1
NURSING-HOME CARE
2
OBJECTIVES
Know and understand:
• The demography and characteristics of the
nursing-home population
• Risk factors for admission to a nursing home
• The requirements of the Omnibus Budget
Reconciliation Act of 1987
• The physician’s clinical, ethical, and legal
responsibilities to nursing-home residents
3
TOPICS COVERED
• The Nursing-Home Population
• Nursing-Home Availability and Financing
• Staffing Patterns
• Factors Associated with Placement
• The Interface of Acute and Long-term Care
• Quality Issues and Legislation Influencing Care in the
Nursing Home
• Medical Care Issues
• Physician Practice in the Nursing Home
4
DEMOGRAPHICS
• More than 1.4 million Americans live in nursing homes
 Representing 2.8% of Americans who are > 65 years old
 15% of nursing-home residents are < 65 years old
 Average age = 82.6 years
• In recent years (1999-2008), the numbers of Hispanic,
Asian, and black Americans living in nursing homes have
increased
• The number of older adults with intellectual and/or
developmental disabilities living in nursing homes has
increased as their older parent-caregivers have died or
become unable to care for them
THE NURSING HOME POPULATION
(1 of 3)
Need assistance with 3+ ADLs
80%
Dependent on assistance for eating
57%
Incontinence
>60%
Hearing and Visual Impairments
33%
Ambulate without assistance
9.4%
Rely on chair for mobility
60.6%
5
6
THE NURSING HOME POPULATION
(2 of 3)
• Today’s population in the nursing home is sicker that the
nursing-home population of the past
• Over two-thirds of long-stay residents in skilled-nursing
facilities have multiple medical conditions
• More than 1 in 20 nursing-home residents have pressure
ulcers
THE NURSING HOME POPULATION
(3 of 3)
Heart Failure or Ischemic Disease
40%
Diabetes
22%
Stroke
Moderate to Severe Cognitive
Impairment
26%
Depression
Behavioral Issues
63%
20-25%
33%
7
8
NURSING-HOME BEDS AVAILABLE
• 15,663 nursing homes
• 1.7 million beds
• 2.4 million discharges
• 1.4 million+ residents
• Beds per home:
 80% have 50-199
 6% have 200+
6%
26%
For profit
69%
Non-profit
Government
More than half of
nursing homes
are part of a chain
9
NURSING HOME AVAILABILITY
• Ancillary services provided in a nursing home are
variable
• Many offer on-site mobile radiography and infusion
services
– Challenges exist to obtain optimal quality images
10
POSTACUTE CARE IN NURSING HOMES
• Response to declining length of hospital stays
and higher care needs of older adults
• Integrates features of acute medical care,
long-term-care nursing, and rehabilitation
• Availability of services varies by locale:
 Dialysis
 Post-operative care
 Orthopedic care
 Rehabilitative care
 Ventilators
 Wound care
11
LENGTH OF NURSING-HOME STAY
90.0%
80%
80.0%
70.0%
60.0%
50.0%
40.0%
25%
30.0%
20.0%
20.0%
10.0%
0.0%
< 90 days
>90 days
>3 years
12
FUNDING OF NURSING-HOME CARE
Spending > $140 billion
Medicaid
22%
Medicare
14%
64%
Other
MEDICARE PAYMENTS FOR
SKILLED NURSING-HOME CARE
• Predicated on patient’s functional needs and
rehabilitative potential to help recovery from acute
illness or injury
• Gains in function must be carefully documented to
ensure reimbursement for rehabilitative services
• Requires 3-day qualifying hospital stay
• First 20 days in skilled-nursing facility: pays in full
• Days 21‒100 require co-payment
• Beyond 100 days, Medicare will not cover
13
14
STAFFING PATTERNS — NURSES
• Higher quality of care correlates with:
 Total nursing hours
 Ratio of RNs to other nursing staff
• Turnover rates of staff are high: Approximately 50%
for direct care staff of nursing facilities, including
50% of nurse assistants and RNs and 35% of LPNs
have been reported
• High turnover rates are associated with increased
rates of hospitalization for nursing- home residents
15
STAFFING PATTERNS — PHYSICIANS
• Historically, the typical nursing-home physician:
 Primary care internist or family medicine physician
 Devotes 2 hours/week to nursing-home care
 Trend of more physicians dedicating their practice to nursinghome medicine
• The perception:
 Excessive regulations and paperwork
 Limited reimbursement
 Undesirability of long-term-care environment
• The reality:
 Challenging and fulfilling work requiring excellent clinical skills
and sensitivity to a variety of ethical, legal, and interdisciplinary
issues
16
STAFFING ISSUES — “CULTURE”
• Closed-staff model may improve care by facilitating
interdisciplinary communication and treatment
• Some evidence suggests lower hospitalization rates in
nursing homes that employ a limited number of
committed doctors
