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Chapter 26

Health Care Delivery Settings and Older Adults

Most Common Diagnosis-Related Groups (DRGs) in Hospitalized Adults 85+

Heart failure

Pneumonia

Urinary tract infections

Cerebrovascular disorders

Digestive disorders

Gastrointestinal hemorrhages

Nutritional and metabolic disorders

Rehabilitation

Renal failure

Heart disease

Malignant neoplasms

Chronic lower respiratory disease

Cerebrovascular disease

Alzheimer’s disease

Major Causes of Death in Adults 65+

Arthritis, diabetes mellitus, hypertension, and heart disease are the most prevalent chronic diseases in older adults and are the leading causes of disability.

Chronic Conditions and Disability

Effective caregiving practices can enable older persons to maintain or improve their independence and to return to their preferred setting at discharge.

Focus needs to be on not only the restoration of health but also the promotion and preservation of health.

Focusing on a functional model addresses concerns related to medical and functional stability.

Philosophy of Care in the Acute Care Environment

Adverse drug reactions—polypharmacy

Falls—Risk factors for hospital falls include intrinsic and extrinsic factors

Infections—UTI, GI, skin, and bloodstream

Hazards of immobility

Unfamiliar environment

Risks of Acute Care Hospitalization

All staff members must have competency assessment specific to patient age groups that are being cared for in the assigned area.

Nursing expertise is particularly needed to guide staff in understanding the unique needs of older patients and enhancing their skill in managing common geriatric syndromes.

Advanced practice nurses can develop and implement protocols for managing common geriatric syndromes—like those defined in the geriatric triad.

Nursing-Specific Competency and Expertise

Includes falls, changes in cognitive status and incontinence

Falls—may be a classic sign of illness for older adults

A strange environment, confusion, medications, immobility, urinary urgency, and age-related sensory changes all contribute to this increased risk.

Geriatric Triad

Requires understanding of older adult’s impaired homeostatic mechanisms, their body systems’ diminished reserve capacity, and their impaired immune response

Must be aware of atypical and subtle common presenting symptoms of disease, i.e., mental status change

Astute observation for delirium

Prevention of nutritional compromise and recognition of adverse drug reactions

Critical Care and Trauma Care

Result of falls

Automobile accidents

Burns

Consequences are usually more severe.

Thermoregulatory mechanism is impaired, so trauma victims are more vulnerable.

Greater risk for complications and mortality

Most Common Traumatic Injuries

Need to be affordable and appropriate to assist older adults to remain in the home while maintaining their quality of life

Home health care, community-based alternative programs, respite care, adult day care programs, senior citizen centers, homemaker programs, home-delivered meals, and transportation are examples of community based care.

Community-based Services

Functional status: an individual’s ability to perform the normal, expected, or required activities for self-care

Functional status determines whether an older adult needs home health care or whether a home health client is recertified for home care services.

Adapting to functional limitations is crucial for maintaining independence.

Home health nurse must assess for functional impairments.

Functional Status

Another eligibility criterion used by various community programs

Change in cognitive status frequently signals change in another body system

Cognitive impairments are associated with functional limitations.

Cognitively impaired individuals often need supervision and cueing, rather than physical assistance, to perform ADLs and IADLs.

Cognitive Function

Older adults prefer to live independently, but it may not be appropriate.

Financial status, functional status, and physical health dictate consideration of alternative housing options.

Housing Options for Older Adults

Assessment of functional status aids in determining the type of services an older adult needs to remain in his or her home.

Formal community services: home health care, homemaker services

Informal community services: senior citizen centers, adult day care services, nutrition services, transportation services, and telephone monitoring services

Community and Home-Based Services

Services provided include information and referral for medical and legal advice; psychological counseling; preretirement and postretirement planning; programs to prevent abuse, neglect, and exploitation; programs to enrich life through educational and social activities; health screening and wellness promotion services; and nutrition services

Area Agencies on Aging

Community facilities that provide a broad range of services:

(1) Health screening; (2) health promotion and wellness programs; (3) social, educational, and recreational activities; (4) congregate meals; and (5) information and referral services for older individuals and their families

Funding for senior centers is provided primarily through the OAA and agencies such as the United Way.

Multipurpose Senior Centers

Provide a variety of health and social services to older adults who live alone or with their families in the community

Most users are frail or cognitively impaired and require assistance with ADLs.

