Mary Anne Johnson MD
COMMUNITY-BASED LONG-TERM CARE
ADULT DAY HEALTH CARE
Ninety percent of adult day health care (ADHC) centers are nonprofit or government programs. ADHC programs provide nursing, social service, rehabilitation, nutrition services, and transportation along with social and therapeutic activities to frail individuals living at home who might otherwise require institutional care. Through structured rehabilitation and activity programs, social support, and monitoring of health status, such programs allow elderly patients to remain at home and provide daytime respite to home caregivers. Typically, a participant attends the program several days a week.
State regulations for ADHC programs vary considerably, but the National Adult Day Services Association has set voluntary standards. Funding may come from Medicaid or other government sources (eg, Veterans Administration contracts), foundations, long-term care insurance, or participants' own resources, often on a sliding-scale basis (Table 8-1). Medicare does not pay for these services.
The Program for All Inclusive Care for the Elderly (PACE) model is centered on ADHC programs but also includes all needed health and social services. In this capitated model, Medicare and Medicaid allocations are combined for each enrollee to cover all services, including physician and hospital services. Some PACE programs also work with government agencies to provide low-income assisted-living housing for frail seniors close to or in the same building as the ADHC program.
Participants in the PACE program must be sufficiently frail to qualify for nursing home care. PACE programs use an interdisciplinary team model to manage and coordinate care across the care continuum. The hospitalization rate for PACE participants is less than half that of elderly persons with similar needs who are not enrolled in a PACE program. Such a finding supports the idea that comprehensive medical and social care programs may be more appropriate models for frail elders than traditionally funded services, which have little care coordination.
Bodenheimer T: Long-term care for frail elderly people—the On Lok model. N Engl J Med 1999;341:1324. [PMID: 10528046]
Center for Medicare and Medicaid Services: http://www.cms.hhs.gov/ pace (This web site provides information about the Program of All Inclusive Care for the Elderly, funding, and regulations.)
National Adult Day Services Association: http://www.nadsa.org (This web site provides general information, a guide to selecting an ADHC program, and a directory of programs by location.)
Assisted-living facilities (often referred to as board and care homes, foster homes, domiciliary care, residential care facilities) can be small, private homes with only a few residents or large complexes built specifically for this purpose. State regulations vary widely on what services can be provided and the types of residents who can be cared for in this setting. Some states are still in the process of developing regulations. In many facilities, residents must be ambulatory and continent, although some homes accept residents with more functional impairment or keep existing residents who become more functionally impaired, depending on state regulations.
Facility staff provide supervision and monitoring for health and safety, assistance with activities of daily living (ADLs) and instrumental ADLs (IADLs), medication administration, transportation to medical appointments, and coordination of services with outside agencies. Licensed nurses are usually not present on site, depending on services provided and state law. Home care agencies may provide on-site skilled nursing services, and residents usually go to the physician's office for medical care.
Generally, residents pay privately for assisted living, but many states provide some Medicaid reimbursement when the assisted-living setting is an alternative to nursing home care for Medicaid recipients. Because personal funds are used most often for this level of care,
there is much more market competition than for other long-term care services, and facilities are quite diverse in terms of amenities.
Table 8-1. Long-term care services & financing.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) offers accreditation for assisted-living facilities, but there are no governing federal regulations. However, assisted-living facilities are now receiving closer scrutiny by regulators. A coalition of organizations involved in assisted living has developed guidelines for assisted-living facilities that may impact any future federal regulatory process.
National Center for Assisted Living: http://www.ncal.org (This web site provides a history of the assisted-living movement, general information about programs and residents, and current topics of interest.)
CASE MANAGEMENT & CONTINUING CARE COMMUNITIES
In most states and communities, there is no single point of access for long-term care services and no coordination between the various programs. Case management or care management programs, which can be either government-sponsored or private, oversee the care of functionally impaired individuals living in the community to ensure that those individuals receive all needed medical and social services and to prevent nursing home placement whenever possible. Care or case management is most needed when elderly individuals are not connected to a strong interdisciplinary team site such as a nursing home, home care program, or ADHC center.
An array of long-term care services may be available as part of a life care or continuing care retirement community where individuals can purchase or rent an apartment while independent and then move, as needed, to higher levels of care such as assisted-living and nursing home care. Meals and social and recreational opportunities are available. Such communities generally require significant financial resources to “buy in” on the part of the applicant.
