1. Care Options for the Aging Population Carey H. Peerman MBA, BSN-RN, LNHA, FACHE

2. Noticing a loved one needs extra help ► Memory loss ► Multiple ER visits (falls) ► Physician observes change ► Change in routine (meds, meals) ► Change in living conditions (yard, store, bills/ money) ► A major health event ► There is a change requiring outside help from family, friends or other. ► Weight loss/ gain ► Memory changes ► Neighbors start calling

3. Noticing a loved one needs extra help ► Most changes are gradual ► The family member may realize their deficit and come up with a plan to cover the noticed loss ► Exception- is major health event ► Family may feel lost/ confused- role reversal- other obligations ► Parent might be resistant to help

4. What are IADL’s ► IADL= Instrumental activities of daily living ► Are more complex skills then those needed for personal self-care. ► Finances, meal preparation, shopping, traveling/ transportation, housework, using the telephone, taking medications. ► First things typically to show decline.

5. What are ADL’s? ► ADL= Activities of Daily Living ► Are a measure of what the person was able to do regarding self care needs ► Mobility- bed, transfer, devices ► Dressing- buttons, zippers, clothes order ► Eating- oral, tube, etc ► Toileting- toilet, bedpan, urinal, cleansing, briefs, ostomy or catheter care ► Personal Hygiene- hair, teeth, bathing, hearing devices

6. How are ADL’s graded? ► Independent ► Supervision ► Physical help limited ► Physical help partial assist ► Total dependence

7. Levels of care ► Independent living ► Assisted Living ► Intensive Assisted Living ► Alzheimer’s Unit Assisted living ► Skilled care ► Nursing home care ► Alzheimer’s Unit Nursing Home ► Community Based care- Adult day care

8. Independent Living options ► Continuing care community- buy in- CCRC ► Apartment housing- (financial, social) ► Community/ Retirement Apartments ► Stay at home with assistance (very costly) ► Green House model of care- Harrisonburg ► AOA support- meals on wheels, medication management devices, bathing and general housekeeping services.

9. When is more help required? ► A further decline in IADL’s or ADL’s- dependence on others to make it day to day ► Another health event or more help managing an existing health problem (diabetic) ► More concern from family, friends, neighbors ► Nurse or Physician may mention the need for more help (assisted living)

10. Home Health ► Can offer PT, OT, ST, RT ► Bathing/ personal care aides- several times a week- not a 24/7 service ► Housekeeping/ meal prep ► Is a Medicare benefit and ordered by the physician ► Private duty sitters/ aides- private money/ some LTC insurance will cover

11. How is level of care determined? ► IADL needs ► ADL needs ► Cognition ► Finances ► Physician recommendation ► Family reports ► Center for Healthy Aging ► Community Resources ► Support systems

12. Independent Living to Assisted Living ► Physician recommended- H&P, UAI (Uniform Assessment Instrument), admissions paperwork. ► Resident will have increased needs for IADL support services and at least 1 ADL

13. What does an AL offer? ► Varies greatly among facilities ► Packages or a la carte ► Meals, housekeeping, laundry, maintenance ► Medication management, assistance with bathing at least 2x a week ► Transportation to MD appointments ► Activities ► Emergency call lights ► Facilities are staffed 24/7 ► Apartment atmosphere ► Additional services optional

14. Are AL’s medical or social models of care? ► Use to be strictly social then due to shift in the healthcare environment become more medically focused. ► Do not have a medical director (varies) ► Do not have Pharmacy services (varies) ► Have Med Tech’s, CNA’s, LPN’s and some RN’s. Offer Rehab services on site. ► Home health and hospice services optional

15. What is Intensive Assisted Living? ► Resident will have greater care needs: toileting, help transferring ► Same care needs are AL just more: changing clothes, bed linens ► Diabetes management ► Specialty food prep- mech soft, puree ► Cost more- could be substitute for Nursing home placement

16. What is an AL Alzheimer’s unit? ► Offer AL services with ADL’s ► Locked units are with specialized trained staff and activities ► Wander, on the move, confused ► At this point do not require 24 hour nursing care but do need 24 hours supervision ► Very individualized how a person moves thru this disease process ► Physician must certify that resident is in need of this specialty unit ► Staff trained to deal with disease process

17. Assisted Living Regulations ► Have changed to require additional training for Administrator’s and Med Tech’s – now register with the state ► Required to have a plan of care and show they are able to meet the resident’s care needs ► Staffing: Administrator, nursing, dietary, activities, maintenance. (social worker) ► Inspections multiple times a year

18. Why is it hard to find AL placement? ► Most are private pay- month to month lease with 30 day notice. Apartment like. ► Medicaid (Auxiliary Grant) beds are limited b/c money doesn’t cover cost of care ► Facility left with what AG resident can pay after medication expenses ► Medications are paid for by the resident or Med D plan ► Seeing an increased need in care ► People trying to stay home

19. What does Ambulatory vs non- ambulatory mean? ► Facilities can be licensed as either ► Really related to Fire Code & Safety ► “Ambulatory”- means able to walk without assistance and could exit the building own their own in case of a fire. ► “Non- Ambulatory”- means wheelchair bound and would need assistance to exit. Can also apply to cognition.

20. When is it time for Nursing home placement? ► Residents health has declined to point that majority of ADL’s and needs 24 hour nursing supervision. ► Toileting, transferring, tub feeding, can’t get to meals, lack of resources to remain in AL ► Physician must recommend NH placement ► Nursing Homes now have the sickest of the sick. Totally dependant.

21. What is ICF? ► ICF= Intermediate care facility= long term care= nursing home placement ► Must physically or mentally need 24 hour care ► Must not be able to live in another lower level of care ► Physician recommended

22. What is the difference between ICF and Skilled care? ► Skilled care= therapy services= rehabilitation services ► Can be due to acute illness, surgery ► Will get PT, OT and/ or ST services after being in hospital for at least 3 days or 72 hours- Medicare rule (going away) ► Physician must recommend

23. What are therapy services ► PT= Physical therapy ► OT= Occupational therapy ► ST= Speech therapy ► RT= Respiratory therapy

24. How does admission work to a NH? ► Hospital referral ► AL referral ► Home referral ► All physician recommended ► Must have ADL needs that require level of care services

25. What is a NH Alzheimer’s unit? ► Residents have higher care needs then AL Alzheimer units ► Have progressed further in the Alzheimer’s process ► Special training/ staffing ► Special activities programming ► Locked area with wander guard system ► Really a transitional unit until last stages of disease process occur ► Becoming less popular due to over debility

26. Hospice services ► Additional care and support at end of life ► Can be offered at any level of care ► Physician recommended ► Medicare benefit ► Cover medication related to terminal illness ► PASS illegal in VA ► Make patient comfortable

27. PACE Programs ► Offers support in the homes, and adult day care opportunities ► Becomes the care provider and is an enrollment plan ► Manage their patients for best outcomes

28. What is the future of Long term care? ► Shifts in healthcare/ computers/ PODS ► Community Resources ► Decrease funding ► Increased demand with Baby Boomers coming ► Complex healthcare needs ► Acuity of residents ► Increased age/ Life span

29. ► QUESTIONS???????