Week: Nursing Homes
Discussion Topic
In this forum, what do you see as some very important issues in nursing homes? (for example: service or staff & operational issues) Why do you think these are major issues? What can be done to prevent or fix the issue?
(NYC)
Outside research is welcomed.
An initial posting of at least 275 words
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
CHAPTER HIGHLIGHTS
They include those certified by Medicare as Skilled Nursing Facilities (SNF) and what
used to be called Intermediate Care Facilities (ICF), the primary difference being the
amount of nursing care provided.
Nursing homes grew out of early charity-based forms of care for people without family to
care for them or other sources of help.
They came into their own when the federal government became involved with assisting
the needy with passage of the Social Security Act in 1935 and the Medicare and
Medicaid amendments in 1965.
They suffered through a lingering poor public image.
Philosophy of care
Medical vs. Social Model – Nursing facilities find themselves sitting solidly astride the
line between acute care and long-term care.
A Multidisciplinary Approach – They utilize a combination of medical, social, residential,
and other allied professionals to provide needed services, blending those disciplinary
specialties to develop and implement care plans for individual consumers.
Chapter 4 1
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Family Involvement – Another distinguishing characteristic of long-term care in general,
and nursing facilities in particular, is the degree to which family members are involved in
the care of the primary consumer.
More for-profit than nonprofit
More than half owned by national multi-facility chains
Occupancy
The occupancy rate for nursing facilities has declined from a high of 89.0 percent in 2007
to 86.0 percent to 2013.
Nursing
Physical therapy
Occupational therapy
Speech therapy
Medical and dental services
Medications
Laboratory and x-ray services as needed.
Special Care Units – many facilities created special care units to meet the needs of a wider
variety of residents. They may be:
Based on a Specific Diagnosis or Disability
Alzheimer’s Disease
Chapter 4 2
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Mental Health & Mental Retardation
Brain Injury
AIDS
Based on Age
Pediatric
Young Adults
Consumers Served
By age:
Mostly elderly
By care Needs:
Admitted because of functional disabilities, resulting from a number of medical or
physical conditions
May include both physical and mental disabilities
By gender Mix:
Three-quarters women
Market Forces Impacting Nursing Facilities
Need-Driven Vs. Choice-Driven Admissions – most residents do not choose to be
admitted, but must be due to their conditions.
Family/Physician Initiated Admissions – admission is usually not at the request of the
resident but by family or a family physician.
Chapter 4 3
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Hospital Readmissions – under the Affordable Care Act’s Hospital Readmissions
Reduction Program, hospitals that readmit “excessive” numbers of Medicare patients
within 30 days of discharge now face significant penalties.
Location Relative to the Resident’s Family – facilities are often chosen so the resident
can be close to family members.
Alternative Types of Care (or Lack of) – some are admitted to nursing facilities because
of a lack of other alternatives (e.g., community-based care).
Regulations
There are three primary categories of regulations:
Affecting Residents – Regulations concerning care and quality of care
Affecting Employees – regulations protecting employees from unfair treatment
Affecting Building Construction and Safety – regulations assuring proper construction
and maintenance of facilities.
Financing Nursing Facilities
Medicaid is the largest source (two-thirds)
It covers the medically indigent
Medicare is the next largest
It provides limited coverage
Other sources include insurance and out-of-pocket
Staffing/Human Resource Issues
Chapter 4 4
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Nature of the Work Force – nursing facilities utilize a staffing mix that combines both
highly trained and relatively untrained
staff.
Must provide both clinical and non-clinical care
Government regulations, particularly OBRA and Medicare, specify the numbers of
staff on duty on each work shift and the mix of personnel categories making up that
staff.
Nursing
Certified Nurse Aides
Medical Coverage
Other Specialists
Recruitment/Turnover Issues
Aging of the workforce – the population group available to provide care is getting
smaller due to aging
Relatively low pay – the amount allowed by Medicaid (the primary payment source)
is not adequate
Competition from other sectors – staff can make more working elsewhere, even in
fast-food restaurants
Legal/Ethical Issues
Day-To-Day Quality of Life Issues
Desire for privacy, personal autonomy
Individual vs. group choice is an issue
Chapter 4 5
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
End of Life Issues
Many residents live out their last days in a nursing facility
Competency and choice are issues
Management of Nursing Facilities
Management Qualifications:
Must be licensed by states
Some variation in state regulations
Management Challenges & Opportunities:
Balancing Cost and Quality – never enough resources
Integration of Differing Levels of Service – many are part of a multi-level facility
providing several types of care, possibly including assisted living, home health care
and/or subacute care in addition to skilled and nursing care.
