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Adult devleopment and Aging: Chapter 12: Long term care
Terms in this set (51)
An institutional facility
*Provides individuals with medical or psychiratric care along with programs intended to restore their lost functioning.
Institutional facilites for long-term care
*People with chronic disabilites, cognitive disorders, or physical infirmities that keep them from living independently may recieve treatment in one of a variety of institutional long-term care settings.
1) Nursing homes
2) Residential care facilities
*Provide individuals with medical or psychiatric care along with programs intended to restore lost functioning
*Is a type of medical institution that provides a room, meals, skilled nursing and rehabilitative care, medical services, and protective supervision.
*30% of residents are discharged and able to move back into the community after being treated for the condition that required their admission.
*About 1 quarter of people admitted to nursing homes die there, and another 36% move to another facility.
1) Skilled nursing facilities
2) Intermediate care facility
Skilled Nursing facilities
*Provide the most intensive nursing care available outside of a hospital
• nasal feeding
• oxygen therapy
• blood pressure
• elimination retraining
• bed baths
Intermediate care facility
*Health-related services are provided to individuals who do not require hospital or skilled nursing facility care but do require some type of institutional care beside food and a place to live.
Nursing home facts
*Nursing home services have become big business in the US
*In the year 2008, nursing home expenditures were estimated to be $138.4 billion, or about 5% of the total health care expenditures in the US.
*The cost of nursing home care is rising faster than the cost of other medical care goods and services.
-$60,000 is average private pay facility
*The % of older adults has declined in the 20 years between 1985 and 2004, reflecting increases in home health services and generally better health of the over-65 population.
*As of 2008 there were 15,700 nursin homes in the US
-1.7 million bed, 83% occupied
Residential care facilities
*An alternative to a nursing home
*Provides 24 hour supportive care services and supervision to individuals who do not require skilled nursing care, but do require care above the level of room and board
*They provide meals, housekeeping, and assistance with personal care such as bathing and grooming.
1) Board and care homes
2) Group homes
3) Assisted living facilities
4) Adult foster care
Board and care homes
*Are group living arrangments designed to meet the needs of people who cannot live on their own in the community but who also need some nursing services.
*Typically understaffed and not properly trained
*Provide independent, private living in a house shared by several older individuals
*Residents split the cost of rent, housekeeping services, utilities, and meals.
Assisted living facilites
*Housing complexes in which older people live independently in their own apartments
*Residents pay a regular monthly rent that usually includes meal service in communal dining rooms, transportation for shopping and appointments, social activities, etc.
*These facilities are professionally managed and licensed and may represent one of several levels provided within the same housing community.
*Most residents pay the rental and other fees out of their own funds.
*These facilites are often too expensive for the moderate and low-income older adults, and those that are affordable do not offer high levels of service or privacy.
Adult foster care
*An older adult may receive this in which a family provides care in their home.
*The services provided in foster care include meals, housekeeping, and help with dressing, eating, bathing, and other personal care.
-Caregiver's resources may spread thin
-Other residents may suffer from lack of attention if one gets sick
-Lack of privacy
Community based facilites
*Some of these services are offered by volunteer groups at no cost to the individual, others are fee based and of these services, some may be paid for by medicare.
1) Home health services
2) Geriatric partial hospital
3) Accessory dwelling units
4) Subsidized housing
5) Continuing care retirement community (CCRC)
Home health services
*A variety of services such as
1) Meals on wheels
2) Friendly visiting
*Teaching older adults who are receiving home health care a variety of strategies to maintain their functional ability, such as fall prevention, muscle strength training, and home safety, can help maximize mobility and reduce costs associated with institutionalization.
*In 2008, $64.7 billion was spent in the US on home health care; 79% of these costs were publicly funded.
Geriatric partial hospital
*Daily outpatient therapy is provided with intensive, structured multidiciplinary service to older persons who have recently been discharged from a psychiatric facility.
*Therapists in this setting focus on medication management and compliance, social functioning, discharge planning, and relapse prevention
Geriatric continuing day treatment
*A less intense program than the geriatric partial hospital program, in which clients attend a day treatment program 3 days a week but are encouraged to live independently during the remaing days of the week.
