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NURSING HOME CARE. Swedish Family Medicine October 10, 2000 Pat Borman, MD. GOALS. Review the historical perspectives of nursing home care in the USA Understand the roles of physicians in providing nursing home care

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Nursing home care

NURSING HOME CARE

Swedish Family Medicine

October 10, 2000

Pat Borman, MD


Goals
GOALS

  • Review the historical perspectives of nursing home care in the USA

  • Understand the roles of physicians in providing nursing home care

  • Be familiar with the geriatric syndromes common to nursing home care


Demographics
DEMOGRAPHICS

  • Those >65 have a 40% risk of needing long term care

  • 1.5 million now and 6 million by 2030

  • 5% off all elderly are institutionalized

    • 1% Age 65-74

    • 15% Men >85

    • 25% Women >85


Historical view
HISTORICAL VIEW

  • 1935 Social Security Act funding States fail to secure quality

  • 1965 Title 18 & 19 Federal oversight has little impact

  • 1987 OBRA with MDS, RAP and teeth!


Obra mandates
OBRA MANDATES

Residents Bill of Rights

Guidelines to restrict the use of:

  • Restraints

  • Psychoactive drugs

  • Unnecessary Drugs


Obra mandates1
OBRA MANDATES

Requires periodic assessment of resident functional capacity

  • Minimal Data Set

  • Resident Assessment Protocols

    ?WHY HAS OBRA BEEN SO EFFECTIVE?


Types of placement
TYPES OF PLACEMENT

  • Short Term Stay

    • 50% of admits, 45% stay < 3 months

    • Hospital stepdown

    • Acute rehabilitation

  • Long Term Stay

    • Average length of stay 19 months

    • 18-25% die in the nursing home


Physician roles
PHYSICIAN ROLES

PRIMARY GOALS OF CARE

  • Safe supportive environment

  • Maximize function and quality of life

  • Stabilize chronic illness

  • Prevent illness

  • Recognize and manage acute problems


Physician roles1
PHYSICIAN ROLES

  • Reliance on bedside diagnosis

    Limited lab and consultative services

  • REMEMBER you are visiting patients in their HOME -- accord proper respect

  • Care above cure, comfort above all


Monitoring requirements
MONITORING REQUIREMENTS

ADMIT EXAMINATION

  • Within 48 hours of admit

  • Can be done in hospital, office or NH

    PERIODIC VISITS

  • Every 30 days for 3 months

  • Every 60 days thereafter

    ACUTE PROBLEM VISITS

    ANNUAL REVIEW VISITS


Admissions checklist
ADMISSIONS CHECKLIST

  • History

    • Include Immunizations, Eye, Dental, Podiatric, Pain, Depression

  • Physical

    • Nutrition, Hearing, Vision, Mobility, Cognition

  • Medication Review: link with diagnoses

  • Functional Assessment ADL

  • Advance Directives

  • Formulate Problem List and Plan of Care


Common problems in nursing home patients

Incontinence

Fever and Infections

Confusion/Delirium

Pressure Ulcers

Falls

Malnutrition

Pain Management

Polypharmacy

Depression

Dementia

COMMON PROBLEMS IN NURSING HOME PATIENTS


Nursing home protocols
NURSING HOME PROTOCOLS

To comply with OBRA many facilities have

protocols for common problems.

  • Incontenence

  • Pressure Ulcers

  • Falls

  • Use of restraints


Nursing home problems case 1
NURSING HOMEPROBLEMS CASE #1

  • Mrs Worth is a 92 y.o. widowed white female with diabetes, hypertension and osteoarthritis. She is usually quite sharp but for two days the NH staff noticed she is confused, agitated and intermittently drowsy. She doesn’t want to eat, is picking at her clothing and has started staying up all night. She has fallen twice, not common for her.


Nursing home problems case 2
NURSING HOME PROBLEMS CASE #2

  • Mr. Sullivan is a 88 y.o. white man with moderately advanced dementia. He was unresponsive to Aricept and Cognex. He paces and wanders continually and shows aggression with attempts to redirect him. In the last 6 months he has lost more than 10% of his body weight and 8 pounds in the last month.


Conclusions
Conclusions

NURSING HOME CARE is a natural extension of the Family Practice mission to care for individuals and their families throughout their life span.


Conclusions1
CONCLUSIONS

Nursing Home Care requires compassion and a comforting and caring approach.

This work confirms that we can each help improve the end of life for someone we know.


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