INSTITUTIONAL LONG-TERM CARE
COMMUNITY & HOSPITAL-BASED NURSING HOMES
Almost 50% of individuals reaching age 65 will spend some time in a nursing home during their lifetime. Much regulatory attention has been paid to nursing home care, and nursing homes are subject to very strict regulatory compliance, with standards set by the federal government and surveyed by state licensing agencies.
Many hospitals operate skilled nursing units within their facilities to provide ongoing care for patients recently
discharged. Hospital-based units are typically staffed at a higher nurse-patient ratio and have more licensed staff than community facilities. In these hospital-based facilities, stays are relatively short; care is focused on rehabilitation and discharge to home or a lower level of care.
The typical community nursing home is a 100-bed facility run as part of a proprietary (for profit) chain. Sixty-seven percent of facilities are proprietary, 27% are nonprofit, and 6% are government or other facilities. In community-based facilities, the population is generally very heterogeneous, requiring services ranging from restorative care and rehabilitation to hospice and long-term care.
The degree of medical complexity in nursing homes has increased dramatically because patients are being discharged from the hospital with more unresolved problems and there are other long-term care options for those with fewer care needs, creating major challenges for nursing homes.
Harrington C: Regulating nursing homes. Residential nursing facilities in the United States. BMJ 2001;323:507. [PMID: 11532849]
American Association of Retired Persons: http://www.aarp.org/confacts/health/choosingnh.html (This site contains the AARP's guide to choosing a nursing home.)
American Health Care Association: http://www.ahca.org (Web site provides general information and links to other sites.)
National Citizens' Coalition for Nursing Home Reform: http://www.nccnhr.org (This web site provides consumers with information about policies, quality of care, the ombudsman program, and advocacy groups.)
National Library of Medicine Medline Plus: http://www.medlineplus.gov/nursinghomes.html (This health information page provides links to organizations, consumer guides to nursing homes, information about nursing home regulations and inspections, alternatives to nursing homes, and research studies about nursing homes.)
Medicare will pay for nursing home care only when the patient has had a previous acute hospital admission and meets criteria for skilled care requiring treatment by a registered nurse or rehabilitation therapist (see Table 8-1). Medicare will pay for 20 days of nursing home care and part of the cost for an additional 80 days per episode of illness.
Individuals who do not qualify for Medicare payment for nursing home care because they do not have coverage, do not have a defined skilled need, or have exhausted their benefits must use personal assets for payment. Once personal assets have been spent down to a predetermined level, individuals are eligible for Medicaid nursing home benefits. This requires that many older persons become impoverished to qualify. At an average daily cost of $116, even short stays can be financially catastrophic.
States vary in their clinical eligibility criteria for Medicaid payment of nursing home care. However, in general, Medicaid covers a broader array of care needs than Medicare. Long-term care insurance is available, but many elderly people are unfamiliar with the policies or with the need for long-term care insurance, and less than 20% of the elderly can afford it.
Minimum Data Set
For each person admitted to a nursing home, the interdisciplinary team must complete a federally mandated minimum data set (MDS) based on a comprehensive resident assessment. Information in the physician's admission note and progress notes is used by other disciplines to complete the MDS. The MDS is extremely important because it leads to development of the care plan and determines Medicare reimbursement. In addition, facilities and regulatory agencies use the data to monitor quality of care.
The physician's admission evaluation should include a detailed history, with emphasis not only on recent and chronic medical conditions but also on past and present functional status, medications, immunizations, sensory impairments, pain, symptoms of depression, social support, and presence of an advance directive. The admission physical examination should be complete, with a focus on the conditions leading to nursing home admission. The examination should include, in particular, assessment of functional abilities (ADLs, IADLs), cognitive status, affect, ability to make health care decisions, condition of the skin and feet, vision and hearing deficits, orthostatic hypotension, and nutritional status. A problem list should be generated with individualized goals of care, and a medical care plan should be developed in concert with the interdisciplinary team, the resident, and the resident's family.
Medicare-Mandated Physician Visits
Medicare regulations require that the physician make monthly visits for the first 90 days of a resident's nursing home stay and then every 60 days thereafter. Depending on the state, Medicaid regulations may require more frequent, usually monthly, visits. Medicare has clearly articulated that all medically necessary visits to nursing home residents will be reimbursed. Thus, if a
resident requires daily or weekly visits, appropriate documentation by the physician of the medical need for the visit should be sufficient to ensure reimbursement.
