1. Chapter 34 Long-Term Care

2. Introduction
Long-term care (LTC) facilities are becoming more complex and dynamic
Medically complex population
Subacute care units
Consumers more informed of standards of care
Nurses have the ability to establish long-term (LT) relationships with their patients and practice healing arts

3. Development of Long-Term Institutional Care
History of a negative image overshadows positive aspects of care
Media highlights of abuse and substandard conditions
Small minority of facilities
Reimbursement policies that limit the ability to provide high-quality care

4. Development of Long-Term Institutional Care (cont.)
Before the 20th century
Europe at the end of the 17th century
The United States
Cared for at home (family or paid)
Almshouses
Limited resources; basic care at best
Able residents expected to work at the institution

5. Development of Long-Term Institutional Care (cont.)
Minimal patient autonomy
Characteristics of “total institutions” (sociologist Erving Goffman, 1961)
This approach to care cast residents as inmates rather than as unique individuals
Isolation from mainstream society
Residents developed abnormal behaviors

6. Development of Long-Term Institutional Care (cont.)
During the 20th century
Care in the early 1900s
1935: Social Security enacted
1946: Hill-Burton Hospital Survey and Construction Act
1960s: Effect of Medicare and Medicaid
1987: Omnibus Budget Reconciliation Act (OBRA)
Nursing home regulations developed

7. Question
Which of the following government initiatives had the first impact on promoting the growth of nursing homes?
Social Security
Hill-Burton Act
Medicare and Medicaid
Private insurance availability

8. Answer B. Hill-Burton Act
Rationale: In 1946, the government contributed to nursing home growth by granting funds to help construct long-term care facilities through the Hill- Burton Hospital Survey and Construction Act.

9. Lessons to Be Learned from History
A vision and clear model for LTC is necessary.
When nursing fails to exercise leadership, nonnurses determine nursing practice.
When nursing does not attempt to correct problems in the health care system, others will, and public perception will be that nurses are part of the problem.
Entrepreneurial thinking can benefit nursing and patients

10. Facility-Based Care Today
Nursing homes now referred to as long-term care (LTC) facilities
Improvements due to federal regulations and increased professional interest
Licensed staff and certified nursing assistants
Decreased use of restraints
Improved documentation
Continued problems

11. Nursing Home Standards
Regulations describe minimum standards
Based on laws
Required for reimbursement
Minimum standards to be licensed and certified
States can create higher standards
Joint Commission publishes higher standards that facilities can choose to follow

12. Nursing Home Residents
Functionally dependent as a result of physical or mental impairment
Functional ability determines the need for LTC placement
Statistics
Oftentimes caregiving needs exceeded the family’s capacity to meet those needs
A crisis situation may trigger the need for placement in a nursing home

13. Question
What percentage of the older adult population resides in an LTC facility at any given time? 5%
10%
15%
20%

14. Answer
A. 5%
Rationale: At any given time, only 5% of the older adult population resides in an LTC facility. A higher percentage will need this form of care at some future point in their lives.

15. Nursing Roles and Responsibilities
Need for highly competent nurses
Oversee status of residents
Monitor competency and performance of unlicensed caregivers
Staff education
Role modeling and coaching
Staff supervision

16. Nursing Roles and Responsibilities (cont.)
Performance evaluation
Clinical and administrative duties
Admission assessments and completion of the Minimum Data Set (MDS) tool
Identification of problems directs care planning activity
Written care plan guides nursing actions

17. Nursing Roles and Responsibilities (cont.)
Evaluation of effectiveness of care
Independent nursing practice
Ability to develop long-term relationships
Other specialized roles of professional nurses in the LTC setting

18. Question Is the following statement true or false?
The Minimum Data Set (MDS) is a standardized assessment tool that must be completed when a patient is admitted to an LTC facility, whenever there is a change in the resident’s status, and annually.

19. Answer
True
Rationale: The MDS assessment tool is coordinated by a registered nurse, and most of the entries on the MDS rely on nursing assessment. The tool is completed when an individual is admitted to an LTC facility, whenever there is a change in the resident’s status, and annually.

20. Assisted Living Communities
Care for individuals with less complex needs
Less stringent regulations
Fewer licensed nurses available
Increasing number of beds
Private pay (majority)
Challenges for gerontological nurses

21. Community-Based and Home Health Care
Increased numbers of older adults with chronic conditions and/or disabilities are receiving long-term health and social services in their personal residences.
Homemaker services, respite care, home monitoring systems

22. Looking Forward: A New Model of LTC
LTC emerged without a clearly defined model
Nurse’s role is to define a new model
Holism and healing versus the medical model
Hierarchy of resident needs:
Hygiene
Holism
Healing
Assumptions of the model of holism and healing

23. Hierarchy of Nursing Home Residents’ Needs
From Eliopoulos, C. (2007). Transforming nursing homes into healing centers: A holistic model for long-term care. Glen Arm, MD: Health Education Network.

24. Looking Forward: A New Model of LTC (cont.)
Key elements of the culture change movement:
Creating a home-like environment
Consistent staff assignments
Individualized care
Nurturing positive relationships
Staff education
Empowering residents and their caregivers

25. Looking Forward: A New Model of LTC (cont.)
Culture change movement programs
Eden Alternative
Offers residents a life worth living
Wellspring Program (2012)
Emphasis on quality improvement (QI) measures
The Green House Project (2003)
Designing the ideal nursing home