long-term health care

Introduction

Definition: A set of health, personal care & social services delivered over a sustained period of time to persons who have lost or never acquired some degree of functional capacity.

Sites of care:

• acute hospital
• nursing home
• home
• assisted living

Funding:

• Medicare
• Medicaid
• Private
• new models

Out of pocket expenditures

• nursing homes 42%
• hospitalization 6%
• physicians 21%

Private Insurance

• Medigap
• HMOs

New models

• Medicare & Medicaid combined (PACE)
• special HMO
• Veterans Health System
• other capitated models

Goals of nursing home care (see nursing home)

Unique factors in clinical long-term-care

• different goals for care
• prevalence of specific conditions
• different approaches to care
  • prevention/health maintenance
  • emphasis on function
  • interdisciplinary
• limited data
• complicated decision making
• administrative policies & procedures
• logistical & resource constraints
• legal liability

Evidence on quality:

• pressure ulcers
• chronic bladder catheters
• physical restraints
• psychotropic medications
• polypharmacy
• continence management
• nutrition/hydration
• depression
• falls
• pain management/palliative care
• infections
• use & documentation of advance directives
• emergency room visits
• acute hospitalizations

Evolving changes:

• funding
• regulation
• legal liability
• sociodemographic
• growth of subacute care
• growth of assited living

Changes in funding:

• prospective payment for postacute ('subacute') care
• in nursing home system, based on MDS/RUGS
• capitated care programs

Regulation:

• OBRA 1987
  • resident autonomy
  • highest practical level of function
  • quality of care standards
• OBRA & quality of care
  • medical necessity/unavoidability
  • physical & chemical restraints
  • resident assessment
  • MDS -> triggers -> RAPS -> care plan

Legal liability:

• increasing number of lawsuits against facilities & physicians
• bad outcome vs substandard or negligent care

Sociodemographic changes

• number of frail, very old people
• availability of family caregiver
• expectations of older people & their families

Growth of subacute care:

• sicker patient population
  • nursing care needs
  • medically complex
  • rehabilitation potential
• rapid turnover
• requires
  • adequate reimbursement
  • skilled nurses
  • availability of high-quality medical care & ancillary services (laboratory, pharmacy etc)
  • change in mindset

Growth of assisted living:

• national study 1999
  • 11,459 facilities, average size 53 beds
  • 611,300 total beds
  • 521,500 residents
• unregulated care of very frail older people
• lack of health professional oversight

Strategies:

• regulation
• legal actions
• reimbursement
• integrated care systems
• nursing care
• medical care
• quality standards
• quality improvement programs
• technology
• research
• translating research into practice

Regulation:

• standards for staffing
• make the survey process outcomes based & educational NOT as adversarial & punitive
• avoid further unfunded mandates

Legal actions:

• selected cases
• involvement of experts

Reimbursement:

• adequate staffing
  • nursing
  • physicians, nurse practitioners, physician assistants
  • rehabilitation therapists
  • ancillary services
• enlightened capitation
  • risk adjustment (e.g. RUGS)
  • adequate payments, assuming efficient care
  • outcome monitoring based on quality indicators
  • appropriate incentives

Integrated care systems:

• components
  • community-based programs
  • institutional care
  • acute hospital
  • provider network
• shared vision, goals & financial incentives
• care standards
• information systems

Nursing:

• education
• salary
• professional opportunities
• practice standards
  • critical pathways

Medical care:

• education
• reimbursement
• professional respect (e.g. AMDA, AGS, other organization)
• clinical practice guidelines
• interdisciplinary communication
• medical director role
• preventive/health maintenance strategies
• documentation
• geropsychiatrists. geropsychologists
• NPs/PAs
• propective decision making

Preventive/Health maintenance protocols

• primary prevention
  • influenza
  • pressure sores
  • deconditioning
  • malnutrition, dehydration
  • falls
• infection control
  • nosocomial & endemic infections
  • catheter care
• monitoring
  • diabetes
  • congestive heart failure
  • drug therapy

Nurse practitioners/physician assistants

• liason between medical & nursing staff
• communication with families
• implement preventive strategies
• assessment & management of acute & subacute illnesses

Prospective decision making

• advance directives
• policies & procedures
• communication
• documentation

Quality standards

• MDS-based quality indicators
• ACOVE project
• resident/family satisfaction

Technology:

• information systems
• internet
• robotics
• monitoring devices

Research:

• types
  • basic
  • translational
  • clinical intervention
  • health services
• challenges
  • fear
  • costs to facilities
  • subject recruitment/consent
  • subject attrition
  • need for multi-site studies
  • human subject concerns

Translating research into practice

• feasible interventions
  • practicality
  • cost
• staff training & buy in
• targeting
• CQI programs
• resident/family satisfaction
• survey process
• reimbursement for effective interventions

More general terms

• health care