Discussion w3 652

Q-1

Overall the differences between acute rehab, skilled care, long-term care, and hospice patients depend on the category of the facility and their services offered (Alina Health, n.d.); (Differences Between LTACHs, IRFs and SNFs, 2021); (Smith, Kulhari, Wolfram, & Furlan, 2017). Some examples include the complexity of medical care in which intensive care needs to be provided continuously so an LTACH would be most appropriate such as long-term weaning from a trach or a ventilatior (Differences Between LTACHs, IRFs and SNFs, 2021). Another example would be the level of therapy offered,  and an LTACH may offer some, but not as intense or as skilled as an Inpatient Rehab Facility for those who need aggressive rehab to get back to a prior level of functioning (Differences Between LTACHs, IRFs and SNFs, 2021). A skilled nursing facility tends to be the middle ground for patients who don't qualify for inpatient rehab due to medical conditions holding them back, but those medical conditions don't require intensive care so they don't qualify for an LTACH (Differences Between LTACHs, IRFs, and SNFs, 2021). In the question of dialysis, both LTACHs and SNFs can provide either onsite dialysis or transportation to dialysis centers depending on the facility capabilities, but rehab facilities usually do not thus renders the patient unable to be placed (Differences Between LTACHs, IRFs and SNFs, 2021). However, in my career I have seen people be admitted to rehab facilities, but then have additional arrangements for transportation to a dialysis center, but their medical requirements were extremely low on discharge. 

Hospice is unique from the others in the fact that the admission criteria include a terminal diagnosis (Matthews & Daigle, 2020). Notably, the most major difference between hospice and the others is that the goal of hospice is not to restore the patient to the prior level of functioning or to decrease their therapies, but to provide a comfortable, dignified experience while the patient passes on (Matthews & Daigle, 2020).

An example of an intermediate care facility that helps to precipitate progression to an independent living facility would be that if someone had an acute stroke (Smith, Kulhari, Wolfram, & Furlan, 2017). There are several factors that play into the placement of an acute stroke patient, such as the severity of the stroke, neurological deficits, and hours of therapy that are estimated to either get the patient back to their baseline, or to a point of which they can care for themselves (Smith, Kulhari, Wolfram, & Furlan, 2017). This is also dependent on the ability of the patient to be involved in and participate in set hours of rehabilitation therapy or days of rehabilitation therapy (Smith, Kulhari, Wolfram, & Furlan, 2017). Most acute strokes usually are able to be placed in a short or intermediate-length acute care facility depending on the factors mentioned previously (Smith, Kulhari, Wolfram, & Furlan, 2017). These patients are able to utilize the intense therapy to regain the ability that they have lost from the stroke, and then once they improve to a point of self-care, they can then be transitioned to an independent living facility (Smith, Kulhari, Wolfram, & Furlan, 2017). Ultimately this bridge program is a plan in place for that patient, but the ultimate goal is to restore all of the patient's functions and send them back to their prior living arrangement (Smith, Kulhari, Wolfram, & Furlan, 2017).

References:

Alina Health (n.d.). Guidelines for Admission to the Acute Inpatient Rehabilitation Units at Abbot Northwestern and United Hospitals. AlinaHealth. Retrieved from [PDF]: https://www.allinahealth.org/-/media/allina-health/files/uploadedfiles/ckri-inpatient-guidelines.pdf

Differences Between LTACHs, IRFs and SNFs (2021). Post Acute Medical. Retrieved from: https://postacutemedical.com/company/company-updates/differences-between-ltachs-irfs-and-snfs

Matthews, B., & Daigle, J. (2020). Connecting the dots between caregiver expectations and perceptions during the hospice care continuum: Lessons for interdisciplinary teams. International Journal of Healthcare Management, 13, 120–132. https://doi-org.lopes.idm.oclc.org/10.1080/20479700.2018.1453575

Smith, A. L., Kulhari, A., Wolfram, J. A., & Furlan, A. (2017). Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility. Journal of Stroke and Cerebrovascular Diseases, 26(4), 711–716. https://doi-org.lopes.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2015.12.037

Q-2

Inpatient rehabilitation is an acute rehabilitation facility that is intended for patients that require intense multidisciplinary rehabilitation (Ang & Dave, 2017, p. 463). Patients should have one of the following diagnosis based on Medicare Inpatient Rehabilitation Facility: stroke, spinal cord injury, amputation, congenital deformity, major multiple traumas, femur fracture, brain injury, neurological disorders, active polyarticular rheumatoid arthritis, systemic vasculitides with joint inflammation, severe or advanced osteoarthritis, hip or joint replacement to qualify for the rehabilitation (Ang & Dave, 2017, p. 466). Patients should need rehabilitation and should tolerate an average of 3 hours of therapy per day at least five days a week with a minimum of two disciplines such as physical therapy, occupational therapy, and speech therapy.