Federally regulated

Medicaid is a major funding source for most of these programs; however, participants usually pay part of the fee.

Adult Daycare Services

Provides short-term relief or time off for persons providing home care to ill, disabled, or frail older adults

Adult day care services are a form of respite provided outside the home.

Private pay and state programs that target lower income families are the two main funding sources.

Respite Care

Include such things as housecleaning, laundry services, food shopping, meal preparation, and running errands

Usually not covered by Medicare or Medicaid

In most states, no licensing or certification is required for the individual providing the care.

Homemaker Services

Provide older adults with inexpensive, nutritious meals at home or in group settings

Home-delivery programs such as Meals-on-Wheels deliver hot meals to the home once or twice a day, 5 days a week, and can accommodate special diets

Congregate meal sites provide meals in group settings such as senior centers, churches, synagogues, schools, and senior housing.

Nutrition Services

Community based transportation services for disabled older adults through public or private agencies with minimal fee

Transportation Services

Provide regular phone contact to older persons who live alone or are alone during the day.

Visitors make home visits for the purpose of companionship, assistance with correspondence, and needs assessment.

These services are usually offered for a monthly fee.

Telephone Monitoring and Friendly Visitors

Home monitoring systems that allow older persons to obtain immediate assistance in emergent situations, such as after a fall or when suffering life-threatening symptoms

Small device worn on the body (encouraged to be a necklace) and, when triggered, will send an alarm to a central monitoring station which summons help

Can be purchased or leased for a monthly fee

Personal Emergency Response Systems (PERS)

Multiple health and social services delivered to recovering, chronically ill, or disabled individuals of all ages in their place of residence

Services are covered by Medicare, Medicaid, private insurance, managed care plans, and private pay.

Home Health Care

Have a skilled care need

Be homebound

Be unable to perform the skilled care alone and have no one in the home to provide care

Require only intermittent care

Specific criteria established for coverage by physician, home health agency, disciplines providing care, and other entities providing goods or services to the patient

Home Health Care Recipient Requirements

Home care

Proprietary agencies

Facility-based agencies

Visiting nurse associations

Types of Home Health Care Agencies

Individuals who at one time could be treated only in the hospital can now be managed at home.

Home care is less expensive than hospitalization in most cases.

People recover faster at home than in institutions

Hospital-acquired infections from exposure to multiple infectious processes are minimized in a person’s home.

Benefits of Home Care

Involves assisting older adults to remain in the home and avoid institutionalization by having available resources that are responsive to their needs

Screening for home care needs begins at the time of admission to a hospital to ensure adequate time to plan for continuity of care.

Facilitated by social worker or case manager

Continuity of Care

Nurse’s role—conduct initial evaluation visit, assesses the client’s physical, functional, emotional, socioeconomic, and environmental well-being and carries out various nursing interventions like wound care and patient teaching

Implementing the Plan of Treatment

Knows about acute and chronic disease processes and how they affect older adults

Knows about gerontology, pharmacokinetics, rehabilitation nursing, and principles and presentation of disease processes in older adults

Knows about learning principles and interpersonal communication techniques, aware of cultural differences

Coordinates care and knows that observations made must be acted on immediately

Characteristics of a Home Care Nurse

Hospice provides care and services to terminally ill persons and their families, which enable individuals to die in facilities or at home.

Care is designed to address the physical, emotional, psychological, and spiritual needs of dying persons and provide support services for their families.

Goal: provide comfort care, not a cure

Hospice is a specific type of palliative care.

Hospice

Is a broader concept: therapy aimed at relieving or reducing the intensity of uncomfortable symptoms; not aimed at producing a cure

Provided in settings outside a hospice program and currently not subject to the same regulations as hospice programs

Control of pain, other symptoms, and of psychological, social, and spiritual problems is paramount.

Goal is achievement of the best possible quality of life for clients and families.

Palliative Care

Interdisciplinary team members use their skills and expertise to meet the needs of dying persons and their families such as:

Teaching family and friends how to administer medications

Helping dying persons maintain as much mobility and activity as possible

Listening and responding to a dying person’s needs

Help is available 24 hours a day.

Hospice Services

Fully covered with Medicare Part A—eligible when meeting three conditions:

The patient is terminally ill and has a life expectancy of 6 months or less.