Interim visits to the postacute nursing home resident can focus on the most acute problems and monitor progress toward discharge. In the long-term resident, interim visits could focus on a particular issue (eg, discussion of an advance directive or management of a particular chronic problem). Each visit should include a discussion with the nursing staff and review of interdisciplinary notes, laboratory studies, and consultation reports as well as a review of any new problems, progress of chronic problems, and responses to any previously initiated treatments. This should include, in particular, assessment of response to pain medication, psychoactive medications of any kind, and any medication changes. During the interim visits, relevant physical examinations should be done and appropriate health maintenance and screening activities addressed, such as vaccines and cancer screening, as appropriate for the resident.
Annual Resident Assessments
The physician should perform a comprehensive assessment of the resident at the annual MDS review, contributing to the interdisciplinary team's assessment. This yearly assessment should include a problem-oriented note with updates for history and physical examination, summaries of laboratory tests and other interventions, and responses to treatments.
The physician should also perform a comprehensive review of symptoms, especially looking for those that may go unreported, such as constipation, incontinence, insomnia, and depression. Assessments of pain, weight, and functional status should be part of the annual assessment, and evaluations should be completed and documented for any significant changes.
Health maintenance and screening activities that need to be done annually should be reassessed at this time. Based on the high risk of tuberculosis (TB) in nursing home residents, purified protein derivative testing should be done annually. The Centers for Disease Control recommends influenza vaccine for all nursing home residents annually before the influenza season and pneumococcal vaccine at least once. Routine annual laboratory studies are generally not indicated, although some nursing home physicians recommend annual hematocrit, electrolytes, renal function studies, thyroid function studies, and urinalysis.
At the annual review, it is also important for the physician to review and update the goals of care, advance directives, and the interdisciplinary care plan. Ideally, the physician should attend interdisciplinary team care planning conferences, which are held within 14 days of admission, quarterly, and annually.
Federal regulations require the nursing home to notify the resident's physician of any significant injury or change in condition. Some facilities and physician groups have developed guidelines for when to call the physician, based on a common understanding of how quickly a resident with particular signs or symptoms needs to be evaluated. However, nursing judgment about the need to call should always supersede any written guidelines.
Most physicians who care for nursing home residents are unable to respond personally to calls regarding a change in a resident's condition. Thus, many nursing home problems are handled over the telephone, and in many instances nursing home residents are transferred to an emergency room for evaluation. These practices often result in administration of inappropriate medications such as antibiotics, unnecessary transfers to emergency rooms, and failure to follow a resident's advance directives. Implementation of a nurse practitioner/physician team approach has been demonstrated to improve care and reduce emergency room visits and hospitalizations for nursing home residents; in this model, the nurse practitioner responds to calls and performs on-site evaluations.
If a resident is transferred to an emergency room, it is essential for the physician to communicate directly with the emergency room physician to ensure continuity of care and respect for the resident's wishes and advance directives. In addition, the transfer of medical information from nursing home to hospital and from hospital to nursing home must be complete to maintain continuity of care and provide optimal care in both settings.
Mehr DR et al: Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI study. JAMA 2001;286:2427. [PMID: 11712938]
Center for Aging Practices at University of Medicine and Dentistry of New Jersey: http://www.umdnj.edu/nhweb (This is a web-based course for health professionals regarding nursing home regulations, quality indicators, and funding.)
SPECIFIC CLINICAL ISSUES
Falls & Restraint Use
When a resident falls, a medical evaluation may identify a cause such as orthostatic hypotension, medication side effect, loss of functional status, or sensory deficits. Environmental or situational causes can often be ameliorated by providing residents with appropriate foot wear, modifying floor coverings, improving access to a toilet or commode, and improving staff supervision of the resident.
In the past, restraints were used very frequently in nursing homes and were prescribed primarily to prevent falls. However, restraints can cause serious injuries and death, facilitate deconditioning, increase residents' dependence on others, and increase agitation. In addition, because residents are not mobile in restraints, there is an increased risk of pneumonia, constipation, incontinence, and pressure ulcers.
Probably one of the most important consequences of restraint use is loss of resident dignity. Restraints also demoralize staff; facilities that have reduced or eliminated restraints have experienced a significant decrease in staff turnover. Regulatory agencies carefully monitor the use of restraints in nursing homes. Regulations require documentation of need for restraints, use of nonrestraint alternatives as a first step, careful monitoring of residents during restraint use, and attempts to reduce restraint use. Physicians' responsibilities regarding restraint use include ensuring that medical causes for falls have been evaluated and eliminated, that symptoms leading to agitation have been evaluated and treated (eg, pain), and that a care plan has been developed to address the condition for which restraints are being considered or used.
