Discussion Board
© 2010 Jones and Bartlett Publishers, LLC
© 2010 Jones and Bartlett Publishers, LLC
Chapter 1
Overview of Long-Term Care
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Introduction
- LTC is associated with physical/mental deficits that limit a person’s ability to do daily tasks
- LTC services are needed mostly by the elderly
- LTC is a set of diverse services that include informal care, community-based services, and institutional services
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Why the need for Long-Term Care
Three main circumstances create the need:
Need for assistance with daily living tasks
Because of physical/mental disability, severe illness, or cognitive impairment
Measures to assess the level of dependency:
1. Activities of daily living (ADL) scale
2. Instrumental activities of daily living
(IADL) deficits
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Why the need for Long-Term Care
Need for continuity of care after hospitalization
Subacute care
Clinically complex care
Rehabilitation while recovering from accidents or surgery
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Why the need for Long-Term Care
Need for care in specialized environments
Specialized pediatric environments because of intellectual/developmental disabilities (IDD)
Dementia and Alzheimer’s disease
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Dimensions and Principles of LTC
Variety of services to serve different needs
Services are individualized
Total care must be coordinated
They must promote functional independence
Services are delivered over an extended period
Current technology should be used
Evidence-based practices should be employed
The approach should be holistic
Quality of care should be maximized
Quality of life should be maximized
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Variety of Services - 1
- Variety of services are needed because
- People’s needs differ
- Even the elderly are not a homogeneous group
- Needs change over time
- Needs do not necessarily change from lighter to more intensive levels of care
- People’s preferences vary
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Variety of Services - 2
LTC is an amalgam of 5 distinct services:
Medical care, nursing, and rehabilitation
Mental health services and dementia care
Social support
Supportive housing
Hospice services
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Variety of Services - 3
Medical care, nursing, and rehabilitation
- Post-acute skilled nursing care
- Clinical management of chronic conditions and comorbidity, to include tertiary prevention
- Restoration or maintenance of physical function
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Variety of Services - 4
Mental health services and dementia care
- Mental health care is generally delivered by specialized outpatient and inpatient providers
- Moderate to severe dementia generally requires institutional care
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Variety of Services - 5
Social support
- Assistive and counseling services
- To help people cope with various situations that bring on stress
- Stressors can accompany the aging process or may be event driven (e.g., conflict)
- Manifestations: anger, denial, confusion, fear, despondency, depression
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Variety of Services - 6
Supportive housing
- Compensate for people’s disabilities
- Congregate housing with support services (meals, housekeeping, transportation, etc.)
- Basic amenities: Space, privacy, safety, comfort, cleanliness
- Other amenities: Homelike environment, social activities, recreation, décor
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Variety of Services - 7
Hospice services
- End-of-life care for the terminally ill (life expectancy is ≤6 months)
- A cluster of services: Medical, spiritual, legal, financial, and support for family
- Emphasis shifts from medical treatment to comfort, palliative care, and social support
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Individualized Services
- See Figure 1-1
- Assessment: To identify needs
- Current physical, mental, and emotional condition
- Past medical and psychosocial history
- Social history: family, former occupation, leisure activities, cultural factors
- Individualized plan of care
- Customized interventions to address needs
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Well-Coordinated Total Care
- Total care: Any health care need is recognized, evaluated, and addressed
- Care is coordinated with non-LTC health care providers when needed
Examples: (1) Obtaining specialized services from dentists, optometrists, podiatrists, etc. (2) Transfer to a hospital to address an acute episode (3) Mental health care.