Coordination with Other Facilities, Organizations – it is no longer possible/feasible to
stand alone.
Significant Trends and Their Impact on Nursing Facilities
Rising Acuity Levels – as acute care hospitals try to save money, higher acuity patients
are sent to nursing facilities.
Managed Care – has become a primary form of reimbursement and comes with strings
attached.
Other Reimbursement Trends:
Chapter 4 6
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Prospective Payment
Private LTC Insurance – not a large enough source of reimbursement
Payment Bundling – the ACA created a system of payment bundling where a single
entity would receive a sum of money to cover the costs of an episode of care spanning
two or more providers
Rising Liability Insurance Costs – threaten the survival of providers
Consumer Choice – the single, most important trend today is the demand by consumers
for more choice in their care
Chapter 4 7
- CHAPTER FOUR: NURSING FACILITIES
- CHAPTER HIGHLIGHTS.c
- .c2.Philosophy of care
- The occupancy rate for nursing facilities has declined from a high of 89.0 percent in 2007 to 86.0 percent to 2013.
- .c2.Special Care Units – many facilities created special care units to meet the needs of a wider variety of residents. They may be:
- .c2.Consumers Served
- .c2.Market Forces Impacting Nursing Facilities
- .c2.Regulations
- .c2.Financing Nursing Facilities
- .c2.Staffing/Human Resource Issues
- Legal/.c2.Ethical Issues
- .c2.Management of Nursing Facilities
- .c2.Significant Trends and Their Impact on Nursing Facilities
Introduction
Nursing facilities used to be called “nursing homes”
How nursing facilities developed
.c3.Medical vs. Social Model – Nursing facilities find themselves sitting solidly astride the line between acute care and long-term care.
.c2.A Multidisciplinary Approach – They utilize a combination of medical, social, residential, and other allied professionals to provide needed services, blending those disciplinary specialties to develop and implement care plans for individual consumers.
.c3.Family Involvement – Another distinguishing characteristic of long-term care in general, and nursing facilities in particular, is the degree to which family members are involved in the care of the primary consumer.
Ownership of Nursing Facilities
This may be due to competition from community-based services.
Services Provided
By age:
Mostly elderly
.c3.By care Needs:
AAAdmitted because of functional disabilities, resulting from a number of medical or physical conditions
.c3.;By gender Mix:
.c3.Need-Driven Vs. Choice-Driven Admissions – most residents do not choose to be admitted, but must be due to their conditions.
.c3.Family/Physician Initiated Admissions – admission is usually not at the request of the resident but by family or a family physician.
.c3. Hospital Readmissions – under the Affordable Care Act’s Hospital Readmissions Reduction Program, hospitals that readmit “excessive” numbers of Medicare patients within 30 days of discharge now face significant penalties.
Location Relative to the Resident’s Family – facilities are often chosen so the resident can be close to family members.
.c3.Alternative Types of Care (or Lack of) – some are admitted to nursing facilities because of a lack of other alternatives (e.g., community-based care).
.c3.There are three primary categories of regulations:
Affecting Residents – Regulations concerning care and quality of care
.c3. Affecting Employees – regulations protecting employees from unfair treatment
.c3. Affecting Building Construction and Safety – regulations assuring proper construction and maintenance of facilities.
.c3.Nature of the Work Force – nursing facilities utilize a staffing mix that combines both highly trained and relatively untrained staff.
.c4.Nursing
.c4.Certified Nurse Aides
.c4.Medical Coverage
.c4.Other Specialists
.c3.Recruitment/Turnover Issues
.c3.Day-To-Day Quality of Life Issues
.c3.End of Life Issues
.c3.Management Qualifications:
.c3.Management Challenges & Opportunities:
.c4.Balancing Cost and Quality – never enough resources
.c4.Integration of Differing Levels of Service – many are part of a multi-level facility providing several types of care, possibly including assisted living, home health care and/or subacute care in addition to skilled and nursing care.
