Changing Needs of Patients and Families in Long Term Care Facilities

The purpose of this paper is to describe the changing needs of patients in long-term care facilities and their families. The argument will be made that the characteristics of residents have changed significantly with the implementation of prospective payment for hospital care of Medicare patients. In addition to the traditional nursing home resident, staff will be expected to respond to the needs of patients who are both more acutely ill and responsive to aggressive rehabilitative efforts as well as to patients who are more critically ill and near death. The implications of these changes for the social work staff of long-term care facilities will be discussed.     

Patient-care directives and infection control: the potential conflict of interest during epidemics in long-term care facilities.

Patient-care directives in long-term care facilities ensure that the aggressiveness of diagnostic and therapeutic interventions accurately reflects the desires of the patient. The results of our investigation of two outbreaks of fatal respiratory illness in long-term care facilities illustrate how patient-care directives may have delayed response to the outbreaks. Despite a cluster of deaths in each facility, staff delayed collection of laboratory specimens until patients with no directives restricting the medical workup became ill. Directives focus on the needs of the individual patient and family, but when an outbreak occurs, they may conflict with community needs. The challenge for the infection control practitioner is to recognize when community needs outweigh individual desires so that appropriate laboratory investigations can identify the cause of the illness.     

Infection control in pediatric extended care facilities.

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools. Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Hospice: a comprehensive program

Having begun operations in 1991 with six employees, four volunteers, and three patients, the St. Louis-based Incarnate Word Family and Alzheimer's Hospice today boasts 44 professional employees, 6 clerical staff, and more than 100 volunteers. The hospice offers a medically supervised home care program in which staff work closely with patients and families throughout the illness and bereavement period. Using a palliative rather than curative approach, the Incarnate Word Family and Alzheimer's Hospice focuses on enhancing the remaining life of the patient. Patients are enrolled based on their need for care, not on their ability to pay for services. To meet the unique needs of certain patients, the hospice offers a variety of specialized services, including pediatric, Alzheimer's, and AIDS care. Collaborative efforts with local agencies include cross-training, continuing education, client referrals, and support services. In 1993 Incarnate Word introduced hospice services to area residential care facilities (RCFs). The program enables RCF residents who develop life-limiting illnesses to remain in the place that they have come to know as home. In March 1994 Incarnate Word Family and Alzheimer's Hospice opened a branch office in north St. Louis. The new location enables the hospice to serve more people and creates an additional resource for physicians treating terminally ill patients. Volunteers provide rest breaks for care givers, help with meal preparation and simple housekeeping, run errands, comfort patients and family, and listen when others may find their story too overwhelming.     

The Promoting Effective Advance Care for Elders (PEACE) randomized pilot study: theoretical framework and study design

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.     

Long-term care and hospital collaboration. To survive in a reformed healthcare system, long-term care facilities can initiate hospital-based SNFs

Establishing relationships with hospitals may be critical for long-term care facilities facing financial pressures and uncertain futures. One option is to initiate collaborative efforts to develop hospital-based skilled nursing facilities (SNFs). Hospitals, under pressure to move patients to less intensive settings and to diversify, are naturally drawn to long-term care as a related business where they can make limited personnel and financial commitments and extend their continuum of care. Before approaching hospitals to initiate collaborative efforts, long-term care providers should understand how they think and what their strengths and weaknesses are. Long-term and acute care providers have many options for collaboration, including management contracts and joint ventures. In a traditional management contract, the long-term care provider furnishes the administrator and a few key staff in exchange for direct reimbursement for those staff plus a management fee. Another option is for the long-term care facility to provide all the staff for a fee or percentage of revenue. Joint venture options are to form a subsidiary corporation to renovate a floor of the hospital or to have the hospital buy a large percentage of the long-term care facility and share the profits. All these options have potential pitfalls, including differing financial expectations and the threat of unionization at the SNF. Nevertheless, for long-term care facilities struggling under reimbursement cutbacks and other pressures, the benefits may outweigh the risks.     

Is patient-focused outpatient cancer care on target?

Patient-focused care seeks to improve both patient and staff satisfaction while reducing the costs associated with health care services. Concepts borrowed from inpatient care settings are now being applied to outpatient facilities. Incorporating many of the Planetree principles in design ensures that patients' physical as well as emotional and psychological needs will be addressed. In addition, these same principles, while patient focused, serve the staff needs as well as by providing varied tasks, increasing levels of responsibility, and improving efficiencies in operations by improved design.     

