1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 37 Long-Term Care

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction Long-term care (LTC) facilities are becoming more complex and dynamic –Medically complex population –Sub-acute 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Development of LTC—(cont.) Before the 20 th 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Development of LTC—(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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Development of LTC—(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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following government initiatives had the first impact on promoting the growth of nursing homes? a. Social Security b. Hill-Burton Act c. Medicare and Medicaid d. Private insurance availability

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a. Hill-Burton Act 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lessons to Be Learned from History A vision and clear model for LTC is necessary When nursing fails to exercise leadership, non-nurses 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What percentage of the older adult population resides in an LTC facility at any given time? a. 5% b. 10% c. 15% d. 20%

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a.5% 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.).

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Looking Forward—(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

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Looking Forward—(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