Skilled Nursing Facilities Nursing Home Steven Tam MD

Skilled Nursing Facilities (Nursing Home) Steven Tam, MD Assistant Clinical Professor UCI Internal Medicine/Geriatrics

Educational Objectives: • Become familiar with Nursing Homes and other facilities • Understand who are candidates for Nursing Homes and other facilities • Define the services provided. • Identify important issues at Nursing Homes

The Stats! • Approximately 1. 5 million Americans (~4. 2%)>65 have spent time in a skilled nursing facility – 2004 National Nursing Home Survey » Jones AL, et al. 2009 Vital Health Stat 167: 1 -155. • Expected to be 3 million in 2030 if continues at this rate. • ~50% of those 95 and older live in nursing homes. • 51% of nursing home residents require assistance with all ADLs

Skilled Nursing Facilities (Nursing Homes) • Skilled Nursing Facility: part of a Nursing Home or Hospital that provides skilled nursing care. • Registered Nurses who provide skilled nursing care to people, along with interdisciplinary staff/team – – Licensed practical and vocational nurses Physical Therapy, Occupation Therapy Speech Therapy Social Worker/Case Manager • Skilled care usually a short period – Custodial Care may be required for longer period

Skilled Nursing Facilities (Nursing Homes) • A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises. • >80% of nursing homes use community physicians to provide care • Average family physician supervises 9. 6 nursing home residents and conducts 2. 3 nursing home visits per week » 2008 AAFP survey

Skilled Medical Care • Skilled Services: • RN doing wound care or administering and monitoring IV antibiotics • A physical therapist working to improve strength and balance in a patient with difficulty walking • A speech therapist helping a patient speak and swallow after a stroke. • An occupational therapist helping a patient relearn dressing, grooming and eating. • Skilled care may also involve managing injections, ostomy management and tracheotomy care amongst other needs.

Custodial Care • Need assistance with ADLS – Bathing – Dressing – Eating – Grooming – Getting in and out of bed, or walking around – Toileting (incontinence care) • Often provided at a Nursing Home • May also be temporary

Who May Need a Nursing Home? • Skilled Nursing facility is for Patients who: – Require a short stay for skilled services prior to returning to previous residence – Can no longer care for their own personal needs, such as feeding, bathing, toileting (custodial care) because of medical, physical, behavioral problems – Need more care than can be provided at home – Has extensive medical needs requiring daily attention, or monitoring

Who May Need a Nursing Home? • Special Needs in Skilled Nursing Facility – – Dialysis, Dementia care, Respiratory Care, Parkinson’s Care – Hospice care, Chronic Psychiatric Care

Nursing Home Costs • Medicare coverage for skilled care: – Medicare Part A (Hospital Insurance) – Qualifying 3 day hospital stay 30 days prior to Nursing home admission – 100 day benefit period (renewable if not hospitalized, or in SNF for 60 consecutive days) – 1 st 20 days, Medicare covers full cost • Between Day 21 and 100 there is a copay • After Day 100, Medicare covers nothing.

Nursing Home Costs • Medigap may cover deductibles/other charges • Medicaid for Custodial care, Long Term Care Insurance

Nursing Home Costs • 2004: Met. Life Market Survey of Nursing Home and Home Care costs, $192/day, or $70, 080 a year – Private room • Shared room $169/day, or $61, 685 a year. • Costs can vary with location – – Alaska, highest rates for private room $204, 765/yr, or $561/day – Shreveport, Louisiana, lowest $36, 135/yr, or $99/day

What’s the Alternative? • • • Assisted Living facility Subsidized senior housing Board and care homes Continuing care retirement communities Program of All-Inclusive Care for the Elderly and the Social Managed Care Plan

What’s the alternative? ALF • In 2002, ~1 million people lived in assisted living. » Mc. Cormick JC, et al. 2003 Health Care Finance Rev 24: 143 -150 • Transition period? • Offers help with ADLS, but none or limited medical care. • >80% require help with ADLS • 40% describe their health as poor

What’s the Alternative? ALF • Greater emphasis on personal privacy and autonomy. • No onsite RN • ALF provide only personal assistance that can be performed by someone with little or no medical training. – Patient’s may visit MD if onsite clinic available, at MD office, or if there is a Housecall MD.

What’s the Alternative? Continuing Care Retirement Communities • Continuing Care Retirement Communities: provides independent living, housing-withservices, and Nursing home care in one location • Enables seniors to remain in a familiar setting as they grow older • Many enter while they are healthy and active, knowing they will be able to stay in the same community • May be able to move within the different levels of care.

Important Issues in Skilled Nursing Facilities • Transitions of Care – To and From Acute Care settings – To Home and or other Long Term Care options • End of Life Care – ~1/3 rd of nursing home residents die within one year of admission – Estimated by 2020, 40% of all deaths will occur in nursing homes. » Oliver DP, et al. 2004 J Am Med Dir Assoc 5(3): 147 -155 – End of life care similar to that in the community setting, and hospice and palliative care can be provided in the skilled nursing facility

Important Issues in Skilled Nursing Facilities • Infections – Similar nosocomial infection rates to acute care hospitals? – MRSA 10 -30% prevalent in nursing homes. » Pacio GA, et al. 2003 Infect Control Hosp Epid 24(4): 246250 – C. Difficile Colitis – Scabies – Influenza, Tuberculosis – Infection control programs

Important Issues in Skilled Nursing Facilities • Abuse and Neglect – Surveys of nursing home residents suggest abuse, neglect common? • Frailty – Fatigue – Inactivity – Slowness – Weakness – Weight loss

Important Issues in Skilled Nursing Facilities • Nutrition and weight loss – Various strategies • • Liberating diet Frequent meals Supplements between meals Resistance strength training Family presence and socialization Assess feeding disability and need for assistance Appetite stimulants? – Artificial Nutrition (maybe a limited role).

Important Issues in Skilled Nursing Facilities • Pain Management – Est. 45 -80% of nursing home residents with chronic pain » Unwin BK, et al. 2010 American Family Physician 81(10): 1229 -1237 • Pressure Ulcers: can be common in Nursing homes – management principles usually similar to the community.

Important Issues in Skilled Nursing Facilities • Urine Incontinence and Retention – ~55% of nursing home residents » Unwin BK, et al. 2010 American Family Physician 81(10): 12291237 • Treatment strategies (evaluation, review meds, toileting programs, pharmacologic therapy) • Catheters: must require a valid reason!

Important Issues in Skilled Nursing Facilities • Falls – 20% of deaths from falls are amongst nursing home residents. » www. cdc. gov/ncipc/factsheets/nursing. htm – Causes maybe multifactorial • Restraints – Careful and thorough review, used only when no safer alternative. • Adverse Drug Events – Common in nursing homes; 40 -50% considered preventable. » Gurwitz JH, et al. 2000 Am J Med 109(2): 87 -94

Important Issues in Skilled Nursing Facilities • Dementia – ~67 -78% of nursing home residents – Behaviors can be a serious problem • Nonpharmacologic treatment (identify triggers, activities, environment modification, staff and family education). • Pharmacologic treatment: higher risk of morbidity/mortality?

Important Issues in Skilled Nursing Facilities • Delirium: up to 60% of nursing home residents • Depression: estimated that 12 -16 percent of older adults in nursing homes have major depression » Unwin BK, et al. 2010 American Family Physician 81(10): 12291237

Conclusions • A Nursing Home is a facility where an interdisciplinary team provides care for the patient – Including nursing services, physical and occupational therapy • There alternatives to the Nursing Home. • Those requiring a Nursing Home may do so for a variety of reasons