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Promotion of Functional Independence
Goal of LTC: To enable the patient to maintain functional independence at the maximum level practicable
- Restoration of normal function is generally not possible
- Use of adaptive equipment
- Motivate the patient to do as much as possible
- Ongoing maintenance therapy
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Extended Period of Care
- LTC is generally needed for longer than just a few days
- Short-term services (less than 90 days):
- Rehabilitation
- Post-acute convalescence or stabilization
- In case of severe health and disablement issues, and for community-based services, LTC may be needed for years
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Use of Current Technology
- Certain technologies can enable people to live in the community
- Technology can improve overall safety and quality of care
- Other types of technology are meant for institutional use
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Use of Evidence-Based Practices
- Best practices are established through clinical research
- Best practices are standardized into clinical practice guidelines
- A guideline is indicated for the treatment of a specific health condition
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Holistic Approach
It addresses four areas of a person’s total well-being:
- Physical – technical aspects of care
- Mental – mental and emotional well-being
- Social – companionship, information, counseling, and recreation
- Spiritual – faith and religious context
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Maximizing Quality of Care
- Quality of care = desirable outcomes
- Clinical outcomes
- Satisfaction-related outcomes
- Requires a culture of continuous improvement
- Regulatory standards as well as clinical practice guidelines should be implemented
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Maximizing Quality of Life
- Total living experience that results in satisfaction with one’s life
- Five factors:
- Lifestyle factors
- Living environment
- Palliation
- Human factors
- Personal choices
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The Elderly and Long-Term Care (1)
- The elderly are the primary clients of LTC
- Chronic ailments, comorbidity, disability, and dependency tend to follow each other (Figure 1-2)
- ADL and IADL limitations increase with age (Figure 1-3) – severe declines may suggest the need for institutional care
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The Elderly and Long-Term Care (2)
- The elderly in fair to poor health are likely to need LTC at some point
- Even those in good to excellent health may need short-term LTC after an accident, surgery, or acute illness
- The growing nonwhite elderly population in poorer health than whites will present social and cultural challenges
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Aging of People with HIV/AIDS
- AIDS has evolved from a terminal illness to a chronic condition
- Prevalence of HIV has been increasing, particularly among the 50+ age group
- Aging HIV/AIDS patients become susceptible to multiple comorbidities and cognitive impairment
- They have lower levels of physical ability and less independence – greater need for LTC
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The LTC Delivery System - 1
Continuum of long-term care (Figure 1-4):
- The informal (unpaid) system is the largest
- Community-based services are:
- Intramural (in-home)
- Extramural (out of the home)
- A variety of institutions deliver services ranging from simple to complex
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The LTC Delivery System - 2
- Complexity of the LTC system necessitates case management:
- A coordinating function
- Special needs of clients are identified
- A trained professional determines which services would be most appropriate
- Referral to services and financial arrangements
- Coordination and monitoring to ensure services are received
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The Informal System
- Most LTC services are provided informally by family, friends, etc. on an unpaid basis
- Most of the care is of a basis nature
- It is also the largest source of financing, although unpaid
- Extent of the support network determines ability to receive informal care: men, minorities, married people, and less educated
- A shrinking pool of informal caregivers
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The Community-Based System - 1
- Formal services delivered by various agencies
- Fourfold objective:
- Deliver LTC in the most economical and least restrictive settings
- Supplement informal caregiving when needed
- Provide temporary respite to family members
- Delay or prevent institutionalization
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The Community-Based System - 2
Intramural and Extramural Services
- Intramural services (in-home services)
- Home health care
- Meals On Wheels
- Homemaker, chores and errands, etc.
- Extramural services
- Adult day care
- Senior centers
- Respite care
© 2010 Jones and Bartlett Publishers, LLC
© 2010 Jones and Bartlett Publishers, LLC
The Institutional System
- Appropriate when needs cannot be met through community-based services
- Inability to live alone or lack of social support may also trigger institutionalization
- An institutional continuum offers services according to the patient’s level of dependency for care
- See Figure 1-4
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Independent or Retirement Housing
- Suitable for people who can manage their own care
- Physically supportive environment to promote an independent lifestyle
- Hotel services may or may not be available
Residential or Personal Care Homes
Light assistive care
Hotel services are generally included
Assisted Living Facilities
24-hour personal care and some nursing services
Suitable for people who cannot function independently but do not need skilled nursing care
Many offer services for dementia
Skilled Nursing Facilities - 1
- Typical nursing homes
- Higher end of the continuum
- Institutional and clinical environment
- Innovative designs and environments are being adopted
- A variety of disabilities often coexist
- Cognitive impairments are common
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Skilled Nursing Facilities - 2
- Facilities employ full-time administrators
- Administrators must understand clinical and social care
- Administrators must be trained in management and leadership skills
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Subacute Care Facilities
- Services previously available only in hospitals
- Cheaper alternative to hospitals
- Acuity level is higher than in skilled nursing facilities
Specialized Care Facilities
- Nursing homes that specialize in a given type of care
- Ventilator care, Alzheimer’s, intensive rehabilitation, etc.
- ICFs/IDD facilities provide specialized programming
for those suffering from mental retardation and associated disabilities (IDDs)
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Long-Term Care and
Complementary Services
- Coordination between LTC and non-LTC care is necessary for meeting patients’ total care needs
- Primary care
- Mental health care
- Specialty care such as cardiology, ophthalmology, dermatology, etc.
- Acute care
- Diagnostics and screening
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