Where Should Grandpa Live? Understanding long-term and post-acute sites of care

1. Where Should Grandpa Live?Understanding long-term and post-acute sites of care Anna Mirk, M.D. Assistant Professor, Emory University School of Medicine Division of General Medicine and Geriatrics Atlanta Veterans Affairs Medical Center Geriatrics, Extended Care and Rehabilitation Anna.Mirk@va.gov

2. Objectives • Describe the demographics of where older Americans live and contrast the differences in sites of care between assisted living and long-term nursing home care. • Understand the available post-acute care settings and the intensity of medical, nursing, and therapy support available at each level. • Understand the vital communication issues in transitions of care.

3. Disclosures • I have no disclosures.

4. Pre-Test #1 • What percentage of persons ≥ 65 y/o in the US live in a nursing home? • A. 1% • B. 4% • C. 8% • D. 12%

5. Answer #1 • B. 4% • approx 1.5 million people live in a nursing home • ( this is approx 4.5% of the >65 population) • 90% of those living in a NH are ≥ 65 • 45% of those living in a NH are ≥ 85 • 71% are female • 50% are incontinent of bladder, 40% of bowel • 50% are “total care” for all ADLs • There are approx 17,000 NHs in the US CDC/NCHS 2004 National NH survey

6. Pre-Test #2 • What percentage of people ≥ 65 y/o in the US will spend time in a NH before they die? • A. 10% • B. 25% • C. 40% • D. 65%

7. Answer #2 • C. 40% • In 1990 43% of people ≥ 65 spent time in a NH prior to death ( NEJM 1991) • This % has not changed in the last 20 yrs • Approx 23% of all deaths in the US occur in a NH (49% in hospital, 23% at home) http://www.cdc.gov/nch/data/series Source: Agency for Healthcare Research and Quality (AHRQ)

8. Pre-Test #3 • What percentage of Women ≥ 85 live alone in the US? • A. 12% • B. 30% • C. 45% • D. 57%

9. Most Older Women Live Alone % of community-dwelling persons ≥ 65 y/o living alone. 2003 US census

10. Women Outlive Men at all Age Groups

11. Can Older Americans Age in Place? • 90% of seniors want to stay in their own homes until they die (age in place) 1 • 80% of persons≥ 65 y/o are home owners2

12. What Happens When you Need Help? • Stay in your own home with in-home help • Move in with family • Assisted Living • Skilled Nursing Facility • Other • Adult Foster Care, Adult Day care, Continuing Care Retirement Community

13. How much assistance does your patient need? • Activities of Daily Living • Walking • Dressing • Bathing • Eating • Getting in and out of bed • Using the toilet • Ability to carry out basic self-care activities

14. Instrumental Activities of Daily Living • Tasks Required to maintain an independent household: • Preparing meals • Grocery shopping • Using the telephone • Taking medication • Managing money • Light housework • Transportation

15. Home Health What is it? Who can get it? Will it be enough help to allow my patient to stay at home?

16. Home Care • Home Health Agencies • Licensed Professionals (Nurse, Physical therapist, occupational therapist, speech therapist, social worker) • Services ordered and supervised by a physician • Only for patients who are “homebound” • Only intermittent services ( a few hours/week) • Can provide wound care, blood draws • Paid by Medicare for those >65

17. Home Care • Non-skilled Home Care • Home Health Aide • Not a nurse, but works for licensed HH agency • Helps with bathing, toileting, dressing. • Covered by Medicare only if you also need skilled Home health care. • Only intermittent service (i.e. 2 hrs/day 3 days/wk) • Services can be purchased out of pocket

18. Assisted Living Facilityvs. Nursing Home What are the differences?

19. Assisted Living Facility • Senior living option for those who need assistance with daily living but not the intensive or skilled nursing care offered in a nursing home

20. Assisted Living Facility • States differ in licensing and regulation • NOT licensed for medical or nursing care • Cannot be “bedridden”- need to be able to exit in an emergency with minimal help • aka: Personal Care home, Group home

21. Assisted LivingTypical Resident • Challenges in daily activities such as bathing, dressing • Many have dementia • Most ALFs provide help with: • Housekeeping • Transportation • Toileting • Dressing • Cooking • Medication oversight • Laundry • 24 hour supervision and security

22. Assisted Living • Cost of care is based on the amount of assistance you need (avg $3,000-$5000/month) • Some facilities offer special units for dementia patients who may be prone to wandering and need additional supervision. • About 40% of persons living in AL have dementia 3

23. Who Lives in a Nursing Home?

24. Who Lives in Nursing Homes? • Two “typical” patient types make up majority of long-term NH residents: • Immobilized and in need of heavy amount of care to move from bed to toilet • Dementia (Alzheimer's) with behaviors that family can no longer manage at home

25. Who Lives in Nursing Homes? • A Physician must write an order for NH admission, along with medication and therapy orders. • Patients admitted to a NH must meet eligibility criteria (vary by state) for NH level care • Generally must need assistance with 2 or more ADLs plus have a need for skilled care • (nursing, PT, OT, wound care )

27. Activities of Daily Living DependenceALF vs. Nursing Home 81% of ALF residents need help with medications ALF data from 2009 ALFA, NCAL Survey. www.ncal.org