In many instances, administrative policies and family requests actually promote the use of restraints; therefore, it is essential that the nursing home administration and staff, as well as residents and families, are educated in the use of, and risks associated with, restraints. This education should include the fact that all falls are not preventable.
Because not all falls are preventable and they may increase with restraint reduction, the physician should ensure that efforts are instituted to decrease injuries should falls occur. These measures may include calcium and vitamin D supplementation, exercise programs, and use of hip pads.
Neufeld RR et al: Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc 1999; 47:1202. [PMID: 10522953]
Ooi WL et al: The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 2000; 108:106.
Ray WA et al: Benzodiazepines and the risk of falls in nursing home residents. J Am Geriatr Soc 2000;48:682. [PMID: 11126303]
Schoenfelder DP: A fall prevention program for elderly individuals. Exercise in long-term care settings. J Gerontol Nurs 2001; 26:43. [PMID: 11111630]
The physician must work with the nursing staff in evaluating possible causes of incontinence and in developing a plan to reduce incontinence or manage it in a way that is appropriate for the individual patient. Catheters should never be used to manage incontinence except if needed in the short term for wound healing. Prompted voiding and timed toileting have been successful in reducing incontinence episodes.
Weight loss is common in nursing home residents and is a predictor of mortality. Weight loss can be related to medical conditions, including swallowing difficulties, medications, pain, dental problems, functional impairment, depression, or chronic medical conditions. In addition, restricted and unpalatable diets are often prescribed for nursing home residents and may contribute to decreased intake. If a reversible cause of weight loss is not found, the physician can educate the resident, if possible, and the family, and jointly assess whether tube feeding is medically appropriate and consistent with the resident's desires and goals of care. Many interventions have been shown to forestall or eliminate the need for tube feeding, even in very demented patients, such as offering favorite foods, changing food consistency, and ensuring that adequate staff is available to assist the resident with eating.
Dehydration in cognitively and physically impaired nursing home residents occurs frequently. Although acute medical illnesses and the use of diuretics may contribute to dehydration, adequate fluid provision by staff will prevent most cases of dehydration.
The Council on Nutritional Clinical Strategies in Long-Term Care has published a useful interdisciplinary clinical guideline for nutritional management in long-term care based on the literature and consensus.
Gessert CE et al: Tube feeding in nursing home residents with severe and irreversible cognitive impairment. J Am Geriatr Soc 2000;48:1593. [PMID: 1129748]
Kayser-Jones J et al: Factors contributing to dehydration in nursing homes: Inadequate staffing and lack of professional supervision. J Am Geriatr Soc 1999;47:1187. [PMID: 10522951]
Thomas DR et al: Nutritional management in long-term care: Development of a clinical guideline. J Gerontol A Biol Sci Med Sci 2000;55A:M725. [PMID: 11129394]
Pressure ulcers occur among patients in all institutional settings. Generally, the rate of pressure ulcer development in nursing homes is a good indicator of overall quality of care. However, pressure ulcers may be present in a high percentage of residents in facilities that care for many patients at the end of life and in those that provide postacute care. Physicians should assess nursing home residents for pressure ulcers and pressure ulcer risk at admission and examine the resident frequently. If a resident develops a pressure ulcer, the
physician should complete a full medical assessment, request a nutritional assessment, and consult with appropriate staff to develop a plan for healing.
Berlowitz DR et al: Are we improving the quality of nursing home care: The case of pressure ulcers. J Am Geriatr Soc 2000; 48:59.
Infections are common as a result of chronic medical conditions, age-related organ deficits, age-related decline in immune function, use of procedures and invasive devices, and congregate living. The most common infections are pneumonia, urinary tract infections, gastroenteritis, and skin and soft tissue infections.
Any change in a resident's condition, particularly one who is unable to articulate symptoms, should prompt a careful evaluation for infection. The physician can work to prevent infections by ensuring that nursing home residents receive an influenza vaccine annually, a pneumococcal vaccine once, TB screening on admission and annually, and appropriate treatment of latent TB. Indwelling catheters increase the risk of urinary tract infections; thus, efforts should be made to avoid these unless absolutely essential (eg, for wound healing). The presence of pressure ulcers increases the risk of skin and soft tissue infection; efforts to prevent pressure ulcers should reduce infection rate. All nursing home staff and physicians should use good infection control practices.
