 Long-term-care facilities are becoming more complex: -Complex Patients -Subacute care units involving higher l level of care, such as, ventilator care, hyperalimentation or other services that would confine a patient to the hospital

 Nurses who are frustrated with abbreviated hospital stays, fragmented care, staffing shortages may enjoy working in a long-term-care facility.  Nurses have the opportunity to get to know their patients and establish relationships with them.

 Historically, long-term-care has a negative image.  Media highlights of abuse and substandard conditions.  Reimbursement policies that limit the ability to provide high-quality care.

 Before the 20 th century institutions were used to care for the mentally ill, developmentally disabled, aged, orphaned, poor, or those suffering from a contagious disease.  Common in Europe by the end of the 17 th century.  Limited funds and low public interest led to custodial care.

 In the US acute or long-term-care was scarce until the 19 th century.  Family was expected to care for family members.

 Erving Goffman, sociologist labeled these facilities “total institutions”, he characterized them as follows:  All activities conducted in the same manner, in the same place.  All individuals treated in the same manner and required to comply with the same acticities and schedules.

 Strict, inflexable schedule of activities and schedules.  Numerous and heavy enforced rules.  Activities that furthered the aims of the institution more than serving the needs of its residents.  This approach to care led patients to institutionalized behaviors.

 By the 1900’s, public and charitable institutions began to replace almshouses.  Funding scarce, poor care.  LTC was used as a dreaded last resort.

 1935, enactment of Social Security.  Provided a means of of private funds to purchase care.  1946 Hill-Burton Act-assists with the construction of hospitals and LTC facilities.  Hilton-Burton act stimulated growth, Medicare & Medicaid was made available for reimbursement.

 number of nursing homes doubled and number of residents tripled.  Operated by business-oriented people instead of medical professionals.  Federal standards were minimal, leading to the stigma of poor conditions of LTC facilities.

 1987 Omnibus Budget Reconciliation Act, (OBRA ‘87) was developed:  This legislation was the beginning of more stringent nursing home regulations: -use of a standardized assessment tool, Minimum Data Set (MDS) - timely development of a written care plan -reduction in the use of restraints and psychotropic drugs

-increase in staffing -protection of resident’s rights -training for nursing assistants OBRA brought about the most profound changes in nursing home care ever witnessed, if standards weren’t followed Medicare and Medicaid reimbursement was terminated.

 A vision and clear model for nursing care is necessary  When nursing fails to exercise leadership, non- nurses will determine nursing practice  When nursing does not attempt to correct problems in the health care system, others will, and public perception will see nurses as part of the problem

 Nursing homes referred to as long-term- care facilities  Licensed staff must be on duty around the clock  Nursing assistants must complete a certification process  Documentation has improved  Continue to be problems

 People who are functionally dependent as a result of physical or mental impairment  Functional ability determines the need for care  Oftentimes family caregiving cannot meet the needs of the individual before long-term care becomes an option  A crisis situation triggers the need for an alternative to home care

 Increased demands and complexities of long-term care facilities necessitate that highly competent nurses be employed in this setting  Unlicensed staffing imposes a greater demand on licensed professionals  Staff education and evaluation  Performance evaluation  Clinical and administrative duties

 Admission assessments and completion of MDS tool  Identify Problems  Direct Care and planning activity  Evaluation of effectiveness of care  Independent nursing practice  Ability to develop long-term relationships

 Care for people with less complex needs  Less stringent regulations  Fewer licensed nurses available  Increasing number of beds  Private pay  Challenges for gerontological nurses