1. Geriatric Interclerkship Locations of Care: Living Arrangements Sarah McGee MD, MPH Associate Professor of Medicine Director of Education Division of Geriatric Medicine University of Massachusetts April 30, 2012

2. Where do you want to live?

3. Independent Living

4. Dependent Living

5. We Imagine it Will Be Like…

7. What we see…

8. Patient needs Resources ADLsSpouse/Family IADLsFriends PhysicalCommunity EmotionalChurch SpiritualFinancial Determinants of location of care and living arrangements

9. How to evaluate patients for “best fit” of various living arrangements Functional Assessment Quality of life and quality of care Safety versus autonomy Getting to know the person, not just the patient/disease What is most important to them? Insurance/cost

10. Independent Living  Own home or apartment  Congregate or senior housing may have: help with some household upkeep congregate meals activities staff specific home health services available through outside agencies  Naturally Occurring Retirement Communities (NORC)

11. Assisted Living “A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with ADLs are available as needed to people who still live on their own in a residential facility” –Center for Medicare and Medicaid Services

12. 2007 975,000 residents 38,000 facilities (25-120 units) 2009 $3022/mo ave cost for pvt unit ($10K-$50K/yr range) Assisted Living Facilities of America National Center for Assisted Living Assisted Living

13.  Means different things in different regions or states  Lack of consensus on what is the best model, social vs medical  Types of patients too frail to stay at home may have mild to moderate dementia often required to toilet themselves and do some of own ADLs  Most do not have 24 hour nursing on site  One hour of personal care/day

14. Assisted Living  Half the price of a nursing home, but what services are you getting?  Liability is hurting development of the industry  Much less regulation than nursing homes right now  Aging in place is a big issue

15. Most Assisted Living Facilities will provide: Health care management and monitoring Help with activities of daily living such as bathing, dressing, and eating Housekeeping and laundry Medication reminders and/or help with medications Recreational and social activities Security Transportation Emergency call system in each unit Assisted Living

18. Aging Together

19. 2010 15,622 facilities (MA 429) 1.66 million beds (MA 48,484) 1.4 million residents Av LOS 875 days Av cost $198/day (Alaska $687, MA $329) %≥65 yo in NH? www.longtermcare.gov www.statehealthfacts.org Long Term Care in Nursing Homes

20.  How do you qualify for nursing home care?  How do you end up in a nursing home?  Have we always had nursing homes?

22. Long Term Care in Nursing Homes  Abuse in 1960s, 1970s led to  Reforms in 1980s (OBRA ’87) led to  Government regulation

23. Can Nursing Homes Be the Best Alternative?

24. Long Term Care in Nursing Homes  How is it changing?  Can we make it a more positive alternative?  Resident-centered care

26. Geriatrics is a Team Sport  Interprofessional teams enhance the comprehensive care of complex patients  Teams are not hierarchical  Each person on the team is valued for his or her unique role and what they bring to the care of the person  Teams include informal caregivers (family, friends)

27. Team Members  CNA (certified nursing assistant)  physical therapist  dietician  chaplain  primary care provider (MD, NP, PA)  psychologist  activity director  registered nurse  occupational therapist  speech therapist  social worker

28. Geriatric Care Teams Regardless of the Setting…

29. Resources Geriatric Interdisciplinary Team Training –http://www.umassd.edu/gitt/http://www.umassd.edu/gitt/ Medicare and Medicaid –www.Medicare.govwww.Medicare.gov –www.longtermcare.govwww.longtermcare.gov –www.cms.govwww.cms.gov Assisted Living Facilities of America –www.alfa.org National Center for Assisted Living –www.ncal.org National Council on the Aging (NCOA) –www.healthyagingprograms.orgwww.healthyagingprograms.org