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Unit 2: Week 2 - Chapter 4 Outline

CHAPTER FOUR: NURSING FACILITIES

LEARNING OBJECTIVES

After completing this chapter, readers will be able to:

1.   Define and describe nursing facilities, how they developed, where they fit in the continuum of care, the services they offer, and who uses them.

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 into the coming millennium and describe the impact of those trends.

CHAPTER HIGHLIGHTS.c

Introduction

·         Nursing facilities used to be called “nursing homes”

·         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.

How nursing facilities developed

·         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.

.c2.Philosophy of care

·         .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

·         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.

·         This may be due to competition from community-based services.

Services Provided

·         Nursing

·         Physical therapy

·         Occupational therapy

·         Speech therapy

·         Medical and dental services

·         Medications

·         Laboratory and x-ray services as needed.

.c2.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

·         .c4.Alzheimer's Disease

·         Mental Health & Mental Retardation

·         Brain Injury

·         AIDS

·         Based on Age

·         Pediatric

·         .c4.Young Adults

.c2.Consumers Served

·         By age:

·         Mostly elderly

·         .c3.By care Needs:

·         AAAdmitted because of functional disabilities, resulting from a number of medical or physical conditions

·         May include both physical and mental disabilities

·         .c3.;By gender Mix:

·         Three-quarters women

.c2.Market Forces Impacting Nursing Facilities

·         .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).

.c2.Regulations

.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.

.c2.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

.c2.Staffing/Human Resource Issues

·         .c3.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.

·         .c4.Nursing

·         .c4.Certified Nurse Aides

·         .c4.Medical Coverage

·         .c4.Other Specialists

·         .c3.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/.c2.Ethical Issues

·         .c3.Day-To-Day Quality of Life Issues

·         Desire for privacy, personal autonomy

·         Individual vs. group choice is an issue

·         .c3.End of Life Issues

·         Many residents live out their last days in a nursing facility

·         Competency and choice are issues

.c2.Management of Nursing Facilities

·         .c3.Management Qualifications:

·         Must be licensed by states

·         Some variation in state regulations

·         .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.

.c2.Significant Trends and Their Impact on Nursing Facilities

·         .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

 

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic

C.  Discuss what a nursing facility is, defining and explaining the terms involved

D.  Discuss how nursing facilities developed:

E.   Discuss the philosophy of care of nursing facilities, including:

1.   Medical vs. social model

2.   Multidisciplinary approach

3.   Family involvement

F.   Ownership. Identify differences in ownership of nursing facilities

G.  Services. Discuss the services provided by nursing facilities:

1.   Routine services

2.   Special care units

H.  Consumers. Identify consumers served

1.   By age and gender

2.   By care needs

I.    Market Forces. Identify and discuss market forces impacting nursing facilities

·         Need-driven vs. choice-driven admissions

·         Family & physician initiated admissions

·         Hospital Readmissions

·         Location relative to the family

·         Alternative types of care (or lack of)

J.    Regulations. Discuss the regulations affecting nursing facilities, including:

1.   Regulations affecting residents

2.   Regulations affecting employees

3.   Regulations affecting building construction and safety

K.  Financing. Discuss how nursing facilities are financed, and by whom

L.   Staffing/Human Resources. Identify and discuss staffing & human resource issues, including:

1.   Nature of the work force

2.   Nursing

3.   Certified Nurse Aides

4.   Medical coverage

5.   Other specialists

6.   Recruitment & turnover issues

M.  Legal & Ethical Issues. Identify and discuss legal and ethical issues, including:

1.   Day-to-day quality of life issues

2.   End-of-life issues

N.  Management. Management of Nursing Facilities

1.   Discuss management qualifications

2.   Discuss management challenges and opportunities

O.  Trends. Identify and discuss significant trends impacting nursing facilities, including:

1.   Rising acuity levels

2.   Managed care

3.   Prospective payment

4.   Private long-term care insurance

5.   Payment Bundling

6.   Rising liability insurance costs

7.   Consumer choice

P.   Summarize the discussion, recapping the key points of the lecture.

 

VOCABULARY TERMS:

ACHCA – (American College of Health Care Administrators) the professional organization representing long-term care administrators.

