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Long Term Care in Geriatrics Seki Balogun, MD, FACP Case 1. • Ms. TJ is an 85year old woman with paraplegia from a • spinal cord injury. She has severe neuropathic pain and is wheelchair dependent. She lives alone, has no relatives in VA. • She had a paid caregiver, 6hrs/day, who helped her with self care (bathing, toileting) and her instrumental ADLs (cooking, cleaning and shopping). • She can no longer afford to pay her caregiver You are her physician, what would be your advice? 1. Tell her to go to the he is e dv A a. .. rt o he r pa y ffe rt o O go ca to go rt o he is e dv A to a. .. ... th e to go rt o re g. .. 0% 0% 0% 0% he 4. ll 3. Te 2. emergency room Advise her to go to a nursing facility Offer to pay her caregiver Advise her to go to an assisted living facility Nursing homes • 1.5 million Americans (most aged 65 years and older) reside in 17,000 nursing facilities nationwide • 43% of adults 65 years and older will stay in a nursing home at some time before they die • 55% have a lifetime use of at least 1 year • 21% have a total lifetime use of 5 years or more LTC: Historical background Twelfth century • “Gerocomeia” in ancient Greece Early 1900 • Europe: special care units for the chronically ill elderly • United States: chronically ill and disabled • Poorhouses Historical background • 1920s • State licensure programs • Standards and oversight were minimal • Mid – 1900s • • • • Social Security Act Private nursing homes Run by nurses Custodial care • Post- world war II: modeled after hospitals • Minimum standard of care Historical background • 1980s • Nursing Home Reform Act (OBRA ’87) • State regulations • Quality of care for the cognitively and functionally impaired Long Term Care Facility • Nursing Homes • Assisted living facilities • Focus of care is to achieve and maintain an optimal level of functioning • Interdisciplinary care Case 2. • Mr. TB is a 90 year old man with multiple • • • medical problems, who was admitted to the hospital last week with community acquired pneumonia. He is now ready for discharge He is deconditioned and is unable to ambulate He lives with and is the caregiver for his wife, who has advanced dementia You are the resident: Do you m :i t.. . ... hi ho ch a rg e hi m di s rg e ot N D is c ha ha is c D m e sk a to rg e hi m hi m ho m e: ... ... 0% 0% 0% 0% rg e 4. ha 3. is c 2. Discharge him home: he did well at home before Discharge him to a skilled nursing facility for rehabilitation Discharge him home with home physical therapy Not discharge him: it would be heartless to do so D 1. Nursing Homes Skilled nursing care • Typically for those discharged from an inpt setting with functional deficits and often medically complex • Require one or more form of therapy (PT, OT, speech) • High degree of nursing care: IV, wound care • Length of stay usually less than 6 months (few days to months) Nursing Homes Long term nursing care • For those who can no longer live independently • Require assistance for self care and IADLs • Significant functional, cognitive or psychosocial deficits Nursing Homes Hospice care • Terminal conditions with less than 6 months to live • Usually in conjunction with an independent hospice organization • Team provides a network of services: physicians, nurses, social workers, chaplain So what should happen to seniors who need some help, but do not require 24 hr nursing care? 1. They should be admitted to the nursing home: better safe than sorry. 2. Their family should care for them: it is their responsibility 3. They could live in an assisted living facility 4. They should pay for a caregiver Assisted Living facility • Residents require some supervision or physical assistance due to functional or cognitive deficits • Usually owned by private organizations • Provision of individual care needs vary with facility • Provides 3 meals and medication administration • Costs about $2-3K/month Assisted living facility • Better received by seniors • More home - like • Less institutionalized setting • Paid by individuals or long term care insurance • There are rare “Auxiliary Grants” for low income people. A few beds in our area at Mountainside in Crozet. HealthCare Financing in LTC • Medicare • Medicaid • Long term care insurance • Private pay Medicare • Federal insurance program run by Centers for • Medicare and Medicaid Services (CMS) Covers acute health care for: • Adults 65 years and over • The disabled • Persons with End Stage Renal disease • Covers skilled nursing care • Does not cover care in assisted living facilities Medicaid Joint federal and State Program • People of all ages who have low income • Eligibility vary from state to state Covers • Medicare part B premiums • Deductibles and co-insurance costs • Long term care (some assisted living facilities) • Home care • Medications Long Term Care Insurance • Premiums vary with plan • Can be expensive Where would you like to spend your golden years? 1. Nursing facility 2. Assisted living facility 3. Home 4. I’d rather die than go to a nursing home 0% Nursing facility Assisted living f... Home I’d rather die th...