Transcript Chapter 19: Global Models of Health Care

Chapter 19: Global
Models of Health Care
Introduction
• Meeting the needs of a rapidly growing
older adult population is challenging
worldwide
• Will compare models of healthcare to
provide insights into how to meet these
challenges
Background
• Japan:
– By 2020, the 65 and older population will
comprise 27% of the total population
• USA:
– The elderly are expected to make up 16.6% of
the total population in the United States
• Italy:
– Just over 24% of the population will be 65 or
older
Japan
• Currently, the elderly in Japan enjoy the highest life
expectancy in the world.
• 1970s free elder care, but was terminated in 1982
• Gold Plan (1989)
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Home help
Short-stay institutions
Day services
Education regarding normal aging
• Long-Term Care Insurance program (2000)
– 65 or older pay 10% of nursing costs + monthly premium
– Can choose among agencies providing services
• Emphasis on caring for elders at home due to overuse of
hospitals– elder abuse addressed as a potential problem
Germany
• 1st country to establish a national health care program
• Solidarity Principle: members of society are responsible
for providing adequately for another’s well-being through
collective action.
• PCP is gatekeepers to hospital access
• In 1995, those age 60 and older comprised 21% of the
German population
• By 2030, 36% of the population will be 60 years of age
and older
• LTC coverage in Social Security System – coverage is
mandatory – created to relieve financial burden of longterm disability and illnesses
• Most German elders still cared for at home by relatives
England
• National Health Service (NHS)
• Universal system of health care based on clinical
need
• Care is free at point of care
• PCPs are independent contractors
• 75% of the funding for the health care comes
from taxes
• Nearly 100% have access but long waits
• Secondary care = referral to specialists or
hospitals for care
Canada
• Health care system known as medicare
• Universal coverage at no cost at the point of
access
• Each of the 10 provinces responsible for
provision of health care services
• Services based on need
• Funded primarily through taxes
• MD in private practice
• Hospitals primarily not-for-profit
• Long wait times
• Vision, dental and meds covered for seniors
U.S. Health Care System and
Policies
• Effects of an Aging Society:
– By the year 2050, 30% of the population will
be over the age of 65 years
– The population over the age of 85 is expected
to double
Effects of Morbidity and Mortality
• Life expectancy is 77.1 in the U.S.
• This is behind many other countries
including Japan, Singapore (highest at 80
years), Canada, Australia, Italy and others
• Number of chronic illnesses increases with
aging population requiring interdisciplinary
team with expertise in geriatrics to meet
the physical and psychosocial
consequences
Social Security
• Federal old-age pension program
• Mandatory participation through payroll
contributions
• Fewer benefits than many other industrialized
nations
• Delayed retirement credit (DRC)
• 75% of poor elderly are women who depend on
social security as main source of income
• Women are 60% of recipients at age 65
Medicare
• Through Social Security Act to provide some kind of
universal health care insurance for elderly and those with
ESRD
• Part A: Hospital insurance
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Inpatient care
Skilled nursing facility
Hospice care
Home health
• Part B: Supplemental medical insurance
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Home health
Doctor visits
Some outpatient therapies
Mental health services
Outpatient hospital services
Medicare (cont’d)
• Part C:
– HMO
– PPO
• Part D:
– Prescription drug plan
• Does now cover some screenings
Medicaid
• Financed by state and federal government
• Administered by state Coverage and eligibility
differ from state to state
• Three types of protection
– Health insurance for low-income families and people
with disabilities
– LTC for older Americans and persons with disabilities
– Supplemental coverage for low-income Medicare
beneficiaries for services not covered by Medicare
• LTC insurance available but very expensive
Settings for Care in the U.S.
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Acute Care
Long-Term Care
Home Care
Assisted Living
Chapter 20: The
Interdisciplinary Team
Bonnie M. Wivell, MS, RN, CNS
Introduction
• Elderly deal with:
– Normal age changes
– Impact of chronic illness
– Realities of real or potential changes in
function and/or cognition
• Interdisciplinary Team
– Diverse skills and expertise
– More effective, better coordinated, and better
quality services
Teams
• Multidisciplinary
– Team members with expertise in certain areas
– Individual goals
• Interdisciplinary
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Different disciplines with common goals
Complex problem solving/more effective treatment
Interdependent in their work
Share accountability for outcomes
Coordination and integration of care assessment and
planning
– Patient seen as a whole
– See pages 655-658 for various members
Why Teams Are Needed
• IOM Crossing the Quality Chasm report
from 2001
• “Effective teams have a culture that fosters
openness, collaboration, teamwork, and
learning from mistakes.”
