Assessment in the nursing home

Nursing homes are an important component of the health care system for elderly people, and their importance will grow over the next several decades. Although the care provided in nursing homes is improving, it is far from optimal in many facilities. Improving the process of assessment in the nursing home is critical to improving nursing home care. This article provides a clinically oriented framework for the assessment of nursing home patients.It focuses on medical, nursing, and interdisciplinary assessment strategies for the assessment of nursing home patients and attempts to emphasize the unique and often complex issues that arise in the nursing home setting.     

Advance care planning in nursing homes: correlates of capacity and possession of advance directives

PURPOSE: The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. DESIGN AND METHODS: The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors. RESULTS: Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged. IMPLICATIONS: Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.     

Cardiopulmonary resuscitation policies and practices. A statewide nursing home study

We determined the prevalence of written cardiopulmonary resuscitation policies in North Carolina nursing homes and evaluated their content according to predetermined criteria. Questionnaires were mailed to 236 state-registered facilities. Two hundred nine nursing homes (88.5%) responded to the questionnaire; 83% reported having a written policy, and half (86 nursing homes) provided copies. Nine of ten nursing homes reported that cardiopulmonary resuscitation was performed at their institution, and a similar number (92%) permitted physician orders restricting cardiopulmonary resuscitation. Written policies were systematically compared with 10 model criteria. Policy content varied substantially. More than half of the policies contained provisions for authorization, informed consent, documentation, competency, review, and applicability of do not resuscitate orders. Less than half contained criteria for autonomy, treatment alternatives, dignity and quality of care, and patient identification. Nursing homes that had written policies were newer, larger, and for-profit; had a greater proportion of skilled nursing care beds; and were more likely to have both Medicare and Medicaid certification. The variations in these policies place nursing home residents at risk for having important personal rights limited or ignored. Inclusion of these 10 policy criteria in a comprehensive cardiopulmonary resuscitation policy would represent an important step toward enhancing the quality of decision making by nursing home residents.     

Cardiopulmonary resuscitation in long-term care facilities: a survey of do-not-resuscitate orders in nursing homes

Growing public debate regarding no cardiopulmonary resuscitation (no-CPR) policies in acute care hospitals, together with recent changes in the patient population of long-term care facilities, has led nursing homes to examine their need for resuscitation policies. To determine current cardiopulmonary resuscitation policies and procedures in nursing homes, medical directors and directors of nursing service in long-term care facilities in Portland, Oregon, were surveyed. Seventy-five percent responded; of these, only 41% reported having a resuscitation policy. Of those with no policy, 70% thought one was needed. Most nursing homes reported that resuscitation was infrequently discussed with patients and families. When a no-CPR determination was made, it was usually documented in the patient's chart. Training in basic life support was required for registered nurses in two thirds of the facilities. Few homes had equipment necessary for advanced life support. It is recommended that: a) nursing homes develop cardiopulmonary resuscitation policies; b) resuscitation orders be made part of the medical record; and c) nursing home personnel increase their ability to perform basic life support.     

Teaching nursing homes: their impact on public policy, patient care, and medical education

In summary, teaching nursing homes can be expected to have an impact on public policy development, patient care, and physician training. It is anticipated that research into the important public policy issues regarding relationships between costs and proprietary status and quality of care will be enhanced by developing teaching nursing homes. It will be important to coordinate efforts and evaluations between pilot projects with different funding bases in order to provide research projects with adequate controls. Many results regarding cost-quality comparisons may be of limited applicability to community institutions because of the higher costs inherent to teaching facilities. Nursing home patients living in teaching facilities can expect to be directly benefitted in terms of receiving increased medical attention. They will reside in model facilities providing what is hoped to be the optimal services in all aspects of nursing home care. Possible detrimental aspects for such patients include increased exposure to heroic interventions and possibly poorer care as a result of medical interference with established nursing home team approaches to patient care. As a result of living in a research environment, patients also may be pressured to participate in protocols to which they are not normally exposed. In addition, because many of the geriatric fellowships are based in Veterans Administration facilities (with their predominantly male patient population), it will be important to ensure that current research adequately studies the common problems of elderly women, who represent 70 per cent of those who are in nursing homes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extended care in nursing homes: a program for a county teaching medical center

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.     

Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.

OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.     

The Patient Self-Determination Act and the future of advance directives

Living wills and other advance directives currently play a limited role in medical decision making. A new federal law, the Patient Self-Determination Act, will require health care providers in hospitals, nursing homes, and other facilities to inquire about the presence of advance directives, to record patient preferences in the medical record, and to develop institutional policies regarding the implementation of these directives. Unfortunately, the law does little to promote discussion or preparation of advance directives before hospitalization. Additional efforts to promote the use of advance directives can take place in the outpatient medical care system, in attorneys' offices, or through health insurers. Because most people have not yet prepared an advance directive, we suggest that institutions develop treatment policies for situations in which the wishes of patients who lack decisional capacity are not known. These policies should be designed to promote the patients' best interests, as defined by the consensus of the institutions' staff and members of the surrounding community.     

Nursing home residents covered by Medicare risk contracts: early findings from the EverCare evaluation project

OBJECTIVES: To compare the characteristics of a sample of EverCare nursing home residents with two control groups: one composed of other residents in the same homes and another made up of residents in matched nursing homes. To compare levels of unmet need, satisfaction with medical care, and the use of advance directives. DESIGN: Quasi-experimental design using two control groups to minimize selection effects. Information collected by in-person surveys of nursing home residents and telephone surveys of proxies and family members. SETTING: Nursing homes affiliated with EverCare and matched control homes. PARTICIPANTS: Nursing home residents and their family members. MEASUREMENTS: Questionnaire addressing function (activities of daily living (ADLs)), unmet care needs, pain, use of advance directives, satisfaction, and caregiver burden. RESULTS: In general, the experimental and control groups were similar, but the EverCare sample had more dementia and less ADL disability. Family members in the EverCare sample expressed greater satisfaction with several aspects of the medical care they received than did controls. Satisfaction of residents in the EverCare sample was more comparable with that of controls. There was no difference in experience with advance directives between EverCare and control groups. CONCLUSIONS: EverCare appears to be a model of managed care worth tracking. It is producing care that is at least comparable with what is available in the fee-for-service environment, with evidence that families seem to appreciate the added attention. There is some suggestion that it has enrolled a less disabled but more demented population. Pending results on the effects of this care on hospitalization and emergency care should shed useful light.     

Standards of medical care for nursing home residents in Europe

ObjectiveNursing home inhabitants represent the most vulnerable and frail group of older people. They have more complex medical backgrounds and more significant care requirements. With an ever-ageing European population, the number of people requiring nursing home care will only increase. It is important then that we optimise the medical care of older people living in nursing homes.MethodsFormalized care standards are essential to optimal care but we feel that such guidelines are lacking. We decided to investigate this by means of a survey on nursing home care standards sent to the geriatric medicine societies around Europe.ResultsOnly five of 25 (20%) health services have a requirement for specific training in geriatric medicine for doctors in nursing homes, while only three of 25 (12%) countries have written medical care standards applicable to nursing home care provided by professional organizations. Four of 25 (16%) had a nursing home doctor society and one of these, The Netherlands, provided written medical care standards for nursing homes which were also adopted by the relevant general practitioner society.DiscussionThe Europe-wide deficiency of documented care standards for nursing homes is alarming. It should be a prerequisite that physicians dealing with these complex patients have undertaken some level of specific training in geriatric medicine. It is important that geriatricians, old age psychiatrists and family doctors across European countries engage more formally on the development of appropriate models for both developing care standards and specifying appropriate training and support for doctors working in nursing homes.     

