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Skilled Nursing Facilities (Nursing Home)


Skilled Nursing Facilities (Nursing Home) Steven Tam, MD Assistant Clinical Professor UCI Internal Medicine/Geriatrics Speaker s notes: 1. These are examples of ... – PowerPoint PPT presentation

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Title: Skilled Nursing Facilities (Nursing Home)

Skilled Nursing Facilities (Nursing Home)
  • Steven Tam, MD
  • Assistant Clinical Professor
  • UCI Internal Medicine/Geriatrics

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

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
  • 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

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
  • 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

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

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.

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

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
  • Need more care than can be provided at home
  • Has extensive medical needs requiring daily
    attention, or monitoring

Who May Need a Nursing Home?
  • Special Needs in Skilled Nursing Facility
  • Dialysis, Dementia care, Respiratory Care,
    Parkinsons Care
  • Hospice care, Chronic Psychiatric Care

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.

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

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

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

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

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

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
  • May be able to move within the different levels
    of care.

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)
  • End of life care similar to that in the community
    setting, and hospice and palliative care can be
    provided in the skilled nursing facility

Important Issues in Skilled Nursing Facilities
  • Infections
  • Similar nosocomial infection rates to acute care
  • 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

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

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).

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

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!

Important Issues in Skilled Nursing Facilities
  • Falls
  • 20 of deaths from falls are amongst nursing home
  • Causes maybe multifactorial
  • Restraints
  • Careful and thorough review, used only when no
    safer alternative.
  • Adverse Drug Events
  • Common in nursing homes 40-50 considered
  • Gurwitz JH, et al. 2000 Am J Med 109(2) 87-94

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

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

  • A Nursing Home is a facility where an
    interdisciplinary team provides care for the
  • 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