• Mandated interdisciplinary education in its
publications
• For patient safety and quality of care
• Assessment, Consultation, Management
Types of Teams
• GITT: Geriatric Interdisciplinary Team Training
• Established in 1994 by John A. Hartford
Foundation
• An organized training program for professionals
of various disciplines focused on learning about
working in teams, use of teams in gerontology
• Development of a core curriculum in
interdisciplinary training
Types of Teams
• GAIT: Geriatric Assessment Interdisciplinary
Team
– An interdisciplinary training model developed in
Maryland as elective for student education from
various healthcare disciplines
• GAT: Geriatric Assessment Team
– Consultation team that evaluates functional, social,
fall risk, nutrition, medication, depression, cognition,
and incontinence problems
• Inpatient or Outpatient
• Underutilized
Types of Patient Care Units
• GEM: Geriatric Evaluation and
Management
• ACE: Acute Care for Elders
• Designated inpatient units wherein the
elderly are assessed and treated
• Staffed with geriatric team members
• Units show better outcomes
• Patients more likely to be discharged
home
Palliative Care & Hospice
• Active across care settings where geriatric
teams are also found
• Goal of Palliation: to prevent and relieve
suffering and to provide the best possible QOL
for patients and their families regardless of the
stage of disease or need for other therapies
• Address EOL physical, psychosocial, and
spiritual issues
• Ease transition from purely curative care to
supportive care
• Care goals determined by patient and family
Challenges
• Socialization to team approach
– Identified roles
– Trust and respect
• Inconsistent team members
• Accreditation issues
– Reimbursement
• Shared power
• Turf issues
Benefits
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More comprehensive approach to care
Increased patient and team member satisfaction
Increased quality of care
More cost effective
– Avoid redundancy of services
• Education of other team members
– New skills
• Increased productivity
• Potential for time saving
Chapter 23: The
Gerontological Nurse as
Manager and Leader
Bonnie M. Wivell, MS, RN, CNS
The Nurse Manager
• All geriatric nurses need to develop
management skills
• A unique position to improve quality, positive
outcomes, and cost-effectiveness of patient care
in a variety of settings
• Multitude of tasks
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Ensuring quality nursing care
Patient and family satisfaction
Staff retention
Commitment
Contentment
Characteristics of an Effective
Nurse Manager
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Organized
Consistent
Fair
Optimistic
Goal-oriented
Flexible
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Creative
Resourceful
Professional
Standard-setter
Trustworthy
Honest
Delegation
• Managerial and legal act
• Skill that must be learned and practice
• Licensed nurse are still accountable for the wellbeing and safety of the patients entrusted to
them
• Inappropriate use of unlicensed assistive
personnel (UAP) in performing functions outside
their scope of practice is a violation of the state
nursing practice act and is a threat to pt. safety.
The RN has an increased scope of liability when
tasks are delegated to a UAP.
