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LONG-TERM CARE DECISION MAKING

Arden L Aylor, MD Geriatrics. LONG-TERM CARE DECISION MAKING. Objectives: Primary Care. Health Maintenance Quick office screening tools Advance Directives Driving issues Care types Placement. Health Maintenance. Primary and secondary disease prevention screening

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LONG-TERM CARE DECISION MAKING

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  1. Arden L Aylor, MD Geriatrics LONG-TERM CARE DECISION MAKING

  2. Objectives: Primary Care • Health Maintenance • Quick office screening tools • Advance Directives • Driving issues • Care types • Placement

  3. Health Maintenance • Primary and secondary disease prevention screening • Control chronic medical problems • Bi-annual medication review • Optimize function: cognitive, auditory, vision, fall screening • Assess for adequate support system • Discuss and document Advanced Directives

  4. Optimize Function • Auditory - annual • Vision - annual • Fall risk • Cognitive screen

  5. Fall Risk • Vital Signs/ Orthostatic • Neurologic assessment • Musculoskeletal assessment • Medications • Footwear • Cognitive assessment • Functional Reach Test

  6. Falls in past year? No falls No Intervention Single fall Recurrent falls Gait & balance problem Yes No Fall Evaluation

  7. Functional Reach Test • Single item test: quick screen for balance problems in older adults • Interpretation:Score of 6 or less indicates a significant increased risk for falls >70% fall in 3 monthsScore between 6-10 inches indicates a moderate risk for falls

  8. Cognitive screen • MMSE • MoCA (Montreal Cognitive Assessment) • Clock • Score (4-1)

  9. Clock 4 3 1 2

  10. Driving Myths • Specific rules for older drivers Renewal is every 2 years for those 85 and older Mail, phone, and electronic renewal are not available for those 79 and older • Renewal conditions: In person • Vision test: At in-person renewals • Written test: No • Road test: No, unless there is a concern (mental or physical) regarding the driver's ability to safely operate a motor vehicle TxDOT

  11. Quick Test

  12. Support & Advance Directives • Adequate support system • Legal Directives • Wills • Financial • Medical Directive • DNR/DNI

  13. Home Health • Home Health Care is skilled nursing need • All Medicare beneficiaries can receive home health • Physical Therapy • Skilled Nursing • Respiratory Care • Medical Equipment • Infusion Therapy • Nursing aid - ADLs • No 24/7 care coverage

  14. Assisted Living • Level A: Resident may require minimal assistance with ADL, must be mobile, may receive home health services • Level B: Resident may receive full assistance with ADL • Resident may be semi-independent and may require the assistance for transfers or to evacuate the facility • Resident may receive assistance with medication • Level C: Resident receive full assistance with ADL • Caregiver 24hrs on sight

  15. Nursing Home Myth • Patients need to go to hospital for nursing home placement

  16. Placement: Nursing Home Types • Skilled Nursing Facility (short-stay): 1-6 months • Terminally ill • Short term rehabilitation • Debilitated post-acute care hospitalization • Nursing Home (long-stay): 6 months to years • Primarily cognitively impaired • Significant impairments of both cognitive and physical functioning • Primarily physically impaired

  17. Palliative Care • Focuses on improving the quality of life of people facing serious illness • Emphasis is placed on pain and symptom management • Goal is to improve the patients ability to tolerate medical treatments

  18. Hospice • Hospice care is end-of-life care • Terminal diagnosis with life expectancy <6 months • Offering medical, psychological and spiritual support • No invasive treatment or PT/OT • Goal to help people who are dying have peace, comfort and dignity • Where: Home, Nursing Home, Hospital, Hospice respite center

  19. Key Points • Advance Directive should be assessed and updated annually • Quick screen tools and be helpful in evaluating function • Patients need not go to hospital for nursing home placement • Palliative offers some degree of therapy • Hospice comfort care

  20. References • Texas Department of Aging and Disability Services Revision: 08-5.07 • American Geriatric Society, 2011 americangeriatrics.org • Center for Medicaid and Medicare Services, 2011 cms.gov • Trailblazers CMS Texas, 2010 trailblazerhealth.com • Federal Government Publication and statistics, 2010 gov/employees/govpubs/Pages/FederalGovernmentPublications.aspx • TxDOT, 2011 txdot.gov

  21. Thank You!

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