Day care centers
*Are another form of community treatment in which individuals receive supervised meals and activities on a daily basis.
Accessory dwelling units
*Also known as an "in-law apartment"
*Is a second living space in the home that allows for the older adult to have independent living quarters, cooking space, and a bathroom.
Subsidized senior housing
*IS provided for individuals with low to moderate incomes.
*People using this type of housing live in low-rent apartment complexes and have access to help with routine tasks such as housekeeping, laundry, and shopping.
Continuing care retirement community (CCRC)
*Which is a housing community that provides different levels of care based on the residents needs.
*WIthin the same CCRC, there may be individual homes or apartments in which residents can live independently, an assisted living facility, and a nursing home.
*Residents move from one setting to another based on their needs, but they continue to remain a part of their CCRC community.
*Different types of contracts based off of needs
*Definite advantages to living here if an individual can afford it.
Characteristics and needs of nursing homes and their residents (In-class notes)
• Nursing homes
▫ For profit: 67%
▫ Cognitive impairment
▫ Personalfunds/privateinsurance:22% ▫ Medicare:14%
Residential care facilities (in-class notes)
• Board and care homes - ADLs
• Group homes
- Rent, housekeeping, utilities, meals
• Assisted living facilities
- Rent, meals, transportation, social activities,
housekeeping, sometimes health services
• Adult foster care
- Family provides care in their home
• Home health services
- Meals, shopping, cleaning, friendly visits, etc.
• Geriatric partial hospital
- Daily outpatient therapy for recently discharged
• Geriatric continuing day treatment • Adult day care centers
• Accessory dwelling units - In-law apartment
• Subsidized housing
- Housekeeping, shopping laundry, etc.
Continuing Care Retirement Community
• Different level of care based on resident's needs
• Independent living apartments - skilled nursing
• Large upfront payment plus monthly fees
• Contract regarding health services
Financing of long-term care (1)
• Social Security
- Social insurance program for retirement, disability, survivorship, and death
- Funded primarily through Federal Insurance Contributions Act tax (FICA): payroll taxes
- Collect age 62 (reduced)
• Full benefits determined by year of birth
- 1960 and later: 67
Financing long-term care (2)
- Health Insurance for the Aged and Disabled (1965)
- Funding from payroll taxes, premiums, general revenue from income taxes, some payments from the states
• Pay as you go
• PARTA Hospital Insurance:
▫ Inpatient care in hospitals
▫ Inpatient care in a skilled nursing facility
▫ Hospice care services
▫ Home health care services
• PART B Medical Insurance (pay a monthly premium based on income)
▫ Medically necessary services
▫ Preventive services
• PARTC Medicare Advantage Plans (run by private companies)
▫ Extra benefits
▫ Operate through provider networks
• PART D Prescription Drug Coverage
▫ Coverage of prescription drugs after deductibles and through a "donut hole"
MEDICARE PART D 2010
Beneficiary pays the first $310 (i.e. up to the deductible)
*From $310 to $2830, beneficiary pay s 25% (therefore maximum out of pocket is $630)
*At $2830, reach the threshold or the beginning of the donut hole. In the donut hole, beneficiary pays 100% of all prescription costs .
*Donut hole ends at catastrophic coverage benefit which begins at $6440
*If beneficiary reaches catastrophic coverage, out-of-pocket expenses will be $4550 (excluding plan premium)
Medicaid (In-class notes)
- Medical care for financially needy
- Administered by the state
- Can cover expenses not covered by Medicare
- Can "spend down" to become eligible
1) in 1966 Medicare covered 19.1 million people at a cost of $1.8 billion
2) By 2008 more than 37.6 million Americans 65 and older were covered, two thirds of whom are enrolled in medicare drug plans
3) By 2083 Medicare is expected to reach 11.4% of the GDP
4) By the year 2018, there will be a deficit in the total Medicare budget due to the fact that expediters will be greater than revenues. (This gap will continue through 2081)
5) in 2007, the social security trustees issued first ever warning about medicare.
