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Chapter 37 Long-Term Care
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Introduction
• Long-term care (LTC) facilities are becoming more complex and dynamic – Medically complex population – Sub-acute care units • Consumers more informed of standards of care • Nurses have the ability to establish long term (LT) relationships with their patients and practice healing arts Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Development of Long-Term Institutional Care
• History of a negative image overshadows positive aspects of care – Media highlights of abuse and substandard conditions • Small minority of facilities • Reimbursement policies that limit the ability to provide high-quality care Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Development of LTC—(cont.)
• Before the 20 th century – Europe at the end of the 17th century – The United States • Cared for at home (family or paid) • Almshouses • Limited resources; basic care at best • Able residents expected to work at the institution Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Development of LTC—(cont.)
Minimal patient autonomy – Characteristics of “total institutions” (sociologist Erving Goffman, 1961) • This approach to care cast residents as inmates rather than as unique individuals • Isolation from mainstream society • Residents developed abnormal behaviors Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Development of LTC—(cont.)
• During the 20th Century – Care in the early 1900s – – – – – 1935: Social Security enacted 1946: Hill-Burton Hospital Survey and Construction Act 1960s: Effect of Medicare and Medicaid 1987: Omnibus Budget Reconciliation Act (OBRA) Nursing home regulations developed Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following government initiatives had the first impact on promoting the growth of nursing homes?
a.
b.
Social Security Hill-Burton Act c.
d.
Medicare and Medicaid Private insurance availability Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
a.
Hill-Burton Act
In 1946, the government contributed to nursing home growth by granting funds to help construct long-term care facilities through the Hill-Burton Hospital Survey and Construction Act.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Lessons to Be Learned from History
• A vision and clear model for LTC is necessary • When nursing fails to exercise leadership, non-nurses determine nursing practice • When nursing does not attempt to correct problems in the health care system, others will, and public perception will be that nurses are part of the problem • Entrepreneurial thinking can benefit nursing and patients Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Facility-Based Care Today
• Nursing homes now referred to as long-term care (LTC) facilities • Improvements due to federal regulations and increased professional interest • Licensed staff and certified nursing assistants • Decreased use of restraints • Improved documentation • Continued problems Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Home Standards
• Regulations describe minimum standards • Based on laws • Required for reimbursement • Minimum standards to be licensed and certified – States can create higher standards • Joint Commission publishes higher standards that facilities can choose to follow Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Home Residents
• Functionally dependent as a result of physical or mental impairment • Functional ability determines the need for LTC placement • Statistics • Oftentimes caregiving needs exceeded the family’s capacity to meet those needs • A crisis situation may trigger the need for placement in a nursing home Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What percentage of the older adult population resides in an LTC facility at any given time?
a.
b.
5% 10% c.
d.
15% 20% Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
a.
5%
At any given time, only 5% of the older adult population resides in an LTC facility. A higher percentage will need this form of care at some future point in their lives.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Roles and Responsibilities
• Need for highly competent nurses • Oversee status of residents • Monitor competency and performance of unlicensed caregivers • Staff education • Role modeling and coaching • Staff supervision Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Roles and Responsibilities— (cont.)
• Performance evaluation • Clinical and administrative duties • Admission assessments and completion of the Minimum Data Set (MDS) tool – Identification of problems directs care planning activity – Written care plan guides nursing actions Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Roles and Responsibilities— (cont.)
• Evaluation of effectiveness of care • Independent nursing practice • Ability to develop long-term relationships • Other specialized roles of professional nurses in the LTC setting Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
The Minimum Data Set (MDS) is a standardized assessment tool that must be completed when a patient is admitted to an LTC facility, whenever there is a change in the resident’s status, and annually.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
True
The MDS assessment tool is coordinated by a registered nurse, and most of the entries on the MDS rely on nursing assessment. The tool is completed when an individual is admitted to an LTC facility, whenever there is a change in the resident’s status, and annually.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assisted Living Communities
• Care for individuals with less complex needs • Less stringent regulations • Fewer licensed nurses available • Increasing number of beds • Private pay (majority) • Challenges for gerontological nurses Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Looking Forward: A New Model of LTC
• LTC emerged without a clearly defined model – Nurse’s role is to define a new model • Holism and healing versus the medical model • Hierarchy of resident needs: – – Hygiene Holism – Healing • Assumptions of the model of holism and healing Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hierarchy of nursing home residents’ needs. (From Eliopoulos, C. (2007). Transforming nursing homes into healing centers: A holistic model for long-term care. Glen Arm, MD: Health Education Network.). Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Looking Forward—(cont.)
• Key elements of the culture change movement: – – Creating a home-like environment Consistent staff assignments – – – – Individualized care Nurturing positive relationships Staff education Empowering residents and their caregivers Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Looking Forward—(cont.)
Culture change movement programs – – – Eden Alternative • Offers residents a life worth living Wellspring Program (2012) • Emphasis on quality improvement (QI) measures The Green House Project (2003) • Designing the ideal nursing home Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins