Chapter 2

1. Chapter 2 Patient Care Settings

2. Learning Objectives • Describe the role of the nurse in community and home health, rehabilitation, and long-term care settings. • Differentiate between community health and community-based nursing. • Describe the types of specialty care that nurses may provide in home health care. • Describe the principles of rehabilitation. • List the four levels of disability.

3. Learning Objectives • Discuss legislation passed to protect the rights of the disabled. • Identify the goals of rehabilitation. • Name the members of the rehabilitation team. • List the types of long-term care facilities. • Discuss the effects of institutionalization on the older adult. • Describe the principles of nursing care in long-term residential facilities.

4. Community Health Nursing Roles Work with many different individuals and groups to create or modify systems of care to improve the health of a defined group Box 2-1 lists many of the roles assumed by the community health nurse Most roles require a bachelor’s degree in nursing; however, the LPN is increasingly visible in community health settings

5. Community-Based Nursing Deriving health care services based on identified community needs and providing various types of care that meet the needs of citizens at various levels of wellness and illness Traditional and nontraditional community settings

6. The Home Health Nurse Gives direct care to the patient, and teaches patient and family to care for themselves Homes often have only a fraction of the resources of the hospital Must assess patient, family, and environment to plan care

7. Figure 2-1

8. Reimbursement Realities in Home Health Home treatment must be authorized by physician Plan of care must include Pertinent diagnoses Mental status evaluations Identification of the types of services needed Supplies and equipment ordered Frequency of visits Prognosis Rehabilitation potential Functional limitations Nutritional requirements Medications and treatments

9. Reimbursement Realities in Home Health Care must be skilled, intermittent, reasonable, and necessary Skilled Care must be the kind that only a nurse trained in that care could be expected to do Intermittent Visits occur periodically; usually do not exceed 28 hours/week Reasonable and necessary Objective clinical evidence must clearly justify the type and frequency of services

10. Reimbursement Realities in Home Health Patient must be homebound Must exert considerable effort to leave the home Medicare also requires that absences from home be infrequent and of short duration According to Medicare regulations, if patients are well enough to leave home frequently, they are able to visit a physician’s office for treatment and are not in need of home care Home health agency must be Medicare certified

11. Types of Home Health Services Skilled nursing “Skilled observation and assessment” The skills of a nurse are required to observe a patient’s progress, to assess the importance of signs and symptoms, and to decide on a course of action

12. Types of Home Health Services Teaching The most important skill in home care Much of what is done in the home must be done by the patient and caregiver

13. Figure 2-2

14. Types of Home Health Services Specialty home care Intravenous therapy The most common intravenous therapies provided in the home are hydration, antibiotics, pain control, total parenteral nutrition, and chemotherapy The nurse’s roll in the delivery of high-technology care in the home includes skilled observation and assessment, the ability to perform skilled procedures, and teaching

15. Types of Home Health Services Specialty home care Ventilator therapy This type of care is complex and should be provided only by nurses and caregivers specifically trained in the use of necessary equipment and procedures Requires around-the-clock observation Physicians and respiratory therapists must be on call for any problems

16. Communication Among Home Health Care Team Members Documentation Provides interdisciplinary communication Reimbursement for home health nursing visits depends on clear documentation of the patient’s homebound status, the skilled nature of the services provided, and the medical need for the services

17. Communication Among Home Health Care Team Members Case conferences The case manager schedules periodic, formal case conferences All disciplines work together to solve clinical problems Conferences provide detailed information about the complexity of problems that may justify increased visits

18. Rehabilitation Concepts Rehabilitation A process of restoration The process of restoring an individual to the best possible health and functioning after a physical or mental impairment

19. Rehabilitation Concepts Impairment A disturbance in functioning May be either physical or psychological

20. Rehabilitation Concepts Disability • A measurable loss of function Usually delineated to indicate a diminished capacity for work

21. Rehabilitation Concepts Handicap An inability to perform daily activities An individual is not able to perform one or more normal activities of daily living (ADLs) because of a mental or physical disability

22. Levels of Disability Level I Slight limitation in one or more ADLs; able to work Level II Moderate limitation in one or more ADLs; able to work but workplace may need modifications Level III Severe limitation in one or more ADLs; unable to work Level IV Total disability, with nearly complete dependence on others for assistance with ADLs; unable to work

23. Rehabilitation Goals Return of function Restoration of as much as possible in the traditional ADLs, such as bathing, dressing, eating, toileting, and walking Ultimate goal is to live independently Not all patients can be restored to their previous state; can learn to adapt to changes Emphasis on abilities rather than disabilities

24. Rehabilitation Goals Prevention of further disability Secondary disabilities may be caused by the patient’s primary disability For example, a stroke patient may develop pneumonia, decubitus ulcers, and/or contractures Rehabilitation process can place additional burdens on family members when roles once filled by the disabled family member must be filled by other members

25. Rehabilitation Legislation Federal government has passed laws to protect the rights of the disabled Vocational Rehabilitation Act of 1920 Social Security Act of 1935 Rehabilitation Act of 1973 Americans with Disabilities Act of 1990

