long-term health care

Definition: A set of health, personal care & social services delivered over a sustained period of time to persons who have lost or never acquired some degree of functional capacity. Sites of care: 1) acute hospital 2) nursing home 3) home 4) assisted living Funding: 1) Medicare 2) Medicaid 3) Private 4) new models Out of pocket expenditures 1) nursing homes 42% 2) hospitalization 6% 2) physicians 21% Private Insurance 1) Medigap 2) HMOs New models 1) Medicare & Medicaid combined (PACE) 2) special HMO 3) Veterans Health System 4) other capitated models Goals of nursing home care (see nursing home) Unique factors in clinical long-term-care 1) different goals for care 2) prevalence of specific conditions 3) different approaches to care a) prevention/health maintenance b) emphasis on function c) interdisciplinary 4) limited data 5) complicated decision making 6) administrative policies & procedures 7) logistical & resource constraints 8) legal liability Evidence on quality: 1) pressure ulcers 2) chronic bladder catheters 3) physical restraints 4) psychotropic medications 5) polypharmacy 6) continence management 7) nutrition/hydration 8) depression 9) falls 10) pain management/palliative care 11) infections 12) use & documentation of advance directives 13) emergency room visits 14) acute hospitalizations Evolving changes: 1) funding 2) regulation 3) legal liability 4) sociodemographic 5) growth of subacute care 6) growth of assited living Changes in funding: 1) prospective payment for postacute ('subacute') care 2) in nursing home system, based on MDS/RUGS 3) capitated care programs Regulation: 1) OBRA 1987 a) resident autonomy b) highest practical level of function c) quality of care standards 2) OBRA & quality of care a) medical necessity/unavoidability b) physical & chemical restraints c) resident assessment d) MDS -> triggers -> RAPS -> care plan Legal liability: 1) increasing number of lawsuits against facilities & physicians 2) bad outcome vs substandard or negligent care Sociodemographic changes 1) number of frail, very old people 2) availability of family caregiver 3) expectations of older people & their families Growth of subacute care: 1) sicker patient population a) nursing care needs b) medically complex c) rehabilitation potential 2) rapid turnover 3) requires a) adequate reimbursement b) skilled nurses c) availability of high-quality medical care & ancillary services (laboratory, pharmacy etc) d) change in mindset Growth of assisted living: 1) national study 1999 a) 11,459 facilities, average size 53 beds b) 611,300 total beds c) 521,500 residents 2) unregulated care of very frail older people 3) lack of health professional oversight Strategies: 1) regulation 2) legal actions 3) reimbursement 4) integrated care systems 5) nursing care 6) medical care 7) quality standards 8) quality improvement programs 9) technology 10) research 11) translating research into practice Regulation: 1) standards for staffing 2) make the survey process outcomes based & educational NOT as adversarial & punitive 3) avoid further unfunded mandates Legal actions: 1) selected cases 2) involvement of experts Reimbursement: 1) adequate staffing a) nursing b) physicians, nurse practitioners, physician assistants c) rehabilitation therapists d) ancillary services 2) enlightened capitation a) risk adjustment (e.g. RUGS) b) adequate payments, assuming efficient care c) outcome monitoring based on quality indicators d) appropriate incentives Integrated care systems: 1) components a) community-based programs b) institutional care c) acute hospital d) provider network 2) shared vision, goals & financial incentives 3) care standards 4) information systems Nursing: 1) education 2) salary 3) professional opportunities 4) practice standards - critical pathways Medical care: 1) education 2) reimbursement 3) professional respect (e.g. AMDA, AGS, other organization) 4) clinical practice guidelines 5) interdisciplinary communication 6) medical director role 7) preventive/health maintenance strategies 8) documentation 9) geropsychiatrists. geropsychologists 10) NPs/PAs 11) propective decision making Preventive/Health maintenance protocols 1) primary prevention a) influenza b) pressure sores c) deconditioning d) malnutrition, dehydration e) falls 2) infection control a) nosocomial & endemic infections b) catheter care 3) monitoring a) diabetes b) congestive heart failure c) drug therapy Nurse practitioners/physician assistants 1) liason between medical & nursing staff 2) communication with families 3) implement preventive strategies 4) assessment & management of acute & subacute illnesses Prospective decision making 1) advance directives 2) policies & procedures 3) communication 4) documentation Quality standards 1) MDS-based quality indicators 2) ACOVE project 3) resident/family satisfaction Technology: 1) information systems 2) internet 3) robotics 4) monitoring devices Research: 1) types a) basic b) translational c) clinical intervention d) health services 2) challenges a) fear b) costs to facilities c) subject recruitment/consent d) subject attrition e) need for multi-site studies f) human subject concerns Translating research into practice 1) feasible interventions a) practicality b) cost 2) staff training & buy in 3) targeting 4) CQI programs 5) resident/family satisfaction 6) survey process 7) reimbursement for effective interventions

References

Ouslander, JG: In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001