NURSING HOME CARE

1. NURSING HOME CARE Swedish Family Medicine October 10, 2000 Pat Borman, MD

2. GOALS • Review the historical perspectives of nursing home care in the USA • Understand the roles of physicians in providing nursing home care • Be familiar with the geriatric syndromes common to nursing home care

3. DEMOGRAPHICS • Those >65 have a 40% risk of needing long term care • 1.5 million now and 6 million by 2030 • 5% off all elderly are institutionalized • 1% Age 65-74 • 15% Men >85 • 25% Women >85

4. HISTORICAL VIEW • 1935 Social Security Act funding States fail to secure quality • 1965 Title 18 & 19 Federal oversight has little impact • 1987 OBRA with MDS, RAP and teeth!

5. OBRA MANDATES Residents Bill of Rights Guidelines to restrict the use of: • Restraints • Psychoactive drugs • Unnecessary Drugs

6. OBRA MANDATES Requires periodic assessment of resident functional capacity • Minimal Data Set • Resident Assessment Protocols ?WHY HAS OBRA BEEN SO EFFECTIVE?

7. TYPES OF PLACEMENT • Short Term Stay • 50% of admits, 45% stay < 3 months • Hospital stepdown • Acute rehabilitation • Long Term Stay • Average length of stay 19 months • 18-25% die in the nursing home

8. PHYSICIAN ROLES PRIMARY GOALS OF CARE • Safe supportive environment • Maximize function and quality of life • Stabilize chronic illness • Prevent illness • Recognize and manage acute problems

9. PHYSICIAN ROLES • Reliance on bedside diagnosis Limited lab and consultative services • REMEMBER you are visiting patients in their HOME -- accord proper respect • Care above cure, comfort above all

10. MONITORING REQUIREMENTS ADMIT EXAMINATION • Within 48 hours of admit • Can be done in hospital, office or NH PERIODIC VISITS • Every 30 days for 3 months • Every 60 days thereafter ACUTE PROBLEM VISITS ANNUAL REVIEW VISITS

11. ADMISSIONS CHECKLIST • History • Include Immunizations, Eye, Dental, Podiatric, Pain, Depression • Physical • Nutrition, Hearing, Vision, Mobility, Cognition • Medication Review: link with diagnoses • Functional Assessment ADL • Advance Directives • Formulate Problem List and Plan of Care

12. Incontinence Fever and Infections Confusion/Delirium Pressure Ulcers Falls Malnutrition Pain Management Polypharmacy Depression Dementia COMMON PROBLEMS IN NURSING HOME PATIENTS

13. NURSING HOME PROTOCOLS To comply with OBRA many facilities have protocols for common problems. • Incontenence • Pressure Ulcers • Falls • Use of restraints

14. NURSING HOMEPROBLEMS CASE #1 • Mrs Worth is a 92 y.o. widowed white female with diabetes, hypertension and osteoarthritis. She is usually quite sharp but for two days the NH staff noticed she is confused, agitated and intermittently drowsy. She doesn’t want to eat, is picking at her clothing and has started staying up all night. She has fallen twice, not common for her.

15. NURSING HOME PROBLEMS CASE #2 • Mr. Sullivan is a 88 y.o. white man with moderately advanced dementia. He was unresponsive to Aricept and Cognex. He paces and wanders continually and shows aggression with attempts to redirect him. In the last 6 months he has lost more than 10% of his body weight and 8 pounds in the last month.

16. Conclusions NURSING HOME CARE is a natural extension of the Family Practice mission to care for individuals and their families throughout their life span.

17. CONCLUSIONS Nursing Home Care requires compassion and a comforting and caring approach. This work confirms that we can each help improve the end of life for someone we know.