There Is No Place Like Home THE FOUNTAINVIEW CENTER FOR ALZHEIMER’S DISEASE There Is No Place Like Home Speaker’s Notes: None Tedd Watts, RN, LNHA, CDP Executive Director

Educational Objectives: Become familiar with Nursing Homes Understand who are candidates for Nursing Homes Define the services provided. Identify some important issues at Nursing Homes Speaker’s notes: none

Provide a “home like” Environment As we go through my presentation today and in keeping with the theme of today’s seminar – “There is no place like home” - I want you to keep this image and thought in your mind “Provide a ‘home like’ environment”.

The Stats! Approximately 1.4 million Americans (~4.1%)>65 have spent time in a skilled nursing facility – 2012 National Nursing Home Survey Harris-Kojetin, L., et al. (2013). Vital Health Stat, 3(37). Expected to be 3 million in 2030 if continues at this rate. ~42% of those 95 and older live in nursing homes. 51% of nursing home residents require assistance with all ADLs Speaker’s notes: With the aging population, Nursing homes become increasingly important

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 Speaker’s notes: What is a skilled nursing facility? Who is the interdisciplinary team at the SNF? We’ll talk more about the requirements for skilled stays in a nursing home in a couple of slides.

Skilled Nursing Facilities (Nursing Homes) A licensed physician supervises each patient’s care and a nurse or other medical professional are 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 Speaker’s notes: None

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. Speaker’s notes: What are the skilled services that are provided?

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 Speaker’s notes: 1. These are examples of Basic activities of daily living (ADLs)

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 Speaker’s notes: Examples of patients that may need a short stay in a Skilled Nursing Facility include patients following surgery or a prolonged hospital stay. Also suitable for those who can no longer care for themselves.

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 Speaker’s notes: Some additional services that may be seen in skilled nursing facilities

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) 1st 20 days, Medicare covers full cost Between Day 21 and 100 there is a copay (Currently $164.50/day) After Day 100, Medicare covers nothing. Speaker’s notes: How is nursing home care paid for. In order to qualify a patient must also demonstrate a daily need for skilled care, and progress with skilled therapies.

Nursing Home Costs Medigap may cover deductibles/other charges Medicaid for Custodial care, Long Term Care Insurance Speaker’s notes: Long term patients may have their costs of care covered by Medicaid, or long term care insurance policies. If not the patient will have to bear the costs.

Nursing Home Costs 2016: Genworth Market Survey of Nursing Home and Home Care costs, $257/day, or $92,378 a year – Private room Shared room $228/day, or $82,125 a year. Costs can vary with location – Alaska, highest rates for private room $297,840/yr, or $816/day Louisiana, lowest rates for private room $61,663/yr, or $169/day Speaker’s notes: 1. Nursing homes can be very expensive.

What’s the Alternative? Assisted Living facility Subsidized senior housing Board and care homes (personal care homes) Continuing care retirement communities Program of All-Inclusive Care for the Elderly and the Social Managed Care Plan Speaker’s notes: Other places patients who need extra care may be able to find it. This also includes living at home with hired in home assistance.

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 11.7% of nursing home residents die within one year of admission Estimated by 2020, 30% of all deaths will occur in nursing homes. Tanuseputro, P., 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 Speaker’s notes: Communication barriers can be a problem in transitions of care. Important to be able to communicate the nursing home course of care to the hospital or outpatient MD, and vice versa.

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? Speaker’s notes: Behavior problems can be the trigger for placement into a skilled nursing facility. Use medicines cautiously.

Oversight & Regulations State Licensing Laws State licensing laws govern the licensing of nursing homes required for their local operation. Historically, licensing of healthcare facilities, including nursing homes, has been a state prerogative and matter of state law.

Oversight & Regulations Medicare/Medicaid Certification laws Federal Medicare/Medicaid certification laws govern the certification of nursing homes required for participation in the Medicare program, Medicaid program, or both. In 2015, Medicaid, which pays for long-term care in Medicaid-certified facilities, accounted for about 44% of national nursing home expenditures. In 2015, Medicare, which pays for skilled nursing care for a limited time, accounted for about 20% of such expenditures. An estimated 95% of all nursing homes participate in Medicare, Medicaid, or both.

Oversight & Regulations 1987 Congress enacted legislation requiring all nursing home participating in Medicare and/or Medicaid programs to comply with certain quality of care rules. This was in response to widespread reports of neglect and abuse in nursing homes prior to 1987 There are 372 specific regulations listed in the Requirements of Participation (RoP) Nursing Homes are the 2nd highest regulated industry; 2nd only to nuclear power plants Some of these regulations include: Sufficient staffing levels Completion of comprehensive assessments Development of care plans Resident Rights Quality of life requirements Abuse & Neglect prevention

Oversight & Regulations Nursing Homes inspections are: Unannounced As a standard last between 4-5 consecutive days 10% of all inspections must start outside of normal business hours , or on a holiday. Happen between 9 – 15 months from the last incpection Exception, complaint surveys

Today’s Nursing Homes were Yesterday’s Step Down Units Provide a home like environment with Increased level of care expectations Increased regulations Decreased reimbursement Increased consumer demands When I think of home I think of comfort, family and love. Sometimes in our industry we can not provide the material things that might remind of one of “home”. While there is truly is no place like home, we strive daily to ensure that our residents live in an environment that is as comfortable as possible. That those who live with us, and those that rely on us to provide care to their loved ones, become like family to us. Regardless of all of the things that we have talked about today, the one thing we do daily to make our settings as “home-like” as possible is to love on those that are entrusted to our care.

Pros & Cons Pros Cons Full-time Care Structured schedules Active social life Specialized medical care Respite for caregivers Cons Cost Nursing Home horror stories Subjectivity of care standards Increased burden of care without increased resources

Thank you! Questions? Speaker’s notes: None