.c4.Coordination with Other Facilities, Organizations – it is no longer possible/feasible to stand alone.
.c3.Rising Acuity Levels – as acute care hospitals try to save money, higher acuity patients are sent to nursing facilities.
.c3.Managed Care – has become a primary form of reimbursement and comes with strings attached.
.c3.Other Reimbursement Trends:
.c4.Prospective Payment
.c4.Private LTC Insurance – not a large enough source of reimbursement
Payment Bundling – the ACA created a system of payment bundling where a single entity would receive a sum of money to cover the costs of an episode of care spanning two or more providers
Rising Liability Insurance Costs – threaten the survival of providers
.c3.Consumer Choice – the single, most important trend today is the demand by consumers for more choice in their care
Chapter 4
Nursing Care Facilities
1. Define and describe
nursing facilities
2. Identify sources of financing for nursing
facilities
3. Identify and describe regulations affecting
nursing facilities
4. Identify and discuss ethical issues
affecting nursing facilities
5. Identify trends affecting nursing
facilities in the near future and
describe the possible impact of those
trends
Includes:
Facilities licensed by the states offering
room, board, nursing care and some
therapies
Those certified by Medicare as skilled
nursing facilities (SNF) and what used to
be called intermediate care facilities (ICF)
Early charity-based forms of care
Poor public image
Increased regulation
Significant improvement
Still under scrutiny
Medical vs. social model
• “care not cure”
Multidisciplinary approach
Family involvement
Largely for profit (68%)
Nonprofit (25%)
Government owned (6%)
Growth in multifacility chains (55%)
Nursing
Physical therapy
Occupational therapy
Speech therapy
Medical and dental services
Medications
Laboratory and X-ray services
Room and board
By diagnosis or disability:
• Alzheimer’s disease
• Mental health and intellectual disabilities
• Brain injury
• AIDS
By age:
• Pediatric
• Young adult
Elderly – over 90%
Female – two-thirds, male – one-third
Both physical and mental disabilities
• Two-fifths have dementia
• Many have depression
Bathing
Dressing
Eating
Toileting
Transferring
* Average resident needs help with 4 ADLs
Need-driven admissions
Family- and physician-initiated admissions
Hospital Readmissions
Location relative to resident’s family
Alternative types of care (or lack of)
© 2010 Jones an Brtlett Publishers, LLC
Purpose of regulations:
Care is safe and of high quality
Care is not unnecessarily expensive
Services are uniformly accessible
Rights of workers are protected
Affecting residents
Affecting employees
Affecting building construction
and safety
Reimbursement sources:
Medicaid – 66%
Medicare – 13%
Private pay and other sources –
the remainder
Restrictions:
Covers only skilled nursing care
Must follow 3-day hospital stay
Limited to 100 days per “benefit period”
Requires co-payment for days 21–100
Nursing
Certified nurse aides (CNAs)
Medical coverage
Other specialists
• Often on contract basis
Responsibility to:
Protect residents’ rights
Act ethically
Day-to-day quality-of-life issues:
• Autonomy (choice)
• Privacy
End-of-life issues:
• Advance directives
• living will or power of attorney
• Patient Self-Determination Act of 1990
• Cognitive ability?
Licensed by the states
Differing state regulations cover:
• Education requirements
• Hands-on experience
• Continuing education
• NAB
Management Challenges
and Opportunities
Balancing cost and quality
Integration of differing levels of service
Coordination with other facilities and
organizations
Rising acuity levels
Managed care
Prospective payment
Private long-term care insurance
Payment bundling
Rising liability insurance costs
Consumer choice
Nursing facilities have a long history but
are evolving, as is the overall system.
They have gone from being the dominant
form of long-term care to one of many
provider types.
- Slide 1
- Management Challenges and Opportunities
Learning Objectives
Learning Objectives (continued)
What is a Nursing Facility?
How Nursing Facilities Developed
Philosophy of Care
Ownership of Nursing Facilities
Services Provided
Special Care Units
Those Served
Activities of Daily Living (ADLs)
Market Forces
Regulations
Types of Regulations
Financing Nursing Facilities
Medicare Coverage
Staffing and Human Resource Issues
Legal and Ethical Issues
Types of Legal and Ethical Issues
Management Qualifications
Significant Trends
Summary