26. The Rehabilitation Team Nurses must consider the whole patient when planning interventions Difficulties in functioning may affect many aspects of a person’s life and require coordinated services of several health care professionals so the individual can stay well Successful rehabilitation depends on health care workers considering how the individual functions within the family and working closely with other health professionals toward a common goal

27. Approaches to Rehabilitation Rehabilitation patients should be encouraged to do as much as possible for themselves The program should commence immediately after an injury and should involve the patient and family from the outset Nurses should be prepared to handle a wide range of patient and family emotions, from extreme optimism to depression

28. Long-Term Care 16,500 Medicare- or Medicaid-certified nursing homes in the United States provide residential skilled nursing care Nursing home population is about 3.5 million Required by people of all ages who are temporarily or permanently unable to function independently Refers to a range of services that address the health, personal care, and social needs of people who lack some ability for self-care

29. Risks for Institutionalization Age 1% of people ages 65 to 74 years reside in nursing homes 6% of people ages 75 to 84 years reside in nursing homes 20% of people ages 85 years and older reside in nursing homes

30. Risks for Institutionalization ADL dependency 12% of those with one or two ADL limitations reside in nursing homes 50% with five or six ADL limitations reside in nursing homes Other factors Financial resources, living alone or with family, mental illness, type of disease process, and degree of social support

31. Long-Term Care: Levels of Care Domiciliary care Facilities providing basic room, board, and supervision 24-hour care is not provided, and residents usually come and go as they please

32. Long-Term Care: Levels of Care Sheltered housing Similar to domiciliary care facilities, sheltered housing settings have some modifications to provide care for the frail older adult Usually includes community dining facilities 24-hour care is not provided

33. Long-Term Care: Levels of Care Intermediate care Custodial care at a level usually associated with nursing homes Patients often need assistance with two or three ADLs Must have personnel available 24 hours a day Receive no reimbursement under Medicare; some receive financing under Medicaid Require an RN to serve as director of nursing and an LPN to be on duty at least 8 hours a day

34. Figure 2-3

35. Long-Term Care: Levels of Care Skilled care Facility must have skilled health professionals present around the clock Care must be supervised by a physician and requires the services of a registered nurse, physical therapist, or speech therapist

36. Long-Term Care Effect of relocation The more prepared the patient, the better the adjustment Provide as much choice as possible for the patient, and respond to questions and concerns Choices of facility, room location, types of personal belongings, and room decor are helpful, as are tours of the facility before entering Patients should be introduced to other residents with like interests and invited or helped to participate in appropriate activities

37. Effects of Institutionalization Depersonalization Plays a major part in institutional life Caregivers often know little of a resident’s life history and therefore treat the individual resident in light of his/her diagnosis or dysfunctional behavior patterns One way to help see the resident of a long-term care facility as a whole person with past relationships, accomplishments, and interests is to ask family members to bring in photographs

38. Effects of Institutionalization Indignity Routine activities such as toileting and obtaining food and drink must be respected Simple courtesies, such as using a person’s title and last name, knocking before entering the room, and draping during care activities, help the resident maintain dignity

39. Effects of Institutionalization Redefinition of “normal” Behaviors considered normal at home may be labeled abnormal/unacceptable in institution Watching television at 3 AM, loud singing, or sexual activity may not be tolerated, depending on the residence’s rules and routines Important to give residents of long-term care facilities some flexibility and some measure of control in their daily lives

40. Effects of Institutionalization Regression The resident’s physical, mental, and social abilities may be lost because of disuse Important to encourage independence and social interaction as much as possible Avoid infantilizing older patients May be necessary to simplify language and activities for those who are cognitively impaired, but avoid baby talk

41. Effects of Institutionalization Social withdrawal If resident never leaves nursing home, or if family visits are few, the institution can become a barrier, cutting off interest and participation in the outside world The facility becomes patient’s entire world Withdraw into the boundaries of their own room Nurses can help by conversing about events inside and outside the nursing home

42. Principles of Long-Term Residential Care Promotion of independence Successful relocation to long-term care facility depends in part on the ability of patients to do things for themselves; older adult family member in contact with the outside world Set specific goals for each patient that encourage independent functioning

43. Principles of Long-Term Residential Care Maintenance of function Often it is loss of function that prevents an older adult from staying at home Health professionals who are disease oriented concentrate on the disease process at the expense of a functional assessment Interventions, whenever possible, should focus on restoring and preserving function

44. Principles of Long-Term Residential Care Maintenance of autonomy Successful relocation to a long-term care facility depends on preserving as much autonomy as possible Older adults who help select the facility adjust better than those who have no choice in the matter Allow as much flexibility as possible in establishing a routine for the new resident

45. Principles of Long-Term Residential Care Mutually established goals are more likely to be achieved than those selected for the resident Autonomy depends on knowing one’s place in the world and what roles one still plays within the family structure Families who relate to their elder members, reinforce their importance in the family, and keep them up to date on family happenings and decisions support the idea that the elder remains a valued family member

46. Other Patient Care Settings Clinics Physicians offices Schools Adult daycare Respite care Correctional facilities