Chapter 19: Global Models of Health Care

1. Chapter 19: Global Models of Health Care

2. Introduction • Meeting the needs of a rapidly growing older adult population is challenging worldwide • Will compare models of healthcare to provide insights into how to meet these challenges

3. Background Japan: By 2020, the 65 and older population will comprise 27% of the total population USA: The elderly are expected to make up 16.6% of the total population in the United States Italy: Just over 24% of the population will be 65 or older

4. Japan Currently, the elderly in Japan enjoy the highest life expectancy in the world. 1970s free elder care, but was terminated in 1982 Gold Plan (1989) Home help Short-stay institutions Day services Education regarding normal aging Long-Term Care Insurance program (2000) 65 or older pay 10% of nursing costs + monthly premium Can choose among agencies providing services Emphasis on caring for elders at home due to overuse of hospitals– elder abuse addressed as a potential problem

5. Germany 1st country to establish a national health care program Solidarity Principle: members of society are responsible for providing adequately for another’s well-being through collective action. PCP is gatekeepers to hospital access In 1995, those age 60 and older comprised 21% of the German population By 2030, 36% of the population will be 60 years of age and older LTC coverage in Social Security System – coverage is mandatory – created to relieve financial burden of long-term disability and illnesses Most German elders still cared for at home by relatives

6. England National Health Service (NHS) Universal system of health care based on clinical need Care is free at point of care PCPs are independent contractors 75% of the funding for the health care comes from taxes Nearly 100% have access but long waits Secondary care = referral to specialists or hospitals for care

7. Canada • Health care system known as medicare • Universal coverage at no cost at the point of access • Each of the 10 provinces responsible for provision of health care services • Services based on need • Funded primarily through taxes • MD in private practice • Hospitals primarily not-for-profit • Long wait times • Vision, dental and meds covered for seniors

8. U.S. Health Care System and Policies Effects of an Aging Society: By the year 2050, 30% of the population will be over the age of 65 years The population over the age of 85 is expected to double

9. Effects of Morbidity and Mortality Life expectancy is 77.1 in the U.S. This is behind many other countries including Japan, Singapore (highest at 80 years), Canada, Australia, Italy and others Number of chronic illnesses increases with aging population requiring interdisciplinary team with expertise in geriatrics to meet the physical and psychosocial consequences

10. Social Security Federal old-age pension program Mandatory participation through payroll contributions Fewer benefits than many other industrialized nations Delayed retirement credit (DRC) 75% of poor elderly are women who depend on social security as main source of income Women are 60% of recipients at age 65

11. Medicare Through Social Security Act to provide some kind of universal health care insurance for elderly and those with ESRD Part A: Hospital insurance Inpatient care Skilled nursing facility Hospice care Home health Part B: Supplemental medical insurance Lab Home health Doctor visits Some outpatient therapies Mental health services Outpatient hospital services

12. Medicare (cont’d) • Part C: • HMO • PPO • Part D: • Prescription drug plan • Does now cover some screenings

13. Medicaid Financed by state and federal government Administered by state Coverage and eligibility differ from state to state Three types of protection Health insurance for low-income families and people with disabilities LTC for older Americans and persons with disabilities Supplemental coverage for low-income Medicare beneficiaries for services not covered by Medicare LTC insurance available but very expensive

14. Settings for Care in the U.S. Acute Care Long-Term Care Home Care Assisted Living

15. Chapter 20: The Interdisciplinary Team Bonnie M. Wivell, MS, RN, CNS

16. Introduction • Elderly deal with: • Normal age changes • Impact of chronic illness • Realities of real or potential changes in function and/or cognition • Interdisciplinary Team • Diverse skills and expertise • More effective, better coordinated, and better quality services

17. Teams • Multidisciplinary • Team members with expertise in certain areas • Individual goals • Interdisciplinary • Different disciplines with common goals • Complex problem solving/more effective treatment • Interdependent in their work • Share accountability for outcomes • Coordination and integration of care assessment and planning • Patient seen as a whole • See pages 655-658 for various members

