nursing home

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Introduction

Nursing home care

types of facility
- 20,00 nursing home facilities in USA (2001)
- 75% are for profit
- most are small, < 100 beds
- 2 key people, administrator & director of nurses (DON)
nursing home residents
- 4.4% of older persons (> 65 years)
  - < 2% 65-74 years
  - 4.4% 75-84 years
  - 15.4% >= 85 years
- 30% lifetime risk of being in a nursing home
- 40% are > 85 years of age
- women > men; > 80% women if > 85 years^[7]
- single, widowed > married
- dependent in ADL*s, incontinence, especially bowel
- socially isolated
- women living in nursing homes need more assistance with ADLs than men^[7]
- white residents have lowest rates of dependence among different races^[7]
key predictors of institutionalization
- age
- living alone without a spouse
- cognitive impairment - dementia &/or depression
  - 1/2 of patients admitted to nursing home have a diagnosis of dementia (GRS9)^[7]
- functional impairment
sources of nursing home admissions
- from home, precipitated by
  - weakening/failure of support systems
  - behavioral problems
    - wandering
    - nighttime agitation
  - incontinence
- acute care hospital
- readmission after hospitalization
  - infection, dehydration, CAD, GI bleed, fracture
goals of nursing home care
- provide a safe & supportive environment
- maximize functional independence & quality of life
- preserve autonomy
- comfort & dignity for terminally ill
- optimized management of chronic conditions
- prevent acute & iatrogenic illnesses
- recognize & rapidly treat acute conditions
length of stay
- average length of stay is 19 months
- 45-50% stay < 3 months^[7]
  - 23% admitted to SNF rehospitalized with with 30 days^[7]
- 2/3 of patients die in nursing home
staffing patterns in nursing homes
- nursing assistants provide hands-on-care
- RN (10% of staff)
- physician: 10% spend 2 hours/week in nursing home
- nurse practitioners (NP) & physician assistants (PA)
- laboratory, EKG, X-ray, respiratory services are available at the nursing home by outside vendors
physician visits
- initial, H&P within 72 hours of admission
- subsequent visits every 30 days for the 1st 3 months, then every 60 days if medically stable
- telephone management
  - a nurse may not act as a agent of a physician prescribing a class II controlled substance - the physician must communicate directly with the pharmacist before the pharmacist can dispense the medication^[7]
  - a nurse may not take a controlled substance from a back-up supply^[7]; this is in contrast to hospital practices because hospitals are registered with the DEA to dispense & administer controlled substances^[7]
reimbursement/payment
- 50% Medicaid - Medical in Calif (long-term residents)
  - often pays below the cost of care^[20]
- 32% out of pocket
- 12% Medicare (short-term poat acute)
Medicare - Title XVIII
- persons > 65 years who have worked for 11 years
- persons < 65 years who received disability insurance for 2 years
- persons of any age with end-stage renal disease
- two parts
  - A (hospital) - automatic
  - B (outpatient services) - co-pay
- limitations in nursing home
  - need 3 day acute hospital stay - 3 midnights
  - medicare pays fully for the 1st 20 days
    - if still elgible, can get up to 100 days with a copayment
      - 80% Medicare
      - 20% supplemental insurance after the 1st 20 days
subacute care = transitional care = skilled nursing home (SNF)
- usually younger than the average nursing home resident
- admitted from acute care hospital
- 65-75% is paid by Medicare
- services that qualify
Admission to nursing home
- number of admissions has increase since 1994 because more facilities offer short-term services & rehabilitation after hospitalization^[7]
- see physician evaluation at nursing home admission
- see minimum data set for nursing home residents

* ADL = activities of daily living

* H&P = history & physical

Complications

hospitalization (see complicated transition)
high prevalence of both multidrug-resistent gram-negative bacteria & MRSA on colonizing residents & environmental surfaces^[6]

Management

keeping staffing levels constant, day-to-day staffing stability, avoiding days with low staffing of licensed practical nurses & certified nurse aides, is a marker of better quality in nursing homes^[21]