Intensive care ventilators

This study presents ECRI's evaluation findings for four newly tested intensive care ventilators, as well as updated ratings for six previously evaluated models. Intensive care ventilators provide temporary support for critically ill patients who cannot breathe on their own or who require assistance to maintain adequate gas exchange in the lungs. Most of today's models offer a variety of capabilities to help clinicians tailor treatments to each patient, to alert users to potentially dangerous conditions, and to protect the patient when problems arise. We found that all the evaluated models can satisfactorily ventilate patients. However, not all the models would be an appropriate choice for the typical intensive care unit (ICU). Some of the units we tested lack capabilities that we desire for intensive care applications, and some include noteworthy deficiencies, particularly related to their alarm systems. In fact, we rate one unit Unacceptable because its alarm limits default to unsafe values. Of the remaining units, we rate five models Preferred because they offer the functionality to meet the needs of a broad range of ICU patients. Two additional units offer more limited capabilities, but they perform well and are inexpensive; these models, which we rate Acceptable, may be the best choice for some facilities. The final two units are Not Recommended for most new purchases because they lack features that aid in patient-ventilator synchrony; such features can improve patient comfort and thus are highly desirable. ECRI's recommended purchasing strategy, which is detailed in the Conclusions section, will help healthcare facilities select from among the evaluated models.     

Improving communication among attending physicians, long-term care facilities, residents, and residents' families

Effective bidirectional communication between attending physicians and long-term care facilities is of critical importance to ensure timely, appropriate, and high-quality care that is responsive to residents' needs, values, and preferences. Ongoing communication with residents and residents' families is essential to the establishment of mutual trust and respect. This earned trust and respect in turn promotes frank discussions among long-term care practitioners and the facility staff who can then better guide residents and families through difficult care decisions.     

The Centers for Medicare and Medicaid Services Proposal to Pay for Performance

The crisis that was Hurricane Katrina caused several ethical and managerial dilemmas, which will provide further guidance as we begin to plan for the avian flu pandemic that the experts tell us is (to use a theater metaphor with a double entendre) waiting in the wings. The huge natural disaster resulting from Katrina and its aftermath engulfed nursing homes and hospitals, which faced the daunting prospect of caring for severely ill patients as a cascade of events interfered with their ability to provide even the most rudimentary care. Caregivers faced a widening catastrophe that included failed public electrical and water service, failure of emergency electrical generators, and, with rising flood waters, the critical need to move patients who were too ill to transport. This resulted in nursing home residents abandoned to rising flood waters, allegations of euthanizing of hospital patients who could not be moved, and troubling questions of whether those who should have known better failed to plan for the extremes that were Katrina and its after-math. With staff scattered, facilities and equipment damaged or ruined, and demand building as residents return, efforts to deliver health services in New Orleans now face a catastrophe in slow motion.     

GP-BASED EMERGENCY RESPONSE IN RURAL AREAS: IS THERE A NEED?

Rural general practitioners (GPs) traditionally provide the initial care for the very ill and severely traumatised in small and medium-sized rural hospitals. It has been said that these patients would be better managed in a level 1 trauma centre. The present paper will test this hypothesis and shows that the benefits of the expertise available in the large centres may be outweighed by the loss of life in the prehospital phase, most of which occurs before the arrival of the ambulance. General practitioner involvement would enhance the current early retrieval system. Very ill and severe trauma should be assessed and stabilised in the most appropriate local facility. Routine by-passing of local emergency medical services should be avoided. A national standard for training rural GPs in emergency management skills is needed. Emergency facilities and equipment must be maintained and improved throughout rural Australia. These facilities and their staff must be accredited so that the ambulance service can more appropriately determine its transport priorities.     

Quality improvement in long-term care

Creating a culture or environment in which total quality can take root is a challenging undertaking for most healthcare organizations. It requires staff at all levels to acquire new skills and problem-solving techniques and apply them in their daily work processes. Change is rarely easy, and it can become all the more difficult in facilities where budgets are strained, staff turnover is high, patients require special attention, and computer-assisted data collection and analysis is still in its infancy. Such is the situation in many long-term care facilities. Some forward-thinking state organizations, long-term care facilities, and national associations are developing strategies to address these issues. Admittedly, these efforts are still in their infancy, but early reports indicate that TQM has the potential to produce results in this field as it has in other healthcare settings.     