6) This impending crisis became the immediate impetus for the Patient Protection and Affordable Care Act (PPACA) (2010, Obama)
7) IN 1973 the program was expanded to broaden eligibility to citizens already receiving ss benefits, people over 65 who qualify for ss benefits, and individuals with end-stage renal disease and need kidney transplant.
The department of health and human services
*Has the overall responsibility for administration of the medicare program, with the assistance of the social security administration.
Centers for Medicare and Medicaid services (CMS)
*The agency with responsibility for formulation of policy and guidelines, oversight and operation of contracts, maintenance and review of records, and general financing.
*State agencies also play a role in the regulation and administration of the medicare program in consultation with the CMS.
Medicare part a Facts
*Coverage in a skilled nursing facility is included in Part A only if it occurs within 30 days of a hospitalization of 3 days or more and is certified as medically necessary.
*Home health services are also included in part A for the first 100 visits following a 3-day hospital stay.
*Respite periods are also covered for hospice care to allow a break for the patient's caregiver.
*In 2009, opponents to health care reform stated that the changes would include "death panels" to decide who would receive palliative care; however, within existing medicare legislation, hospice care was already fully insured, covering pain relief, supportive medical and social services, physical therapy, nursing services, and symptom management.
Medicare part b facts
*Are preventive treatments, including glaucoma and diabetes screenings as well as bone scans, mammograms, and colonscopies.
Medicare part c facts
*Individuals who have both part A and part B can chose to get their benefits through a variety of risk-based plans including HMOs, preferred provider organizations (PPOs), private fee for service plans, and a health insurance policy administered by the federal government.
*First became available in 1998
*Department of health and human services identified 26 regions across the nation in which PPO plans compete to provide services.
*IN 2009 24% of beneficiaries were enrolled in medicare advantage plans.
Medicare part d facts
*First available in 2006
*Provides prescription drug benefits
*Once you sign up for part D you are no longer eligible to receive prescription benefits through private insurance companies
*As they enter the donut hole, rates of medication adherence decline
*Starting in 2011, qualified beneficiaries will pay 50% less on prescription drugs and by 2020 the donut hole will be closed completely.
*Medicaid was initially formulated for the poor, with an emphasis on dependent children and their mothers, the disabled, and the over 65 population.
-eligibility for medicaid has expanded and it no available to a large number of low-income pregnant women, poor children, and some medicare beneficiaries who are not eligible for an cash assistance programs.
*Changes in legislation have also focused on increased access, better quality of care, specific benefits, enhanced outreach programs, and fewer limits on services.
-addition of managed care as an alternative means of providing health services.
*This program allows people to "spend down" their assets to the point of being eligible for medicaid by paying medical expenses to offset their excess income (when income is too high)
*Services that are covered by both programs are first paid by medicare then the difference is paid by medicaid, up to the states payment limit.
*In 2008 it provided $344.3 billion
*Together medicare and medicaid (federal and state) financed $813.5 billion in health care services in 2008, which was 34% of the nation's total health care bill of $2.3 trillion (private and public funding combined and 82% of all federal spending on health.
Legislative Issues in Care of Older Adults
*Funding of these services is provided by federal and state agencies
1) 1987 Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)
-Nursing Home Reform Act (NHRA)
2) 1977 Balanced Budget Act
3) 1998 Nursing Home Initiative
4) Congressional Hearings on Nursing Home Abuse
5) 2002 Nursing Home Quality Initiative
6) 2007 GAO Report
1987 Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)
*The current US laws governing the operation of institutional facilites have their origins in a report completed by the Institute of Medicine in 1986 called "Improving the Quality of Care in Nursing Homes."
-The result of this was the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)
-included the Nursing Home Reform Act (NHRA)
*OBRA 1987 mandated that facilites must meet physical standards, provide adequate professional staffing and services, and maintain policies governing their administrative and medical procedures.
*A significant component of this legislation was the provision of safeguards to assure quality of care and protection of residents' rights.
