Tips and Tricks for Successful Navigation in Long Term Care Jessica Kalender-Rich, MD Landon Center on Aging Department of Internal Medicine, General and Geriatric Medicine July 5, 2017
Objectives To identify common misconceptions of long term care To review barriers to hospice and palliative medicine in the long term care setting To acknowledge ways to work within the LTC system successfully
The Continuum of Facility Care Independent Living Assisted Living Post-Acute Skilled Care Nursing Home, LONG TERM CARE Dementia Unit, LONG TERM CARE Other less common institutions: group homes, etc.
What do you think of when you think of nursing homes??
Hospice was designed for use in the home A nursing facility can be someone s home.
Who lives in a nursing home? Dementia (8x risk) Age Functional Disability Medication usage Less social support Women White Widowed High Caregiver burden
Who dies in the nursing home? Depends on regional, religious, socioeconomic factors More and more people. 1989 18.9% deaths in NH 1997 24.1% deaths in NH 2020 40% deaths in NH Miller, Teno, Mor. Hospice and Palliative Care in the Nursing Homes. Clinics in Geriatric Medicine 20 (2004) 717-734
Length of Stay Of the people that died Median and mean LOS = 5 months 53% died within 6 mo of placement Women lived longer Kelly, et al. Length of Stay for Older Adults Residing in Nursing homes at the End of Life. JAGs. (58) 1701-6; 2010.
History of Hospice in NH Not available until 1986 1997 30% NH contracted with hospice 2000 76% NH contracted with hospice 1997 4.2% deaths involved hospice 2000 15% deaths involved hospice Miller, Teno, Mor. Hospice and Palliative Care in the Nursing Homes. Clinics in Geriatric Medicine 20 (2004) 717-734
Differences in the NH population 40% with primary diagnosis of cancer Compared to 63% of all hospice enrollees 70% are women Compared to 53% of all hospice enrollees
Differences in NH Population
NH Culture Culture of the NH Task based MDS Extending life but dying with comfort - conflicting Ownership Physician Availability Funding Lopez, et al. The Influence of Nursing Home Culture on the Use of Feeding Tubes. Archives of Internal Medicine. 170(1), Jan 11, 2010. Miller, Teno, Mor. Hospice and Palliative Care in the Nursing Homes. Clinics in Geriatric Medicine 20 (2004) 717-734
MDS Example https://www.cms.gov/nursinghomequalityinits/downloads/mds20mdsallforms.pdf
Nuts and Bolts Attending Physician writes order for consult Often with nursing recommendation Social Worker contacts contracting hospice Intake visit, etc. Visits from hospice employees similar to home Fewer nurse visits, same # visits/week Miller. Hospice Care in Nursing Homes: Is Site of Care Associated with Visit Volume? JAGS. 52, 1331-6, 2004.
Nuts and Bolts Orders written by nursing or physician/app nursing from NH or from hospice Approved by attending per Conditions of Participation
Conditions of Participation Designed to improve Quality of Care Patients rights- to hospice, etc. Comprehensive Assessment Interdisciplinary care plan *Coordination of Services http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf
Required in the Agreement Which services will be provided by LTC vs hospice How two entities will communicate Conditions when LTC should contact hospice immediately
Dollars and Cents Considered routine home care Hospice benefit paid directly to agency Per diem hospice rate Pays for everything related to terminal illness A skilled nursing patient will make the facility WAY more money Stevenson and Bramson. Hospice Care in the Nursing Home Setting: A Review of the Literature. J of Pain and Symptom Mgmt. 38:3, Sept 09. http://www.efmoody.com/longterm/nursingstatistics.html
Barriers SNF benefit vs hospice benefit Facility reluctance Maximizing health and facilitating comfortable death Communication/Physician Involvement High Turnover late referrals Miller, Teno, Mor. Hospice and Palliative Care in the Nursing Homes. Clinics in Geriatric Medicine 20 (2004) 717-734
Benefits Fewer hospitalizations Fewer invasive treatments Better pain and symptom control More psychosocial support
Palliative Medicine Barriers are VERY slowly coming down Some facilities have consultants in place Reimbursement concerns SNF + Hospice is so sticky On some level, the entire facility continuum is practicing some degree of palliative medicne
Entering the LTC World It s a whole different world Different types of nurses, in different types of roles Different systems of medical records Different ways to communicate with primary providers (sometimes) Different amounts of control
Things to remember You are entering their world They own it day in and day out, and you are a visitor They may not think they need you Or they may need you for the wrong reasons Ask questions Family frequently identifies facility staff as primary providers
Things to remember Goals are all the same Path may be different Dependent on folks with very high care ratios to dose medications and assess symptoms Consider scheduled meds over prn
Things to remember May use a different pharmacy with different rules Order what you think you will need to ensure its arrival Provider may order more labs/meds than you think necessary Nursing may have difficulty transitioning goals
Objectives To identify common misconceptions of long term care To review barriers to hospice and palliative medicine in the long term care setting To acknowledge ways to work within the LTC system successfully
Questions??