Care must be provided by hospice program vs. standard Medicare benefits.

Care must be provided by a Medicare-certified hospice program.

Covers pain and symptom-control medications for a terminal illness, and durable medical equipment needed

Hospice as a Medicare Benefit

A collection of health, personal, and social services provided over a prolonged period

Persons living in nursing facilities are called residents.

Settings may be categorized on a continuum according to the complexity of care provided and the amount of skilled care and services required.

All nursing facilities must function under the federal regulations set forth by Omnibus Budget Reconciliation Act (OBRA).

Long-Term Care

Residents have the right to autonomy and to be active participants and decision makers in their care and life in the institutional setting.

All departments within the nursing facility, including social services, activities, nursing, dietary, and maintenance, must share responsibility for ensuring the enforcement of resident rights.

Resident Rights a Nursing Facility

Interdisciplinary functional assessment of residents is the cornerstone of clinical practice.

Resident assessment instrument (RAI)—is completed for each resident on admission, annually, when a significant change of condition occurs

Minimum data set (MDS)—is a tool that includes a comprehensive assessment of residents

Resident assessment protocols (RAPs)

Resident Assessment

Skin and nail care programs are important to a resident’s overall health and quality of life.

Focused on prevention and treatment of skin problems

Development of pressure ulcers during a person’s stay in a nursing facility is considered an indicator of poor quality of care.

Most facilities require at least weekly monitoring by a registered nurse.

Skin Care Program

As functional dependence increases, incontinence increases

Has financial, physical, and psychosocial consequences

Physical consequences include skin breakdown, urinary tract infections, and an increased risk of falling and consequent hip fracture.

Psychologically distressing health problem; may lead to depression, decreased self-esteem, and social isolation

Incontinence

Nutritional status of older people is an important determinant of quality of life, morbidity, and mortality.

Meeting a resident’s nutritional needs requires involvement of the entire health care team.

Any weight loss or weight gain must be carefully monitored.

The reasons for the loss or gain and the interventions taken must be documented.

Nutrition

Nurses are responsible for monitoring the therapeutic effects, side effects, any allergic reactions to medication, and the clinical manifestations of polypharmacy.

Routine use of long-acting benzodiazepines, hypnotics, sedatives, anxiolytics, and antipsychotics has been curtailed since the enactment of OBRA.

Residents must be informed of medication changes.

Medications

OBRA mandates that facilities provide services directed at achieving the highest practicable level of physical, mental, and psychosocial well-being for residents.

Intensive rehabilitation programs are reimbursed through Medicare Part A.

Restorative nursing programs are reimbursed through Medicare Part B.

Facilities must provide the required rehabilitation services or obtain them from an outside source.

Rehabilitation

OBRA requires nursing facilities to have an infection control program designed to provide a safe, sanitary, and comfortable environment.

Purpose: prevent development and transmission of disease

Facilities must have policies and procedures for investigating, controlling, and preventing infections.

Infection Control

Behavioral problems may jeopardize the safety of the resident or other residents.

60% of nursing facility residents have some degree of cognitive deficit which frequently precipitate difficult behaviors.

Use of physical and chemical restraints is restricted.

Emphasis is placed on using behavioral interventions and environmental modifications.

Mental Health

Functional nursing

Team nursing

Primary team nursing

Nursing Care Delivery Systems

Attractive long-term care setting, placed between home care and the nursing facility in the continuum of long-term care

Regulations are minimal so there is diversity in the types of service delivery models, types of services offered, and the setting within which assisted living is provided.

Assisted Living Programs

Special care units specialized units for persons with Alzheimer’s disease and dementia.

Subacute care—persons are stable and no longer acutely ill but may require rehabilitation, intravenous medication therapy, parenteral nutrition, complex respiratory care, and wound management

Is a growing industry

Specialty Care Settings

Creativity in “everyday” nursing facilities

For example, dogs, cats, and other animals that can live in the facility and serve as loving companions to the residents.

Nurse practitioners in nursing facilities in collaboration with physicians have been shown to reduce emergency department transfers, hospital days, and subacute days.

Innovations in the Nursing Facility

Professional nurses play a dominant role in improving and transforming this practice setting.

Nurses can prepare themselves for this role thru increased education in gerontologic nursing, nursing administration, health care regulation, and public policy related to long-term care.

The Future of the Nursing Facility