R2/R3 LONGITUDINAL LONG TERM CARE ROTATION
INTRODUCTION TO LONG TERM CARE
FACULTY
Pat Borman, MD
Carroll Haymon, MD
Carla Ainsworth,
MD
Eric Troyer, MD
GOALS
1. Understand
the different roles of informal and formal long term care (LTC) in the
continuum of geriatric health care including:
Physician Home
Visits, Home Health, Sub-acute, Short Term and Long Term Care, Hospice
2. Discuss
factors affecting the need for nursing home admission and criteria for discharge
3. Outline
physician requirements for patient care in the nursing home
4. Develop
knowledge and skills for the evaluation and treatment of common medical
complications
in long term care including:
Incontinence, Infections, Pressure
Ulcers, Pain Management, Falls, Malnutrition and Polypharmacy
5. Review
ethical considerations in End of Life Planning in LTC and model effective
communication
strategies to develop consensus
SUPERVISION
Park
West Kline Galland
Horizon House
1730
California 7500 Seward Park
S 900 University Street
West
Seattle Lake
Washington Seattle, WA 98101
937-9750 725-8800
382-3234
Carroll Haymon,
MD, Carla Ainsworth,
MD Eric Troyer, MD
Carla Ainsworth.
MD Pat Borman,
MD
Thursdays
FRIDAY AM
9:15-12:00
WEDNESDAY PM 1:45-4:30
QUARTERLIES 10:00 -
12:00 QUARTERLIES 2:00 - 4:00
ROUTINE VISITS
Residents are responsible to see
their assigned LTC patients every 30-60 days with additional acute care visits
as needed. Home visits on Horizon House patients are due at least quarterly.
Each visit should be precepted by a geriatric faculty member at the time of the
visit. If you must see your patient when the preceptor is not physically
present, the visit should still be precepted with geriatric faculty or a
geriatric fellow. During daytimes hours during the week residents will handle
telephone contact initiated by the LTC facility concerning their patient. After
5 pm and on weekends the Family Practice Service on call physician will be
responsible for LTC facility calls. The resident will be responsible for
providing the nursing home with an alternate care provider contact for illness
or vacation absences. Please be considerate to sign out active care issues to
your coverage (labs pending, illness alerts). Develop a reminder system to keep
track of when you are due to see your patient. Let your site supervisor know if
a visit is due and hospital rotations or an away elective will make you unable
to see your patient as scheduled.
QUARTERLIES AT PARK WEST AND
KLINE GALLAND
Residents are responsible for
seeing their patient prior to the quarterly. Each resident will make a concise
case presentation. Discussion will address the teaching/learning points
surrounding the patient cases. Next an interactive presentation on important
long term care topics will take place. The quarterly topics include:
1.
Orientation to LTC
2.
The Physician Role and
Multidisciplinary Team Members
3.
Coding and Billing in LTC
4.
Medication Management and Reduction
of Polypharmacy
5.
Assessing Acute Changes in the
Patient
6.
Infections in LTC
7.
Dementia, Geropsychiatry and
Difficult Behaviors
8.
Preventive Medicine in LTC
9.
Communication Skills
10.
Pain Management
11.
Reflections on LTC, Feedback
PHYSICIAN REQUIREMENTS IN LONG TERM CARE
1. Admit
Examination within 48 - 72 hours of admission
History
Reason for admission,
Status of active problems
Past medical and surgical
history
Preventative care
vaccinations, eye, dental, podiatric
Medications
Review of Symptoms
Physical
Systems approach AND
orthostatics, nutritional status, hearing screen, vision, mobility
Cognitive function,
Affective status, Functional Status with ADL, IADL,
Socioeconomic Status
Family involvement,
finances, social history
End of Life Planning
Advanced Directives,
Desired intensity of care, Return to hospital or not, DPOA, Living Will
Care Plan Development to design
medical and multidisciplinary involvement to meet patients needs
2. Periodic
Visits are required every 30 days for the first 3 months and every 60 days
thereafter
Medical Progress Notes for Long
Term Care Patients
S New complaints and
symptoms related to active medical conditions
O General appearance,
weight, VS
Directed physical
exam, reports on functional and behavioral status
Rehabilitation
progress, interdisciplinary team member reports, Lab, Consults
A Differential diagnosis
of new concerns, status of active problems, response to interventions
P Changes in diet,
medications, treatments, interventions, diagnostics, discharge planning if
indicated
3. Visits
are indicated when acute problems arise. Telephone medicine is a common
strategy when you cannot “drop everything” and go there in person.
4. Annual Review of Long Term
Care Patients is required.