Notes

staff often complain of work overload
staff turnover is high
predictors of patient safety
- efficiency
- work climate
- goal clarity
  - safety is the norm; it is multifactorial
- work stress
environmental predictors of patient safety
- design safety
- limited space
- obstacles
- equipment misuse & malfunction
- staff & organization of care
diabetes mellitus in long-term care
- intensive glycemic care of limited value^[15]
- hyperglycemic hyperosmalar nonketotic coma a concern
- avoid insulin sliding scale
- restrictive diabetic diets are counterproductive & should be avoided^[15]

More general terms

health care setting

More specific terms

Additional terms

References

↑ Eslami, M., UCLA School of medicine, 2001
↑ Ouslander J, JAMA 262:2582, 1989
↑ Ouslander & Ouslander, Ann Intern Med, 20:584, 1994
↑ Ouslander et al: in: Medical Care in Nursing Home, McGraw Hill, NY, 1991
↑ Ouslander, JG: In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
↑ ^6.0 ^6.1 O'Fallon E et al Multidrug-resistant gram-negative bacteria at a long-term care facility: Assessment of residents, healthcare workers, and inanimate surfaces. Infect Control Hosp Epidemiol 2009 Dec; 30:1172. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19835474
↑ ^7.00 ^7.01 ^7.02 ^7.03 ^7.04 ^7.05 ^7.06 ^7.07 ^7.08 ^7.09 ^7.10 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
↑ Koren MJ. Person-centered care for nursing home residents: the culture- change movement. Health Aff (Millwood). 2010 Feb;29(2):312-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20056692
↑ Simor AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: a review. J Am Geriatr Soc. 2010 Aug;58(8):1556-64. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20646106
↑ Arnetz JE, Zhdanova LS, Elsouhag D et al Organizational climate determinants of resident safety culture in nursing homes. Gerontologist. 2011 Dec;51(6):739-49 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21708985
↑ Hill EE, Nguyen TH, Shaha M, Wenzel JA et al Person-environment interactions contributing to nursing home resident falls. Res Gerontol Nurs. 2009 Oct;2(4):287-96 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20077985
↑ Elon RD, Schlosberg C, Levenson S, Brandt N. DEA enforcement in long-term care: is a collaborative correction feasible? J Am Med Dir Assoc. 2011 May;12(4):263-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21527167
↑ Gaugler JE, Duval S, Anderson KA, Kane RL. Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatr. 2007 Jun 19;7:13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17578574
↑ U.S. Department of Health and Human Services (HHS) HHS proposes to improve care and safety for nursing homes residents. July 13, 2015 http://www.hhs.gov/news/press/2015pres/07/20150713d.html
↑ ^15.0 ^15.1 ^15.2 Munshi MN et al. Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care 2016 Feb; 39:308 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26798150
↑ Nazir A, Unroe K, Tegeler M et al Systematic review of interdisciplinary interventions in nursing homes. J Am Med Dir Assoc. 2013 Jul;14(7):471-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23566932
↑ Zimmerman S, Shier V, Saliba D. Transforming nursing home culture: evidence for practice and policy. Gerontologist. 2014 Feb;54 Suppl 1:S1-5. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24443601
↑ Selbak G, Engedal K, Bergh S. The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. J Am Med Dir Assoc. 2013 Mar;14(3):161-9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23168112
↑ Thomas JM, Cooney LM Jr, Fried TR. Systematic review: Health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality. J Am Geriatr Soc. 2013 Jun;61(6):902-11. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23692412 Free PMC Article
↑ ^20.0 ^20.1 Grabowski DC, Mor V Nursing Home Care in Crisis in the Wake of COVID-19. JAMA. Published online May 22, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32442303 https://jamanetwork.com/journals/jama/fullarticle/2766599
↑ ^21.0 ^21.1 Mukamel DB, Saliba D, Ladd H et al Association of Staffing Instability With Quality of Nursing Home Care. JAMA Netw Open. 2023;6(1):e2250389 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36626170 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800160