• In one study, quality of drug use in nursing homes
correlated with enhanced nurse-doctor communication
and regular interprofessional team discussions
FACTORS ASSOCIATED WITH
NURSING-HOME PLACEMENT
• Increasing age
• Low income
• Low social activity
• Poor family supports (especially lack of spouse
and children)
• Cognitive and functional impairment
17
INTERFACE OF ACUTE AND
LONG-TERM CARE (1 of 2)
• Most nursing-home residents are admitted from an
acute-care hospital
• Nursing-home residents have high rates of
hospitalization, most commonly due to infection
• NPs and PAs working in concert with a primary
care physician as a team:
 Have been shown to reduce hospitalization rates
while maintaining cost of neutrality
18
INTERFACE OF ACUTE
AND LONG-TERM CARE (2 of 2)
Suboptimal information transfer is common:
• Missing or illegible transfer summaries
• Omission of prescribed medications
• Advance directives not documented
• Psychosocial issues and behavior problems
not reported
19
INTERVENTIONS TO REDUCE ACUTE
CARE TRANSFERS (INTERACT)
• Developed with the support of CMS to improve early
identification, assessment, documentation and
communication about status changes in nursing home
residents
• Goal is to reduce frequency of hospital transfers
• INTERACT II intervention’s communication tools,
clinical care paths and advanced care planning tools
reduced acute hospital admissions by 17%
http://interact2.net
20
THE OMNIBUS BUDGET
RECONCILIATION ACT (OBRA)
21
• Passed in 1987 to set training guidelines and minimum staffing
requirements for nursing homes
• Mandates that each individual in a nursing facility receive and
be provided the necessary care and services to achieve and
maintain “the highest practicable physical, medical and
psychological well-being” that can be obtained
• Bolstered residents’ rights:
 Limited use of restraints
 Limited use of psychoactive medications
• Initiated the Minimum Data Set (MDS)
• Requires documentation of the need for all medications,
particularly psychoactive agents
22
THE MINIMUM DATA SET (MDS) (1 of 2)
• Periodic comprehensive clinical assessment
of all residents
• Used to compile nursing facility quality
measures such as pain, pressure ulcers,
weight loss, depression, rates of vaccination,
restraint use, and urinary tract infection
• Identification of current or potential problem
triggers review of diagnostic and therapeutic
protocols
23
THE MINIMUM DATA SET (MDS) (2 of 2)
•
In 2010, CMS updated the MDS to version 3.0
•
MDS 3.0 includes five-star quality ratings of nursing homes
• Included as part of the publicly reported quality measures
• Developed to help consumers, families, and caregivers
make comparisons about nursing homes and areas of
strength or concern
• Based on three sources of data: 1) Facility’s health
inspection survey results, 2) Staffing levels, 3)Quality
measures
•
In 2015, nursing home ratings included the percentage of a
facility’s residents who are prescribed antipsychotic drugs
LEGISLATION IN
THE NURSING HOME (1 of 2)
• Each federal regulation for long-term care is
given a tag number, often called “F-Tags”
• Adherence to regulations is assessed by
mandatory site visit surveys every 15 months,
where facility procedures, quality of care, and
quality of life for residents are reviewed
• Failure to meet regulatory standards for care is
cited in a “deficiency”
24
LEGISLATION IN
THE NURSING HOME (2 of 2)
• Penalties are imposed related to nature and severity of
deficiency
• National set of quality indicators based on MDS allows
facilities to compare their performance to local and
national norms (www.cms.hhs.gov)
• The 2010 Affordable Care Act included a provision that
will require all 16,000 nursing homes in the nation
certified by CMS to establish Quality Assurance and
Performance Improvement (QAPI) programs
25
26
ROLE OF THE MEDICAL DIRECTOR
• Influences the quality of physician practice by:
 Coordinating medical care that meets current standards
for care in the nursing home
 Setting quality standards and specific policies and
procedures in concert with medical staff
 Ensuring compliance with government guidelines
 Working with the administrator and director of nursing
to foster effective team care and appropriate continuing
staff education
• Certification is offered by the American Medical Directors
Association (www.amda.com)
• Every skilled-nursing facility must designate a licensed
physician to serve as Medical Director (F501)
27
MEDICATION REGULATION (1 of 2)
• OBRA requires monthly evaluation of medications by
a pharmacist
• Medications must be reviewed at regular intervals