18. Why Teams Are Needed • IOM Crossing the Quality Chasm report from 2001 • “Effective teams have a culture that fosters openness, collaboration, teamwork, and learning from mistakes.” • Mandated interdisciplinary education in its publications • For patient safety and quality of care • Assessment, Consultation, Management

19. Types of Teams • GITT: Geriatric Interdisciplinary Team Training • Established in 1994 by John A. Hartford Foundation • An organized training program for professionals of various disciplines focused on learning about working in teams, use of teams in gerontology • Development of a core curriculum in interdisciplinary training

20. Types of Teams • GAIT: Geriatric Assessment Interdisciplinary Team • An interdisciplinary training model developed in Maryland as elective for student education from various healthcare disciplines • GAT: Geriatric Assessment Team • Consultation team that evaluates functional, social, fall risk, nutrition, medication, depression, cognition, and incontinence problems • Inpatient or Outpatient • Underutilized

21. Types of Patient Care Units • GEM: Geriatric Evaluation and Management • ACE: Acute Care for Elders • Designated inpatient units wherein the elderly are assessed and treated • Staffed with geriatric team members • Units show better outcomes • Patients more likely to be discharged home

22. Palliative Care & Hospice • Active across care settings where geriatric teams are also found • Goal of Palliation: to prevent and relieve suffering and to provide the best possible QOL for patients and their families regardless of the stage of disease or need for other therapies • Address EOL physical, psychosocial, and spiritual issues • Ease transition from purely curative care to supportive care • Care goals determined by patient and family

23. Challenges • Socialization to team approach • Identified roles • Trust and respect • Inconsistent team members • Accreditation issues • Reimbursement • Shared power • Turf issues

24. Benefits • More comprehensive approach to care • Increased patient and team member satisfaction • Increased quality of care • More cost effective • Avoid redundancy of services • Education of other team members • New skills • Increased productivity • Potential for time saving

25. Chapter 23: The Gerontological Nurse as Manager and Leader Bonnie M. Wivell, MS, RN, CNS

26. The Nurse Manager • All geriatric nurses need to develop management skills • A unique position to improve quality, positive outcomes, and cost-effectiveness of patient care in a variety of settings • Multitude of tasks • Ensuring quality nursing care • Patient and family satisfaction • Staff retention • Commitment • Contentment

27. Organized Consistent Fair Optimistic Goal-oriented Flexible Creative Resourceful Professional Standard-setter Trustworthy Honest Characteristics of an Effective Nurse Manager

28. Delegation • Managerial and legal act • Skill that must be learned and practice • Licensed nurse are still accountable for the well-being and safety of the patients entrusted to them • Inappropriate use of unlicensed assistive personnel (UAP) in performing functions outside their scope of practice is a violation of the state nursing practice act and is a threat to pt. safety. The RN has an increased scope of liability when tasks are delegated to a UAP.

29. The Delegation Process • Right Task • Right Circumstances • Right Person • Right Direction/Communication • Right Supervision

30. Team building Goal setting Facilitating change Stress management Decision-making Conflict resolution Expertise Communication Listening Inspiring trust Skills of Nurse Managers

31. The Nurse Leader • Effective leaders are often good managers • However, a good manager is not always a good leader • Leaders tend to be visionaries who focus on the larger picture • Managers focus on day-to-day operations • Leaders can be mentored to be more effective managers

32. Leadership Strategies • Transactional: leading by an inconsistent system of rewards and consequences • Transformational: leading by example, encouragement, and empowerment of the staff • Strategies: • See past the present • Using good communications techniques • Trust through positioning • Development of self

33. Charismatic Leader • Characterized by their determination to change the current state of affairs accompanied by an awareness of forces in the environment and their followers’ needs • 3 stages • Determine the conditions that cause change and recognize followers • Encourages followers to partake in the vision • Ability and desire to go above and beyond

34. Leadership styles • Authoritarian: leader makes decisions with little input from staff • Democratic: welcome the input from staff and believe their opinions are important • Laissez-faire: relaxed; “go with the flow” • Situational: choose style based on the situation

