1. Long-Term Care Chapter 38 Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Jeanelle F. Jimenez RN, BSN, CCRN

2. Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Long-Term Care Long-term care is defined by the American Nurses Association (ANA) as the provision of physical, psychologic, spiritual, social, and economic services to help people attain, maintain, and regain their optimum level of functioning. Long-term care is provided in a variety of settings and offers a broad spectrum of services.

3. Slide 3Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care The Home  Most older adults live in a home setting, with only a small percentage of those aged 65 or older residing in an institutional setting.  Care of the older adult at home may involve a great deal of participation from loved ones.  It costs approximately half as much to care for an older adult at home as it would cost in a long-term care facility.  Home patients may require only minimal assistance, or they might receive complex medical therapies.

4. Slide 4Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Hospice  Provides services to patients and families as the end of life approaches.  The philosophy of maintaining comfort as death approaches is central to hospice care.  Provide nursing interventions to meet basic needs; ADLs; pain and symptom management; and spiritual and psychosocial support for the patient, family, and significant others.  Care providers include CNAs, HHAs, LPN/LVNs, and RNs.

5. Slide 5Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Adult Daycare  Community-based programs are designed to meet the needs of functionally or cognitively impaired adults through an individualized plan of care.  These structured, comprehensive programs provide a variety of services, including physical care, mental stimulation, socialization, assistance with health maintenance, and health referrals, during any part of the day but providing less than 24 hours’ care.  They are designed to serve adults who require supervision, social opportunities, or assistance due to a physical or cognitive impairment.

6. Slide 6Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 38-2 Available settings that provide long-term care services.

7. Slide 7Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Residential Care Settings  Primarily an older adult population, offering a wide variety of services  Assisted living A type of residential care setting whereby the adult patient rents a small one-bedroom or studio-type apartment and can receive several personal care services  Continuing care retirement communities Offer a complete range of housing and health care accommodations, from independent living to 24-hour skilled nursing care

8. Slide 8Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings  Subacute unit This type of institutional setting provides a less expensive alternative to acute care when patients have high-acuity medical and nursing intervention needs. Most are located in freestanding skilled nursing facilities; others are former hospital units that have been reclassified to provide subacute care. They provide a stronger rehabilitative focus and shorter length of stay than a long-term care facility.

9. Slide 9Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings  Long-term care facility Most dominant setting for long-term care services Commonly known as a nursing home or extended care facility Provides services to primarily older adults Provides 24-hour care to individuals who do not require inpatient hospital services but who do not have options for care at home or by other community agencies/services

10. Slide 10Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Because the long-term care facility becomes a home for the older adult, the adults are referred to as residents rather than as patients. Most residents have more than one health disorder when they are admitted, and more than half have three or more medical diagnoses.

11. Slide 11Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) The most common disorders on admission are as follows:  Cardiovascular disease, including hypertension and cerebrovascular accident  Mental and cognitive disorders, including depression, anxiety, and dementia  Endocrine disorders, including type 2 diabetes mellitus and hypothyroidism

12. Slide 12Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Two categories of residents  Short-term: transferred from an acute care facility to which he or she had been admitted for an acute illness or worsening of a chronic illness; admitted primarily for rehabilitation and expected to be discharged within 6 months  Long-term: usually stays in the facility until he or she dies or is transferred to an acute care facility. Most residents are long term.

13. Slide 13Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Interdisciplinary setting  Health care professionals work together as an interdisciplinary team to meet the needs of the older adult. Facility is managed by an administrator and has a director of nursing (DON). These facilities are highly regulated by state and federal agencies to ensure quality services to a potentially vulnerable population.

14. Slide 14Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Restorative nursing care  Basic concepts of physical therapy for maintenance of functional mobility and physical activity; care is provided by CNAs who have completed an educational program for restorative care Omnibus Budget Reconciliation Act (OBRA)  Defines requirements for the quality of care given to residents of long-term care facilities

15. Slide 15Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Medicare  A federally funded national health insurance program in the United States for people over age 65  Provide funding to long-term care facilities by adhering to the HCFA guidelines for reimbursement

16. Slide 16Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Medicaid  A federally funded, state-operated program of medical assistance to people with low incomes  A large source of revenue for the long-term care facility

17. Slide 17Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Several different types of nursing can be seen in this setting  Team nursing  Functional nursing  Total resident care  Combination of the above

18. Slide 18Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) The interdisciplinary functional assessment of the resident is the cornerstone of clinical practice. Resident Assessment Instrument (RAI)  OBRA-prescribed method of resident assessment and care plan development  Consists of three parts o Minimum Data Set (MDS) o Resident Assessment Protocols (RAP) o Utilization Guidelines

19. Slide 19Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Setting for Long-Term Care Institutional Settings (continued)  Long-term care facility (continued) Documentation of the resident’s condition, including vital signs and weights, is required only on a monthly basis. The exception to this charting is a condition change, acute illness, or incident reporting, which must be documented at or soon after the time of occurrence.

20. Slide 20Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process Nursing Diagnoses  Aspiration, risk for  Airway clearance, ineffective  Gas exchange, impaired  Cardiac output, decreased  Nutrition: less than body requirements  Fluid volume, risk for deficient  Incontinence  Thought process, disturbed  Confusion, chronic

21. Slide 21Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process Nursing Diagnoses (continued)  Self-care deficit  Injury, risk for  Mobility, impaired physical  Skin integrity, risk for impairment  Self-esteem, chronic low  Grieving  Anxiety  Social isolation