*The conditions of the Nursing Home Refore Act specify that nursing homes must be licensed in accordance with state and local laws, including all applicable laws pertaining to staff, licensing, and registration, fire, safety, and communicable diseases.
*The facility must admit eligible patients regardless of race, color, or national origin.
*The series of resident rights developed as part of the Nursing Home Reform Act include choice of physician and treatment, freedom from physical and mental abuse, the right to privacy and treatment with respect and dignity, the right to confidential records, and the right to have needs and preferences met.
*Legislation also established procedures to ensure that all conditions are met for maintaining compliance with the law, which are monitored by outside agencies.
1977 Balanced Budget Act
*Changes to the nursing home rates for post-hospital care through medicare were incorporated into this act of 1997.
*Implemented in March 2000
*These changes involved moving to a prospective payment system in which rates paid to skilled nursing facilities cover the costs of furnishing most covered nursing home services, excluding payment for physicians and certain other practitioner services.
*Under the prospective payment system, each facility receives a fixed amount for treating patients diagnosed with a given illness, regardless of the length of stay or type of care received.
*The intention of the change in payments was to curb the rapidly rising costs of Medicare as well as to adjust the payments to the specific needs of the patient.
1998 Nursing Home Initiative
*Ten years after NHRA was put into place, a series of investigations and Senate hearings were conducted that called attention to serious weaknesses in federal and state survey and enforcement activities stipulated by that law.
*Fully (98%) of nursing homes were found to have more than minimal (35%), substandard (33%) or serious (30%) deficiencies.
*In response to these findins President Bill Clinton's administration annouced the 1998 Nursing Home Initative.
*This initiative proposed a series of steps designed to imrpove enforcement of nursing home quality standards that were adopted by HCFA
-increasing checkups, bigger fines, etc.
Congressional Hearings on Nursing Home Abuse
*In September 2000, a Sentae Committee on Aging held a hearing on the outcome of the Nursing Home Initiative.
-this revealed that the initiative had resulted in improvements to state survey and federal oversight procedures, including increases in the number of surveyors, improved tracking of complaints, new methods to detect serious deficiencies, and improved organization of nursing home oversight activities.
*Nationwide, 27% of nursing homes were cited with violations causing actual harm to residents or placing them at risk of death or serious injury; another 43% were cited for violation that created a potential for more than minimal harm.
*The senate hearings also revealed flaws in the surveys
-significant problems were often missed, such as pressure sores, malnutrition, and dehydration.
*Even if serious deficiencies were found, there was inadequate enforcement so that the nursing homes involved did not correct the problems.
*The Senate Committe also found that the majority (54%) of nursing homes were understaffed, putting everyone at risk.
2002 Nursing Home Quality Initiative
*A program intended to help consumers find the highest quality nursing homes
*Quality Improvement Organizations (QIOs), government contractors, were hired to offer assisstance to skilled nursing facilites to help them improve their services.
*Volunteers became ombudspersons
-help families and residents on a daily basis find nursing homes that provide the highest possible quality of care and give consumers tools they need to make an informed decision on selecting a nursing home.
2007 GAO Report
*In 2007 the GAO issued a major report analyzing the effectiveness of the online reporting system based on data from 63 nursing homes in california, Michigan, Pennsylvania, and Texas, institutions that had a history of serious compliance problems.
*Many homes showed a yoyo pattern in which they made changes in order to comply with regulations only to slide back diwn until they were sanctioned.
*Deficiencies in nursing homes remain a significant problem, limiting severely the quality of care that many residents receive.
Characteristics and needs of Nursing homes and their residents facts:
*As of 2004, the percentages rise form 0.9% for persons 65-74 years to 3.6% for persons 75 to 84 years and 13.9% for persons 85+.
*The average size of a nursing facility across the United States is 108 beds, up slightly from 2003
*Not for profit nursing homes have higher quality ratings than their for profit counterparts
*When nursing homes have more private pay patients, they are able to provide better care because the rates for these patients are higher than the reimbursement rates that facilities recieve from governmental subsidies.
