Epidemiology
How many Americans will be an older adult (>65) by 2030?
1 in 5
What makes a patient eligible for nursing home care?
*Need for skilled level of care
*Dependent in at least 2 activities of daily living- bathing, grooming, toileting, dressing, eating, transferring
*ON medicaid and can't afford assisted living
Define OBRA
Federal Omnibus Reconciliation Act of 1987: 1) resident assessment- minimal data set, 2) physical restraints, 3) psychotropic meds 4)Resident rights 5)Medical directors, 6) Minimal staffing requirements, 7) Periodic comprehensive assessments
What is the visit schedule for your nursing home patients?
Initial exam within 72 hours of being admitted- varies by state- comprehensive exam with care plan
Medicare A- every 30 days for first 90 days, and every 60 days thereafter
Acute problem visits as indicated
Discharge visit
What percentage of older Americans have multiple chronic illnesses?
Define long term nursing home stay
>6 months
When would a nursing home stay be private or self pay?
1)When there is no preceding qualifying hospital admission- 3 nights. 2)When a person has run out of skilled days under medicare. 3)When a person doesn't qualify for medicaid
What is meant by the Minimum Data Set in Nursing Home Care (MDS)?
Assessment on admission, in 30 days, then quarterly with change of status
Big survey of factors --> reported to center for medicare and medicaid services and included in the "Star" rating of nursing home.
What is average amount of prescriptions nursing home patients are on?
What are some particularly high risk meds?
Typical resident- 7 to 8 prescription medsHigh risk meds: aspirin, nsaids, digoxin, warfarin, phenytoin,
BEERS LIST MEDS: AVOID
every med needs diagnosis
review every 30 days med list
What percentage of the national health care budget is consumed by treatment of the population > age 65?
66%
What is meant by "SNF?"
Skilled Nursing Facility
Skilled care: IV antibiotics, wound care, rehab (PT/OT/Respiratory therapy/speech), vent dependent, tube feeds
Common diagnoses- gait dysfunction, falls, post ortho surgery, chf
How does one qualify for Medicaid to pay for nursing home care?
1)Medicaid is state government program, rules vary by state. 2) will cover long term care 3) have to spend down assets and meet income requirements to qualify.
What does OBRA say about use of physical restraints in nursing homes?
May include trunk or wrist, full bed side rails, locking chair tray, seat belt,
have to justify and document use
physician order required.
consent of resident and family documented.
need periodic reassessment
What are the indications for long term catheter use in nursing homes?
Comfort measures- palliative care terminally ill
Chronic neurogenic bladder/urinary retention
SKin breakdown made worse by incontinence
UNcorrected bladder outlet obstruction
What percentage of nursing home patients have four to five ADL's impaired, and have cognitive impairment on top of that?
15.8%
What is meant by "LTC?"
Long term care facility:
No skilled requirements
Common diagnoses: Stroke and dementia
How many midnights do you need for skilled nursing home stay?
For Medicare to covered nursing home for skilled need- you need 3 overnights to qualify. this must be within 30 days of admission to skilled facility. observation doesn't count.
What does OBRA say about psychotropic meds?
Need to minimize inappropriate use (sedative meds,behavior issues) - need to document
Weaning trial every 6 months, if fails 2 trials, can maintain med
use justified- schizophrenia, acute psychosis, short term for nausea, hiccups, pruritis
What are the infection control parameters for nursing homes? what is required?
Tuberculosis screening for new residents and all employees (initial 2 step ppd)
annual flu vaccine for residents and staff
pneumonia vaccines for all residents
contact and respiratory precautions when indicated (MRSA, VRE, ESBL, C. diff, INfluenza, COVID)
infectious outbreaks- flu, rotavirus, covid
What percentage of newly admitted and long term nursing home residents have trouble with bowel or bladder control?
60% newly admitted
40% long term
What is meant by "Post acute Care" in the nursing home?
Increased level of acuity due to decline in length of hospital stays, and attempt to decrease hospital readmissions
Features of acute care, long term nursing, and rehab
Variable availability of services- ventilators, dialysis, orthopedic, post op, wound care, rehab
What do you think is the average cost per day of nursing home care?
Bare basics $229/day
Added costs: Provider services and med copays, phone , internet, cable, laundry, diapers, haircuts, nutritional supplements.
What does OBRA say about resident rights, medical directors, and staffing?
Medical directors must be present
Staffing ratio: 65% aides (CNA), 12% RN, 23 % LPNs
What environmental modifications can you make to prevent falls?
Wedge cushions, armrest cushions
Reclining chairs, footstools
Bed and chair alarms
Floor pads, bed wedges
bed height
Hip protectors