The Delegation Process
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Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision
Skills of Nurse Managers
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Team building
Goal setting
Facilitating change
Stress management
Decision-making
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Conflict resolution
Expertise
Communication
Listening
Inspiring trust
The Nurse Leader
• Effective leaders are often good managers
• However, a good manager is not always a
good leader
• Leaders tend to be visionaries who focus on
the larger picture
• Managers focus on day-to-day operations
• Leaders can be mentored to be more
effective managers
Leadership Strategies
• Transactional: leading by an inconsistent
system of rewards and consequences
• Transformational: leading by example,
encouragement, and empowerment of the
staff
• Strategies:
– See past the present
– Using good communications techniques
– Trust through positioning
– Development of self
Charismatic Leader
• Characterized by their determination to
change the current state of affairs
accompanied by an awareness of forces in
the environment and their followers’ needs
• 3 stages
– Determine the conditions that cause change
and recognize followers
– Encourages followers to partake in the vision
– Ability and desire to go above and beyond
Leadership styles
• Authoritarian: leader makes decisions with
little input from staff
• Democratic: welcome the input from staff
and believe their opinions are important
• Laissez-faire: relaxed; “go with the flow”
• Situational: choose style based on the
situation
Leadership in a
Multigenerational Age
• Traditional professional nurses
– Born pre-1945
– Seniority and loyalty are important
– Hard work, pride in doing a good job, working together,
financially conservative, and cautious
– Many of these nurses were trained in hospital-based diploma
program Baby Boomers
• The Baby Boomers (born 1945–1964)
– Represent the largest percentage of the nursing workforce
– Hold many nursing leadership positions
– They challenged and changed the values held by the veteran
nurses
– Sense of professionalism and view of nursing as a career
Leadership in a
Multigenerational Age
• Generation X (Born 1964–1980)
– Parents worked; “latch key” children
– Saw their parents laid off from work after sacrificing their time
with their children to advance their careers
– Value work-life balance
– Want career security and flexibility
• The Millennial or Net Generation (Born 1980–2000)
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Raised during a time of violence, terrorism, and drugs
Embrace multiculturalism and technology
Nursing is an occupation versus a profession
May have as many as 10 career changes (not job changes) in
their lifetime
– Strengths are competence in technology and expectations of
virtual teams
Professional Organizations
• Provide quality care to patients and offers
the latest information in gerontology
• NGNA
• NADONA/LTC
• AANEX
• AALTCN
• AANAC
AHCA
ACHC
AMDA
NAHCA
AAHSA
Chapter 25: Trends That
Impact Gerontological
Nursing
Educational Levels
• LPN, ADN, BSN
• Advanced practice
– GCNS-BC
– GNP
– The ANCC changed the advanced practice designations to help
better distinguish between the various specialties of APRNs
– CNL: ill-defined
• Doctorates
– PhD
– DNP
– The DNP is the proposed new entry level into advanced practice
nursing as of 2015
Life Care Planning
• A life care plan is a comprehensive document designed to help meet
the long-term financial and health needs of a person who has
experienced a catastrophic injury (Weed, 1999).
• Assist with determination of settlements in litigation
• Nurses with rehabilitation backgrounds or case management
experience are well-suited for this role
• Certifications available:
– CLCP
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128 CE hours
Sample life care plan
Pass an exam
Can be earned by nurses or any other disciplines as well
– CNLCP
• The planner is a nurse
• Strict prerequisites
• Large number of practice hours
What is Financial Gerontology?
• Combines the knowledge and skills associated with
financial planning and asset management with expertise
in meeting the unique needs of older adults (i.e.
finances, money/asset management, insurance
needs, living arrangements)
• An emerging field
• Relates gerontological concepts, issues, data and
research findings to financial services
• Three certifications
– Chartered Advisor for Senior Living
– Registered Financial Gerontologist
– Certified Senior Advisor
Trends in LTC
• The broad range of medical, custodial, social,
and other care services that assist people who
have an impaired ability to live independently
for an extended period
• $183 billion spent on LTC services in 2003
• In 2005 Medicaid spent nearly $95 billion
• Use up savings and other financial assets
before eligible for Medicaid
Long-Term Care Insurance
• Covers care outside the hospital, including
diagnostic testing, rehab, custodial care, nursing
home, assisted living, hospice, home health,
adult day care, and respite care
• Purchase to decrease worry about being a
burden, stay financially independent, have more
choices for care, preserve assets and provide
peace of mind
• Can be purchased at any time but premiums
increase with age
Emerging Models of Care
• Continuing care retirement communities
(CCRCs)
– A community living setting or situation
designed for older adults that offers a
continuum of care
• Green Houses:
– 10-12 residents in home setting who enjoy
private rooms and common living space
– Full range of care services
Emerging Models of Care
• Professional Geriatric Care Manager
(PCGM)
– A professional who specializes in helping
families care for older adults while
encouraging independence
• Community living designs
– Concept that focuses on designing, building,
engineering, and marketing to older adults,
especially in senior living communities
Summary
• The U.S. population over age 65 is
projected to double by 2035
• The first baby boomers are beginning to
enter the “senior” market
• The older age groups are becoming more
heterogeneous
• With more older adults in the population,
demand for services is likely to increase
Summary
• Financial planners are taking courses in
aging to cater to the older client, but is this
an area that gerontological nurses should
be working in?
• New models of care are beginning to
emerge and there will likely be additional
models to meet the needs of the baby
boomers as they enter older age
Helpful Websites
• www.geriatricpain.org
• www.nursingsociety.org/gerontology
• www.hartfordign.org