Nursing Facilities

• Pain Management
• Est. 45-80 of nursing home residents with
  chronic pain
• Unwin BK, et al. 2010 American Family Physician
  81(10) 1229-1237
• Pressure Ulcers can be common in Nursing homes
• management principles usually similar to the
  community.

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Important Issues in Skilled Nursing Facilities

• Urine Incontinence and Retention
• 55 of nursing home residents
• Unwin BK, et al. 2010 American Family Physician
  81(10) 1229-1237
• Treatment strategies (evaluation, review meds,
  toileting programs, pharmacologic therapy)
• Catheters must require a valid reason!

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Important Issues in Skilled Nursing Facilities

• Falls
• 20 of deaths from falls are amongst nursing home
  residents.
• www.cdc.gov/ncipc/factsheets/nursing.htm
• Causes maybe multifactorial
• Restraints
• Careful and thorough review, used only when no
  safer alternative.
• Adverse Drug Events
• Common in nursing homes 40-50 considered
  preventable.
• Gurwitz JH, et al. 2000 Am J Med 109(2) 87-94

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Important Issues in Skilled Nursing Facilities

• Dementia
• 67-78 of nursing home residents
• Behaviors can be a serious problem
• Nonpharmacologic treatment (identify triggers,
  activities, environment modification, staff and
  family education).
• Pharmacologic treatment higher risk of
  morbidity/mortality?

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Important Issues in Skilled Nursing Facilities

• Delirium up to 60 of nursing home residents
• Depression estimated that 12-16 percent of older
  adults in nursing homes have major depression
• Unwin BK, et al. 2010 American Family Physician
  81(10) 1229-1237

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Conclusions

• A Nursing Home is a facility where an
  interdisciplinary team provides care for the
  patient
• Including nursing services, physical and
  occupational therapy
• There are alternatives to the Nursing Home.
• Those requiring a Nursing Home may do so for a
  variety of reasons