and include no unnecessary drugs
• Unnecessary drugs are defined as those given:





In excessive doses
For excessive periods of time
Without adequate monitoring
Without adequate indications for use
In the presence of adverse consequences indicating
the need for dose reduction or discontinuation
28
MEDICATION REGULATION (2 of 2)
• OBRA requires that clinical documentation
demonstrate the indication for all
medications, especially psychoactive drugs
• For psychoactive medications, gradual dose
reductions are mandated unless a clinical
contraindication exists and is documented in
the medical record
CHALLENGES IN NURSING-HOME
MEDICAL CARE (1 of 2)
• Heterogeneity of residents, necessitating
individualized approaches to care
• Atypical and subtle presentation of illness
• Limited access to biotechnology
• Dependence on nonphysicians for patient
evaluation
• High prevalence of cognitive impairment
29
CHALLENGES IN NURSING-HOME
MEDICAL CARE (2 of 2)
• The need to involve families in care plans and
provide educational and psychosocial support
for families
• Ethical and legal concerns, such as end-of-life
care, feeding, hydration, and resident rights
• Intense regulatory oversight
30
NEW MODELS OF NURSING HOME CARE
(1 of 2)
• Eden Alternative: Focuses on the development of
collaborative partnerships between caregivers and older
adults and development of a human habitat with continued
contact with plants, animals, and children
• Wellspring Model: Developed learning collaborative alliances
between nursing homes to share management, training, and
data systems with the goal of implementing best practices
through empowerment of frontline workers
• Green House Model: Small groups (6-10) of older adults
reside in small noninstitutional homes set in residential
neighborhoods with care provided by empowered direct-care
staff that accomplishes all care and meal preparation
31
NEW MODELS OF NURSING HOME CARE
(2 of 2)
• Close relationships between staff and residents are
developed in each of the models
•
Evidence to date suggests these models improve
resident quality of life and employee satisfaction, while
preserving or improving quality of care
• Additional research regarding the benefits and costs of
culture change is needed
32
ENHANCING PHYSICIAN
PRACTICE IN THE NURSING HOME
• Schedule and structure visits to benefit from
efficiencies and to become better integrated into
the health care team
• Act in concert with NPs and PAs
• Document the rationale for each medication and
intervention, to protect against potential scrutiny
• Hold frequent discussions with the facility’s
consultant pharmacist
33
PHYSICAN PRACTICE IN THE
NURSING HOME (1 of 3)
Physician Responsibilities Include:
• Comprehensive admission assessment, including
history and physical examination, and review of
available medical records
• Development of a care plan in concert with other
team members, the resident, and the family that is
consistent with the resident’s needs and goals
• Periodic monitoring of chronic health problems at
appropriate intervals, using diagnostic testing,
consultation, and interventions as warranted
34
PHYSICAN PRACTICE IN THE
NURSING HOME (2 of 3)
• Prompt and thorough assessment of acute
medical problems or change in function, instituting
change in the medical treatment plan as indicated
• Communication with interdisciplinary team
members, the resident, and the family concerning
new diagnoses and treatment plans
• Periodic review of all medications, in concert with
the consultant pharmacist, with regard to ongoing
need, side effects, appropriate laboratory
monitoring, and potential interactions
35
PHYSICAN PRACTICE IN THE
NURSING HOME (3 of 3)
• Optimization of quality of life and function, with
special attention to cognition, mobility, falls, skin
integrity, nutrition, and continence
• Determination of each resident’s decision-making
capacity and assistance in establishing advance
directives
• Physical attendance to each resident, with
documentation in the medical record in accordance
with all state and federal guidelines
36
37
OPPORTUNITIES TO IMPROVE MEDICAL
CARE IN THE NURSING HOME
• Several studies have documented misdiagnoses,
inappropriate interventions, and poor preventive care
practices in nursing homes
• The Office of Inspector General (OIG) reported that 22%
of Medicare beneficiaries experienced at least one
harmful adverse event during a post-acute nursing home
stay. Over half (59%) of the adverse events were clearly
or likely preventable and resulted in $2.8 billion spent on
hospital readmissions for corrective treatment.