28. Pre-Test #4 • What is the average cost per month for a private room in a NH in the US? • A. $2,400 • B. $4,800 • C. $7,000 • D. $12,000

29. Answer #4 • C. $7,000/month • Atlanta average is $194/day = $5,820 /month • Source: 2010 MetLife Market Survey of Long-Term Care Costs

30. How Do Older People Pay for Long Term Care? • Assisted Living is paid out of pocket • A few local and state based voucher programs for very poor who would otherwise need NH care • Some long-term care insurance policies will pay • Home care • Generally paid out of pocket for non-skilled care • Nursing Home • Paid out of pocket • Can apply for Medicaid – must spend down assets • Some long-term care insurance will pay • Short rehab stays may be covered by Medicare

31. Where do patients go when they leave the hospital?

32. Hospital Admission • = first of multiple care transitions for older patients • At least 25% of hospitalized pts >65 are discharged to another institution ( eg rehab/SNF) • 12% are discharged with home care services • Of those transferred from hospital to rehab/SNF, nearly 50% have four or more additional care transitions in the next 12 months

33. Can My Patient Go Home? • Medically stable ? • Recovering ADL independence or at baseline? • Sufficient and Willing Caregiver(s)? • Safety/supervision • Meals • Medication supervision • ADLs/IADLs • Do they have insurance or Medicare to cover any needed Home Nursing/PT/OT/speech? • If YES to all Home • If NO consider Rehab * • or SNF • * 3 night hospital stay required for Medicare rehab placement

34. Rehabilitation in a Nursing Home • Many older persons will spend a short time in a nursing home for skilled rehabilitation: • examples: • -After a stroke • -After hip or knee replacement • -post-Prolonged hospitalization

35. Rehabilitation in a Nursing Home • Almost always follows a hospitalization • 72 hour hospital stayrequired for Medicare qualifying stay • Goal is to improve function and return home • Stay is usually 21 days or less • Medicare pays 100% of first 20 nights of rehab • Next 80 days patient pays $141.50/day co-pay • Must be undergoing PT, OT, or Speech therapy

37. Rehabilitation in a Nursing Home • If you can’t participate in rehab, then Medicare will not pay for rehab • Is the patient too demented or otherwise impaired to follow instructions? • Is the patient too weak or debilitated to participate? They probably need “custodial care” • Hospital PT/OT/Speech will give you recommendations on rehab potential for your patient • If the patient stops progressing once at rehab, they will be discharged

38. What level of care is available in a Nursing Home? • No physician in house • No labs on site. STAT= 24 hours • Portable x-ray, read the next day • No pharmacy on site. Meds delivered BID • Limited formulary • No Respiratory therapy, no wall oxygen or suction • No EKG, no telemetry

39. Is my patient ready to discharge to a nursing home? • Can they get by on your discharge orders for 48-72 hours? • often will not see physician for 48-72 hours after arrival • Cannot have need for daily labs or frequent medication adjustments • Cannot need telemetry or frequent vital signs (more than Q8 hours) • Cannot be on IV drips or IV push meds.

40. Communication at Discharge • It is the discharging physicians duty to provide the nursing home with COMPLETE and updated orders for the patient • Updated medication list with stop dates for abx • Diet orders • Allergies • Activity and therapy orders • Wound care orders • CODE STATUS

41. How do you get a patient admitted into a Nursing home? • Consult your Social Worker • Physician fills out two forms (Georgia specific) • DMA-6 (Division of Medical Assistance)- physician certification for need for NH level care- signed by physician licensed in state of GA • PASARR ( Level I) – pre-admission screening and resident review for residents with indicators of mental illness and mental retardation • SW will submit paperwork along with H+P, recent progress notes, PT/OT/speech notes to facilities that patient/family like • Facility screens patient for appropriateness for NH level care, medical stability, and payment source

42. Smooth Transition to Rehab/SNF • D/C IV, PICC, Foley etc if not needed • D/C PRNs if not needed • D/C IV meds and convert to PO when possible • Have an UPDATED med list at discharge • Include name and contact # of discharging provider on discharge instructions • Remember- no doctor will see your patient for the next 48-72 hours!

43. Special Situations • Always consider if your patient may be appropriate for Hospice care • Medicare will cover home hospice care if patient meets criteria. Room and board for Inpatient hospice is not covered by Medicare * • Social work should always discuss a move to hospice care with patient/family because hospice care will affect future Medicare part A hospital coverage. • Veterans are often eligible for many services that may not be covered by Medicare- consult with SW

44. References • 1. AARP – Understanding Senior Housing 1996. • 2. Housing America’s Seniors. Joint Center for Housing Studies. Harvard University. 2000. • 3. ALFA, NCAL 2009 overview of Assisted Living. www.ncal.org • Aging Atlanta. Older Adults in the Atlanta Region. Atlanta Regional Commission Report based on 2000 Census Data. http://www.atlatnatregional.com/resourcecenter/regionaldata.html US Census Bureau Statistical Brief. Sixty-Five plus in the United States. May 1995. Caregiving in the U.S., National Alliance for Caregiving and AARP, 2004. http://www.Medicare.gov http://www.longtermcare.gov http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=15#Lives http://www.payingforseniorcare.com/longtermcare/costs.html#D3 Primary Care Geriatrics. A Case-Based Approach.3rd Edition. Ham and Sloane. 1997.