Acquired immunodeficiency syndrome (AIDS) - A severe immunological disorder caused by the retrovirus HIV, usually resulting in death.

Activities of daily living (ADLs) - Those activities that impact a person's functional ability or disability; including bathing, transferring, toileting, eating, and communicating.

Acuity levels - degrees of illness as represented by the need for treatment or monitoring.

Advance directive - a written statement of an individual's preferences regarding health care received if he or she becomes mentally or physically unable to choose or communicate his or her wishes.

Affordable Care Act (ACA) – Passed in 2010 to greatly expand coverage of millions, as well as adding many new mandates and regulations. Also known as “ObamaCare”.

AHCA – (American Health Care Association) an organization representing long-term care provider organizations, primarily for-profit organizations.

Alzheimer’s disease - a disease generally affecting elderly and middle-aged people, causing loss of memory and other cognitive function.

Americans with Disabilities Act - law passed in 1990 mandating equal treatment of individuals with disabilities

Autonomy - the ability of a consumer to make meaningful decisions, and in doing so, to direct or impact his or her care.

Brain injury units - special care units for the care and treatment of individuals who have suffered traumatic brain injury.

Care vs. Cure - focus on caring for the individual rather than on curing a disease or clinical condition.

Certified Nursing Assistant CNA) - a staff person who provides personal care to residents or patients, working under the supervision of an RN or LPN.

Deinstitutionalization - practice of moving patients or clients from institutional care to noninstitutional settings.

End of life issues - ethical issues dealing with death and/or administration or withholding of treatment when death appears imminent.

Equal Employment Opportunity Commission (EEOC) - federal agency that monitors employment to prevent discrimination.

Fair Labor Standards Act (FLSA) - federal law governing wage and pay issues.

Family Medical Leave Act (FMLA) - law granting leave when there is a newborn child, an adoption, or a spouse who needs care during a serious illness.

Holistic philosophy of care - type of care that emphasizes the importance of the whole person.

Life Safety Code - regulations that address construction, protection, and occupancy features necessary to minimize danger to life

Living will - document created by an individual specifying his or her wishes about future care should he or she be unable to express those wishes at that time.

Managed care organizations (MCOs) - systems that integrate the financing and delivery of health care by means of arrangements with a limited number of providers.

Medical vs. social model - comparison of physician-directed care and model based on social characteristics of care.

Medicare - Title XVIII of the Social Security Act. It provides health insurance for the elderly, and some disabled people.

Multidisciplinary approach to care - approach utilizing the expertise of various health professions rather than relying primarily on one.

National Association of Long-Term Care Administrator Boards (NAB) - a national organization that assists state jurisdictions in the licensing of nursing home administrators.

Nursing Facilities - long-term care facilities that offer room, board, nursing care and certain other therapies.

Nursing Home - name previously used to refer to what is now called “nursing facility.”

Omnibus Budget Reconciliation Act (OBRA) - Also known as the 1987 Nursing Home Reform Act, it established stringent new rules for nursing facilities.

Occupational Safety and Health Administration (OSHA) - federal agency that monitors employee safety and health conditions in business and industry.

Older Americans Act - 1965 law passed for the protection of the elderly.

Patient Self-Determination Act - 1990 act requiring health care providers to inform all consumers of their right to participate in care decisions.

Power of attorney - legal document giving another person the right to make decisions for that consumer (a durable power of attorney refers to making health-related decisions when the individual is no longer able to do so).

Prospective payment system (PPS) - method by which skilled nursing facilities and some other long-term care providers are paid by Medicare.

Skilled nursing facility (SNF) - a long-term care facility providing 24-hour nursing care and other related services.

Special care units (SCUs) - patient or resident care units designed to care for a specific segment of the consumer population.

REFERENCE BOOKS

Long-Term Care: Managing Across the Continuum, 4th Ed By: John Pratt

The Medicare Part D Drug Program, 1st Ed By: Fincham, John