A volunteer program for helping families in a critical care unit

When patients are critically ill, their families suffer extreme emotional distress, often without the support of staff who must focus first on patients' needs. This article describes a social work program that has successfully used volunteers in a critical care unit to facilitate communication between family members and staff, lessen the family's sense of isolation, and provide responsive services in a crisis-oriented setting.     

Scheduling Elective Admissions

Each of the several thousand hospitals in the United States is faced with the task of meeting the demands for its facilities, services, and personnel by individuals seeking satisfaction for their health care needs as well as by physicians seeking satisfaction for their professional needs. In general, these demands are not in perfect balance with the available supply at any point in time. It is the purpose of this paper to identify the specific problems created by excess demand for specific services at a specific institution—Henry Ford Hospital—and to present a scheme to minimize both the magnitude and the adverse effects of the imbalance.

Physicians who are engaged simultaneously in the clinical practice of medicine, in professional education, and in medical research must participate in meeting the health care needs both for a number of patients and for specific, unusual patients so as to satisfy their professional needs.

In general, individuals who need health care want the cost to be minimized and, so, place constraints on the amount of resources they are willing to expend for this purpose.

As a practical expediency, this discussion emphasizes the problems of excess demand for specific services of hospital beds and operating room time. It is suggested that the manner in which these specific services are utilized is fundamental to the simultaneous satisfaction of the needs of the patient and the physician and is representative of how we expect to extend this program to include other services, such as professional staff, operating room staff and inpatient nursing staff.

     

Psychosocial assessment of nursing home residents via MDS 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care

The Minimum Data Set 3.0 has introduced a higher set of expectations for assessment of residents' psychosocial needs, including new interviewing requirements, new measures of depression and resident choice, and new discharge screening procedures. Social service staff are primary providers of psychosocial assessment and care in nursing homes; yet, research demonstrates that many do not possess the minimum qualifications, as specified in federal regulations, to effectively provide these services given the clinical complexity of this client population. Likewise, social service caseloads generally exceed manageable levels. This article addresses the need for enhanced training and support of social service and interdisciplinary staff in long term care facilities in light of the new Minimum Data Set 3.0 assessment procedures as well as new survey and certification guidelines emphasizing quality of life. A set of recommendations will be made with regard to training, appropriate role functions within the context of interdisciplinary care, and needs for more realistic staffing ratios.     

Practical Steps to Improve Air Flow in Long-Term Care Resident Rooms to Reduce COVID-19 Infection Risk

The potential for spread of COVID-19 infections in skilled nursing facilities and other long-term care sites poses new challenges for nursing home administrators to protect patients and staff. It is anticipated that as acute care hospitals reach capacity, nursing homes may retain COVID-19 infected residents longer prior to transferring to an acute care hospital. This article outlines 5 pragmatic steps that long-term care facilities can take to manage airflow within resident rooms to reduce the potential for spread of infectious airborne droplets into surrounding areas, including hallways and adjacent rooms, using strategies adapted from negative-pressure isolation rooms in acute care facilities.     

Staff satisfaction and its components in residential aged care.

OBJECTIVE: The purpose of this study was to assess the direction and magnitude of the effects among the components of staff satisfaction in residential aged care and to examine whether the relationships among satisfaction components vary according to facility type (i.e. nursing homes and hostels). A hostel is a low care facility in which residents are more independent, have a lower level of care needs, and receive personal but not nursing care. DESIGN: A cross-sectional survey design was adopted to collect the required information, and a stratified random sampling approach was utilized to select facilities. Structural equation modeling was used to examine relationships among satisfaction components. SETTING: Seventy residential aged care facilities in Western Australia. STUDY PARTICIPANTS: The sample includes 610 nursing home and 373 hostel care staff. RESULTS: The relationships among satisfaction components are different for nursing home and hostel staff. Professional support is found to have a strong and positive effect on all other aspects of staff satisfaction. CONCLUSION: The findings lead to an improved understanding of the interrelationship among staff satisfaction components, which has important implications through enhancing professional support. This needs to be recognized and emphasized by managers, care providers, and policy makers so as to maintain stable personnel and continuity of care.     

Quality palliative care in long-term care settings

It is paramount that physicians and midlevel practitioners who care for residents in long-term care facilities be able to provide high-quality comfort care to their patients, the majority of whom are frail and suffering from chronic and progressive diseases. Physicians must be knowledgeable in the assessment, prevention, and relief of patients' physical, emotional, and spiritual distress, as well as develop appropriate attitudes, knowledge, and skills to care for patients who are in the last years of life. The provision of high-quality palliative care is the essence of long-term care medicine.