[ref1-1] Eslami, M., UCLA School of medicine, 2001

[ref2-2] Ouslander J, JAMA 262:2582, 1989

[ref3-3] Ouslander & Ouslander, Ann Intern Med, 20:584, 1994

[ref4-4] Ouslander et al: in: Medical Care in Nursing Home, McGraw Hill, NY, 1991

[ref5-5] Ouslander, JG: In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001

[ref6-6] 6.0 ^6.1 O'Fallon E et al Multidrug-resistant gram-negative bacteria at a long-term care facility: Assessment of residents, healthcare workers, and inanimate surfaces. Infect Control Hosp Epidemiol 2009 Dec; 30:1172. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19835474

[ref7-7] 7.00 ^7.01 ^7.02 ^7.03 ^7.04 ^7.05 ^7.06 ^7.07 ^7.08 ^7.09 ^7.10 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016

[ref8-8] Koren MJ. Person-centered care for nursing home residents: the culture- change movement. Health Aff (Millwood). 2010 Feb;29(2):312-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20056692

[ref9-9] Simor AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: a review. J Am Geriatr Soc. 2010 Aug;58(8):1556-64. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20646106

[ref10-10] Arnetz JE, Zhdanova LS, Elsouhag D et al Organizational climate determinants of resident safety culture in nursing homes. Gerontologist. 2011 Dec;51(6):739-49 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21708985

[ref11-11] Hill EE, Nguyen TH, Shaha M, Wenzel JA et al Person-environment interactions contributing to nursing home resident falls. Res Gerontol Nurs. 2009 Oct;2(4):287-96 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20077985

[ref12-12] Elon RD, Schlosberg C, Levenson S, Brandt N. DEA enforcement in long-term care: is a collaborative correction feasible? J Am Med Dir Assoc. 2011 May;12(4):263-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21527167

[ref13-13] Gaugler JE, Duval S, Anderson KA, Kane RL. Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatr. 2007 Jun 19;7:13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17578574

[ref14-14] U.S. Department of Health and Human Services (HHS) HHS proposes to improve care and safety for nursing homes residents. July 13, 2015 http://www.hhs.gov/news/press/2015pres/07/20150713d.html

[ref15-15] 15.0 ^15.1 ^15.2 Munshi MN et al. Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care 2016 Feb; 39:308 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26798150

[ref16-16] Nazir A, Unroe K, Tegeler M et al Systematic review of interdisciplinary interventions in nursing homes. J Am Med Dir Assoc. 2013 Jul;14(7):471-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23566932

[ref17-17] Zimmerman S, Shier V, Saliba D. Transforming nursing home culture: evidence for practice and policy. Gerontologist. 2014 Feb;54 Suppl 1:S1-5. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24443601

[ref18-18] Selbak G, Engedal K, Bergh S. The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. J Am Med Dir Assoc. 2013 Mar;14(3):161-9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23168112

[ref19-19] Thomas JM, Cooney LM Jr, Fried TR. Systematic review: Health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality. J Am Geriatr Soc. 2013 Jun;61(6):902-11. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23692412 Free PMC Article

[ref20-20] 20.0 ^20.1 Grabowski DC, Mor V Nursing Home Care in Crisis in the Wake of COVID-19. JAMA. Published online May 22, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32442303 https://jamanetwork.com/journals/jama/fullarticle/2766599

[ref21-21] 21.0 ^21.1 Mukamel DB, Saliba D, Ladd H et al Association of Staffing Instability With Quality of Nursing Home Care. JAMA Netw Open. 2023;6(1):e2250389 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36626170 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800160

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nursing home

Contents

Introduction

Complications

Management

Notes

More general terms

More specific terms

Additional terms

References

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nursing home

Introduction

Complications

Management

Notes

More general terms

More specific terms

Additional terms

References

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