A patient should go to a skilled nursing facility if the patient requires a continuity of care that is typically started before discharge from the hospital. A patient should be seen by a nurse practitioner or a doctor at least one to two times per week, nursing needs of at least three to four hours per day with the therapy of at least zero to one and half hour per day (Ang & Dave, 2017, p. 465).

Hospice care is a facility that caters to the patient who has reached a terminal phase of life with an expected prognosis of fewer than six months (p. 466). It helps in decreasing the uncomfortable physical symptoms such as pain, dyspnea, constipation, nausea, and excessive mucus production. It can be done at home or in a facility in a non-resource patient. According to Medicare.gov (n.d.), patients who agree to hospice care means that they are agreeing for comfort care instead of cure to their illness (Medicare.gov, n.d.). Pain relief medication, symptom management, durable medical equipment, aide, homemaker services, spiritual and grief counseling for the patient and their families are free.

The long-term care facility is an area wherein the patient requires medically intense care and the care is handled by the hospitalists. The long-term care facility only receives a full Medicare payment rate if: the patient has spent at least three days in an intensive care unit and the patient remains on a ventilator in the long-term care hospital for at least 96 hours (Ang & Dave, 2017, p. 465). Patients who have complex comorbidities not requiring ICU or ventilator at the LCTH, those who have complex psychosocial factors impending discharge, those who have complex wound care that requires extensive dressings and those who are new oncology patient that evolves chemotherapy and radiation plan that requires numerous outpatient care or labwork does not qualify for full payment in a long term care hospital setting.

I started working as a nurse a few years back in the skilled nursing facility, then transfer to a long-term care facility, did a prn job at an inpatient rehabilitation facility. So far, my favorite job is working in an inpatient rehabilitation facility. It is because the majority of my patient is awake, alert, can follow commands and pretty much independent that they require physical therapy or occupational therapy. It is always a joy to see my patient recovers and go home. I enjoyed every minute that I can communicate and help my patient as they transition from the hospital to home.

References:

Ang, E. & Dave, J.K. (2017). Postacute care rehabilitation options. S.C. Mckean, J.J. Ross, Dressler, D.D. & Scheurer, D.B. Principles and practice of hospital medicine (2nd edition) (p. 463- 468). Mcgrawhill education

 

 

Medicare. Gov (n.d.). Hospice Care Coverage. Retrieved from https://www.medicare.gov/coverage/hospice-care

Q-3

Malnutrition is described by the American Society for Parenteral and Enteral Nutrition that requires two of the following attributes such as insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, diminished functional status (Farris & Mattison, 2017, p. 1346). It is commonly seen in hospitalized patients over 65 years old with 40 % of the patients are estimated to be malnourished (Farris & Mattison, 2017, p. 1346). Patients who have malnutrition should be worked up for complete blood count, metabolic panel, thyroid function, vitamin B12, iron, thiamine, liver biochemical, and functional tests.

A patient who has malnutrition is often checked for albumin and pre albumin levels. The normal albumin level is 4 to 6 g/dL (Ferri, 2019, p. 139). Patients who have elevated albumin may be at risk for dehydration and intravenous albumin infusion. Patients who have a decreased albumin level may have liver disease, nephrotic syndrome, poor nutritional status, rapid intravenous hydration, protein-losing enteropathies, severe burns, neoplasia, chronic inflammatory disease, pregnancy, prolonged immobilization, lymphomas, hypervitaminosis A and chronic glomerulonephritis. According to Jensen (2018), albumin lacks sensitivity and specificity of malnutrition but can be a potential risk indicator for morbidity and mortality (Jensen, 2018, p. 2322).

One treatment or modality that helps promotes wound healing is the application of dressings in the wound. There are two types of dressing that we can apply in geriatric patients or patients with wounds. It can be semi-occlusive or occlusive dressings. The semi-occlusive dressings are semipermeable gases such as O2, CO2, and moisture. These are the dressings that provide a moist wound healing environment and are considered impermeable to liquids and increase the chance of wound healing (Robinson,2017, p. 1173). On the other hand, occlusive dressings are the ones that lack the permeability to gases and liquids.

 

 

 

 

 

References:

Farris, G. & Mattison, M. (2017). Malnutrition and weight loss in hospitalized older adults. S.C. Mckean, J.J. Ross, Dressler, D.D. & Scheurer, D.B. Principles and practice of hospital medicine (2nd edition) (p. 1346- 1349). Mcgrawhill education

 

Ferri, F.F. (2019). Ferri’s Best Test. A practical guide to clinical laboratory medicine and diagnostic imaging. Elsevier.

Jensen, G.L. (2018). Malnutrition and Nutritional Assessment. J.L. Jameson, D.L. Kasper, D.L. Longo, A.S. Fauci, S.L. Hauser, J. Loscalzo (Eds). Harrison’s principles of internal medicine (20th ed., Volume2) (p. 2319-2323). Library of Congress Cataloging- in Publication Data.

Robinson, M.V. (2017). Cleaning, irrigating, culturing and dressing an open wound. AACN Procedure Manual for High Acuity, Progressive and Critical Care. D.L., Wiegand (7th edition). Elsevier.