35. Leadership in a Multigenerational Age • Traditional professional nurses • Born pre-1945 • Seniority and loyalty are important • Hard work, pride in doing a good job, working together, financially conservative, and cautious • Many of these nurses were trained in hospital-based diploma program Baby Boomers • The Baby Boomers (born 1945–1964) • Represent the largest percentage of the nursing workforce • Hold many nursing leadership positions • They challenged and changed the values held by the veteran nurses • Sense of professionalism and view of nursing as a career

36. Leadership in a Multigenerational Age • Generation X (Born 1964–1980) • Parents worked; “latch key” children • Saw their parents laid off from work after sacrificing their time with their children to advance their careers • Value work-life balance • Want career security and flexibility • The Millennial or Net Generation (Born 1980–2000) • Raised during a time of violence, terrorism, and drugs • Embrace multiculturalism and technology • Nursing is an occupation versus a profession • May have as many as 10 career changes (not job changes) in their lifetime • Strengths are competence in technology and expectations of virtual teams

37. Professional Organizations • Provide quality care to patients and offers the latest information in gerontology • NGNA AHCA • NADONA/LTC ACHC • AANEX AMDA • AALTCN NAHCA • AANAC AAHSA

38. Chapter 25: Trends That Impact Gerontological Nursing

39. Educational Levels • LPN, ADN, BSN • Advanced practice • GCNS-BC • GNP • The ANCC changed the advanced practice designations to help better distinguish between the various specialties of APRNs • CNL: ill-defined • Doctorates • PhD • DNP • The DNP is the proposed new entry level into advanced practice nursing as of 2015

40. Life Care Planning • A life care plan is a comprehensive document designed to help meet the long-term financial and health needs of a person who has experienced a catastrophic injury (Weed, 1999). • Assist with determination of settlements in litigation • Nurses with rehabilitation backgrounds or case management experience are well-suited for this role • Certifications available: • CLCP • 128 CE hours • Sample life care plan • Pass an exam • Can be earned by nurses or any other disciplines as well • CNLCP • The planner is a nurse • Strict prerequisites • Large number of practice hours

41. What is Financial Gerontology? • Combines the knowledge and skills associated with financial planning and asset management with expertise in meeting the unique needs of older adults (i.e. finances, money/asset management, insurance needs, living arrangements) • An emerging field • Relates gerontological concepts, issues, data and research findings to financial services • Three certifications • Chartered Advisor for Senior Living • Registered Financial Gerontologist • Certified Senior Advisor

42. Trends in LTC • The broad range of medical, custodial, social, and other care services that assist people who have an impaired ability to live independently for an extended period • $183 billion spent on LTC services in 2003 • In 2005 Medicaid spent nearly $95 billion • Use up savings and other financial assets before eligible for Medicaid

43. Long-Term Care Insurance • Covers care outside the hospital, including diagnostic testing, rehab, custodial care, nursing home, assisted living, hospice, home health, adult day care, and respite care • Purchase to decrease worry about being a burden, stay financially independent, have more choices for care, preserve assets and provide peace of mind • Can be purchased at any time but premiums increase with age

44. Emerging Models of Care • Continuing care retirement communities (CCRCs) • A community living setting or situation designed for older adults that offers a continuum of care • Green Houses: • 10-12 residents in home setting who enjoy private rooms and common living space • Full range of care services

45. Emerging Models of Care • Professional Geriatric Care Manager (PCGM) • A professional who specializes in helping families care for older adults while encouraging independence • Community living designs • Concept that focuses on designing, building, engineering, and marketing to older adults, especially in senior living communities

46. Summary • The U.S. population over age 65 is projected to double by 2035 • The first baby boomers are beginning to enter the “senior” market • The older age groups are becoming more heterogeneous • With more older adults in the population, demand for services is likely to increase

47. Summary • Financial planners are taking courses in aging to cater to the older client, but is this an area that gerontological nurses should be working in? • New models of care are beginning to emerge and there will likely be additional models to meet the needs of the baby boomers as they enter older age

48. Helpful Websites • www.geriatricpain.org • www.nursingsociety.org/gerontology • www.hartfordign.org