Active medical
problem list and chronic non-active problems
Review medical
history for events over the last year including monitoring
Current Medication
Review
Symptom review for
common nursing home problems
Physical exam note
any new findings
Functional status
current and changes during the year
Including ADL, IADL, Mobility, Cognitive function, Affective status
Rehabilitation
potential
Social status
family concerns, problems, involvement
Health Care
Maintenance
Vaccinations, audio, ophtho, dental, podiatric, TB testing
Screening tests and results
End of Life
Planning
Review any changes in Advance Directives, HCDPOA, intensity of care desired,
goals of care
GOALS IN LONG TERM CARE
Provide a safe and supportive
environment for chronic illness and dependency
Maximize individual autonomy,
functional capability and quality of life
Stabilize and delay the
progression of chronic conditions
Prevent or recognize and manage
acute and subacute illness rapidly
Avoid treating normal changes of
aging as disease
Supervise the multidisciplinary
team needed to supply excellent long term care
FACTORS THAT MAKE LONG TERM CARE
CHALLENGING
The goals of care are often
different and must be individualized
“Tight Control” of chronic diseases like CHF, DM poses dangers in the frail
elderly
Specific clinical disorders are
prevalent among long term care population
The approach to health care
maintenance and prevention is different
Mental and Functional status tend
to impact quality of life more than medical diagnoses
Assessment must be
interdisciplinary including
Nursing and nursing assistants
Psychosocial
staff including geropsychiatrists, social workers, activity leaders, pets
Rehabilitation
staff including OT, PT, Speech
Nutrition staff
including RD and chefs and family
Ancillary
Specialists including Dental, Ophthamology, Podiatry, Audiology
Pharmacy
Family and
patient support network
Sources of information for
physician care are variable:
Residents may
be nonverbal or cognitively impaired
Family members
and nursing assistant have limited assessment skills but provide crucial
information and details about patient concerns.
Reliance on
telephone for communication about patient changes
Difficulty in smooth transition of
information to and from hospital and primary care physicians
Clinical decision making is
different:
More reliance
on bedside diagnostic skills
Diagnostic and
therapeutic procedures may be unavailable, difficult to obtain, or pose
significant risk of discomfort or iatrogenic harm
Decision making capacity is often limited, knowledge of their values and
preferences is not always known generated ethical challenges
The appropriate site and the
appropriate intensity of medical treatment pose difficult decisions involving
medical, emotional, economic and legal considerations that may result in ethical
conflicts
Logistic considerations, resource
constraints and restrictive reimbursement policies may limit the physicians
abilities and incentives to provide optimal medical care
DEMOGRAPHICS
For people over the age of 65
there is a 40% risk of long term placement.
Only 5% of all people in this age
group are institutionalized at any one time or about 1.5-2 million:
1% age 65-74
15% Men over 85
25% Woman over 85
As the Babyboomers age the nursing
home population is expected to swell to 3.6-5.9 million by 2040.
Who gets admitted and what happens
then?
15% of
hospitalized elderly are discharged to a skilled nursing facility
22% admitted from
the hospital to the nursing home are medically unstable
50% have
unresolved medical conditions
27% require
re-admission to the hospital in less than 30 days and of these 65% die in the
hospital
45% of admissions
for less than 3 months (terminal illness, acute rehab for medical, ortho, neuro)
Average length of
stay is 19 months
25% are discharged
to home
18-25% die in the
nursing home
ECONOMICS OF LONG TERM CARE
MEDICARE will pay for up to
100 days of Skilled Nursing Facility (SNF) care for active
rehabilitation of acute medical problems requiring skilled nursing.. To qualify
for SNF admission the Medicare patient must be hospitalized for a minimum of 72
hours (three overnights) for the acute problem requiring nursing home
admission. Coverage pays for the first 20 days of skilled care at 100%, days
21-100 of skilled need are covered with a $101 per day co-pay. Once the patient
has plateaued or if the patient refuses rehabilitation services the Medicare
benefit stops. Medicare does not cover custodial care at all.
MEDICAID will pay for
skilled nursing and custodial care for the categorically needy. Qualifications
wary by state. In Washington individuals must “spend down” to have no more
than $532 per month income and non-housing assets of less than $2,000. Only
$30-75 per month of income may be reserved for a personal allowance. All other
income must go towards the long term care bill. If married, the spouse may
retain income only up to 150% of the poverty limit, the house and a car for
transportation. The state can place a lean on the assests of the home to help
pay for LTC. In this case, when the patient dies, the estate must reimburse
that state for monies already spent on the patients care. Either the house must
be sold or the descendants must reimburse the state from other monies.
LONG TERM CARE INSURANCE
Currently only 10% of Americans purchase long term care insurance to help
finance their long term care needs.
PRIVATE PAYMENT 56% of
patients pay out of pocket for nursing home expenses not covered by Medicare
until they qualify for Medicaid.
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