 The OIG recommendations to reduce resident harm included
strategies to develop more effective safety cultures, like those
that have been used in hospitals.
QUALITY OF MEDICAL CARE
IN NURSING HOMES
Strategies for enhancing quality of care:
• Specific consultation services (eg, efforts to
reduce falls)
• Interactive educational programs for physicians
and nursing staff
• Discussions with residents about their
preferences for care (eg, advance directives)
38
39
SUMMARY
• There are 15,663 nursing homes in the US with 1.4
million residents and 2.4 million discharges per year
• Nursing-home care has evolved dramatically in recent
years
• Federal law requires periodic comprehensive
assessment of all residents
• Medical care of nursing-home residents is challenging
and fulfilling because it demands excellent clinical skills
and sensitivity to a variety of ethical, legal, and
interdisciplinary issues
40
QUESTION 1 (1 of 3)
• An 82-year-old woman is preparing for discharge to a
skilled-nursing facility after hospitalization for
pneumonia.
She became deconditioned in the hospital and now
needs assistance when she walks.
She still requires oxygen.
• Before admission she lived independently, with minimal
support from her daughter.
• The patient asks about the likelihood of discharge from
the nursing facility back to her own home.
Her daughter is unable to care for her at home.
41
QUESTION 1 (2 of 3)
What is the percentage of residents discharged back to
the community within 3 months of admission to a skillednursing facility?
A. 10%
B. 30%
C. 50%
D. 70%
42
QUESTION 1 (3 of 3)
What is the percentage of residents discharged back to
the community within 3 months of admission to a skillednursing facility?
A. 10%
B. 30%
C. 50%
D. 70%
43
QUESTION 2 (1 of 2)
Which one of the following is the most common syndrome
requiring medical care in the nursing home population?
A. Arthritis
B. Chronic obstructive pulmonary disease
C. Heart failure
D. Dementia
E. Metabolic syndrome
44
QUESTION 2 (2 of 2)
Which one of the following is the most common syndrome
requiring medical care in the nursing home population?
A. Arthritis
B. Chronic obstructive pulmonary disease
C. Heart failure
D. Dementia
E. Metabolic syndrome
45
QUESTION 3 (1 of 2)
Which one of the following is most associated with
decreased transfer rates from skilled-nursing facilities to
hospitals?
A. Increased use of hospice services and advance care
planning directives
B. Financial incentives to decrease transfer rates
C. Early identification of illness and increased
communication between providers
D. Increased diagnostic and therapeutic capacities in
skilled-nursing facilities
E. Increased staffing ratios
46
QUESTION 3 (2 of 2)
Which one of the following is most associated with
decreased transfer rates from skilled-nursing facilities to
hospitals?
A. Increased use of hospice services and advance care
planning directives
B. Financial incentives to decrease transfer rates
C. Early identification of illness and increased
communication between providers
D. Increased diagnostic and therapeutic capacities in
skilled-nursing facilities
E. Increased staffing ratios
47
GRS9 Slides Editor:
Mandi Sehgal, MD
GRS9 Chapter Authors:
Suzanne M. Gillespie, MD, RD, CMD, FACP
Paul R. Katz, MD, CMD, AGSF
GRS9 Question Writer:
George Taler, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society