Inappropriate antibiotic use in nursing homes is common and has led to an increase in antibiotic resistance. For example, Clostridium difficile is a major problem in many nursing homes, and antibiotic-resistant staphylococci and enterococci are being seen more frequently. Physicians can reduce inappropriate antibiotic use by carefully assessing the need for antibiotics in febrile nursing home residents and, when needed, using the narrowest spectrum antibiotic for the shortest period of time.
Bentley DW et al: Practice guidelines for evaluation of fever in long-term care facilities. Clin Infect Dis 2000;31:148. [PMID: 11017809]
Loeb M et al: Development of minimum criteria for the initiation of antibiotics in residents of long-term care facilities: Results of a consensus conference. Infect Control Hosp Epidemiol 2001;22:120. [PMID: 11232875]
Nicolle LE et al: Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 2000;21:537. [PMID: 10968734]
Adverse Drug Reactions
Adverse drug reactions are common among nursing home residents and are more likely to occur with increasing numbers of comorbid conditions; with increasing numbers of medications; in newly admitted residents; and with use of opioids, antidepressants, antipsychotic medications, and antibiotics. Many of these adverse drug reactions are potentially preventable, and physician vigilance is required.
Field TS et al: Risk factors for adverse drug events among nursing home residents. Arch Intern Med 2001;161:1629. [PMID: 11434795]
Behavioral problems (eg, aggression, agitation, inappropriate sexual behavior, wandering, persistent calling out) are very common, especially among cognitively impaired residents. Medical causes include hypoglycemia, hypoxia, medication side effect, infection, pain, sleep deprivation, and depression.
Management of behavioral problems for which there is no reversible cause is often difficult. Involvement of mental health professionals and trained nursing staff may be helpful.
Physicians who work in nursing homes should be familiar with the regulations governing the use of psychoactive medication for behavior management. These regulations require that the use of psychoactive medications be supported by excellent documentation of the clinical need. Antipsychotic medication use, in particular, is carefully reviewed by state licensing agencies, and requirements call for a tapering off of these medications when they are not being used for a primary psychiatric problem. Observational studies indicate that psychoactive medication use decreased after implementation of the federal regulations regarding use of these medications (part of OBRA 87). However, it is not clear that resident outcomes are improved.
Hughes CM et al: The impact of legislation on psychotropic drug use in nursing homes: A cross-national perspective. J Am Geriatr Soc 2000;48:931. [PMID: 10968297]
Ruby CM, Kennedy DH: Psychopharmacologic medication use in nursing home care. Indicators for survey assessment of the drug regimen reviews, recommendations for monitoring, and non-pharmacologic alternatives. Clin Fam Pract 2001;3:577.
One in 5 deaths in the United States occurs in the nursing home, making end-of-life care an important priority in resident care. If the resident's goals of care are clearly documented in an advance directive, it will be easier for the physician and the team to make the transition from aggressive intervention to palliative care. The focus of palliative care in the nursing home is on symptom management, family support, bereavement counseling, and management of the physical, psychological,
and spiritual needs of the resident. Attention is paid particularly to pain but also to dyspnea, constipation, anxiety, agitation, fear, and loneliness. Pain assessment may be difficult in the cognitively impaired resident, but guidelines have been published to help in this assessment. Residents who are dying require intensive medical, psychosocial, and spiritual interventions.
Community hospice organizations may offer services within nursing homes, and some nursing homes have developed their own hospice programs. In nursing homes where there is a specific hospice or palliative care presence, end-of-life hospitalizations are decreased.
Baer WM, Hanson LC: Families' perception of the added value of hospice in the nursing home. J Am Geriatr Soc 2000;48:879. [PMID: 10968290]
Gillick M et al: A patient-centered approach to advance medical planning in the nursing home. J Am Geriatr Soc 2001; 47:227. [PMID: 9988295]
Hanson LC: Care of the dying in long-term care settings. Clin Geriatr Med 2000;16:225. [PMID: 10783426]
Levin JR et al: Life-sustaining treatment decisions for nursing home residents: Who discusses, who decides and what is decided? J Am Geriatr Soc 1999;47:82. [PMID: 9920234]
Miller SC et al: Hospice enrollment and hospitalization of dying nursing home residents. Am J Med 2001;111;38. [PMID: 11448659]
Molloy DW et al: Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA 2000;283:1437. [PMID: 10732933]
Stein W: Pain management in the elderly. Pain in the nursing home. Clin Geriatr Med 2001;17:575. [PMID: 11459722]