*OSCAR system has information from the state surveys of all certified nursing facilities in the US
Characteristics of residents
*Most common primary diagnosis
*Strongest predictors of admission into a nursing home
-inability to carry out basic activities of daily living
prior nursing home admission
*Alzheimer's disease is dound in nearly half (45%) of all nursing home residents
*56.8% of residents are chairbound
*Mood and anxiety disorders (20%)
*Nearly 2/3s (65.2%) of residents receive psychotropic medications, including antidepressants, antianxiety drugs, sedatives and hypnotics, and antipsychotics.
*Nursing home residents have more depressive symptoms and lower self-rated quality of life.
*Those who are paying for their own nursing homes are afforded a greater range of facilities, better accommodations, and higher st-to-patient ratios compared to those who are funded through medicaid.
Nursing home deficiencies
*Monitoring continues on a yearly basis through listing of deficiencies as reported to OSCAR
*Quality of care is on a steady decline.
*In 2008 the state with the highest number of deficiences was Delaware, at 8%.
*In 2008, lack of accident prevention was the number one deficiency, occurring in 44% of all nursing homes in the United States.
*Continence control is a huge issue
-as of 2008 training programs were only available to 6.4% of residents despite the fact that 65.5% were reported to have urinary incontinence.
-Bowel incontinence occurs in 43.3% of all residents, but bowel training is available only to 3.7%
*Worsening continence is one of the top reasons that older residents of nursing homes become socially disengaged.
*The use of physical and chemical drug restraints to keep residents from being aggressive is another key area of adjustment.
-4% of nursing homes
Psychological issues in Long term care
*Residents who feel that they can have mastery over at least some aspects of life in the institution feel less anxious and depressed, experiencing less of the stress that so often accompanies moving from their own homes to the institution.
*A study of the daily life of residents conducted in 2002 revealed that, as was the case in 1960s, residents spend almost 2/3rds of the time in their room, doing nothing at all.
*Social workers are not given sufficient educational preparation to work in these challenging and often stressful settings.
Models of adaptation
*Theoretical models attempting to provide insight into the adaptation of the individual to the institutional environment of a long-term care facility began to develop in the 1970s with the increasing attention in gerontology given to ecological approaches to the aging process
*Many researchers studying institutionalization believed it was important to find ways to maximize the resident's ability to maintain independence even while having to adjust to an environment that inevitably foster dependence.
*When trying to satisfy the needs of everyone, administrators of institutions will inevitably satisfy very few
-control that individual feels he/she has.
*Older adults with more years of education and a greater number of chronic illnesses were likely to state that they wished to be able to make these choices rather than have the decisions made for them.
*Predicts an optimal level of adjustment that institutionalized persons will experience on the basis of their levels of competence (physical and psychological) compared with the demands or "press" of the environment, or the demands it places upon individuals.
*In the optimal situation their is a match between an individual's abilities and the environments demands.
*A small degree of discrepancy is acceptable, but when the mismatch goes outside this range, the individual will experience negative affect and maladaptive behaviors.
*This model is essentially a biopsychosocial one, allowing room for multiple dimensions of competence and press to be considered when evaluating older adults.
Suggestions for improving institutional care
• Meet the needs of the individual
-Recognize and attempt to satisfy their needs for privacy and control
• Use behavioral methods
-Reinforce independent behaviors to reduce dependence on staff
• Create sense of neighborhood
-Break up monotony of environment with smaller units
• Group staffing by residents, not tasks
-Assign staff to meet the needs of a group of residents
* The Green House Model
-offers an alternative to the traditional nursing homes by offering older adults individual homes within a small community of 6-10 residents and skilled nursing staff.
-designed to feel like a home
-self-reports show higher quality of life
• Adopt team approach
-Staffs should work together as a multidisciplinary team
3 key areas that The Institute of Medicine report focuses on:
1) Enhancing competence in geriatric care
2) Increasing recruitment and retention
3) Improving models of care
THIS SET IS OFTEN IN FOLDERS WITH...
Adult Development and Aging-Chapter 5
Adult development and aging: Chapter 6
Adult Development and Aging: Chapter 8
Adult development and aging-Chapter 9-Relationships
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