Advance Directives for Euthanasia in Dementia: How Do They Affect Resident Care in Dutch Nursing Homes? Experiences of Physicians and Relatives

OBJECTIVES: To gain insight into how advance directives for euthanasia affect resident care in Dutch nursing homes. DESIGN: Survey of elderly care physicians and additional qualitative interviews with a selection of elderly care physicians and relatives of people with dementia who had an advance directive for euthanasia. SETTING: Dutch nursing home practice. PARTICIPANTS: Four hundred thirty‐four elderly care physicians completed the general part of the questionnaire; 110 physicians provided case histories. Interviews were conducted with 11 physicians and eight relatives. MEASUREMENTS: The questionnaire contained general questions about the incidence of advance directives for euthanasia in people with dementia. A second part involved questions about the most recent case of a person with dementia and an advance directive for euthanasia who had died. The interviews with elderly care physicians and relatives focused on further exploration of the decision‐making process regarding adherence to the advance directive for euthanasia. RESULTS: Despite law‐based possibilities, advance directives for euthanasia of people with dementia were rarely adhered to, although they seem to have a supportive role in setting limitations on life‐sustaining treatments. Elderly care physicians and relatives were found to be reluctant to adhere to advance directives for euthanasia. Not being able to engage in meaningful communication played a crucial role in this reluctance. CONCLUSION: Advance directives for euthanasia are never adhered to in the Netherlands in the case of people with advanced dementia, and their role in advance care planning and end‐of‐life care of people with advanced dementia is limited. Communication with the patient is essential for elderly care physicians to consider adherence to an advance directive for euthanasia of a person with dementia.     

Custodial nursing home care. Setting realistic goals

Despite concerted effort to rehabilitate and return patients to their homes, the majority of nursing home patients are destined to spend the remainder of their days in institutional settings. These custodial care patients are elderly, have many functional disabilities, and are often demented. The traditional medical approach to care, which emphasizes diagnosis and treatment of specific diseases, is often not appropriate for these patients. Instead, physicians should focus their attention on functional assessment and treatment, nontechnologic management of acute problems, humane terminal care, and the development of an efficient caregiving system within the nursing home.     

Investigation of death clusters in a nursing home

The number of elderly residing in, and dying in, nursing homes is steadily increasing. In 1985, an investigation by the California attorney general's office was undertaken concerning a cluster of deaths in a single rural nursing home. The purpose of this study was to provide information for the investigation. The objectives of the study were to determine if there were excess deaths in the nursing home, and if so, to describe the circumstances surrounding the deaths and the policy implications for the quality of care in nursing homes. All the medical records for patients who died in a single nursing home between January 1, 1983 and April 30, 1985 were examined by the research team. Medical care was compared to desirable standards of care. A majority of the deaths, 52.5%, had major discrepancies from standard care that may have contributed to the patient's death. There were also major discrepancies in the cause of death between the death certificate and evidence from examination of the medical records. The data substantiated an unusual occurrence of deaths in the nursing home at the end of 1983 and again in early 1985, but no single factor or person could be identified as the major cause of the deaths. Although this is an isolated study of one nursing home, it is likely that these problems are not unique and the evaluation approach may be useful in other settings. It is recommended that nursing home deaths be routinely monitored, and that an unusual number of deaths should trigger an extensive investigation.     

Content of advance care planning among Japanese elderly people living at home: A qualitative study

Purpose of studyElderly peoples’ values and preferences for end-of-life care have not yet known in details. The aim of the present study was to investigate the end-of-life wishes and decision making among Japanese elderly people who required home care services. The study was designed to qualitative research strategies, using face to face interview data recorded in nursing care records, with a focus on advance care planning.Design and methodsA total of 102 elderly people (47 males, 55 females) of 6 home care support offices in Hyogo prefecture participated.Results and implicationsWe finally extracted the following 5 themes: anxiety about the future, abandonment of control, clinging to current daily life, precarious mutual support, delegating decision-making. While elderly people living at home generally feel anxious and fearful about the future, they seemed to try to avoid thinking too seriously about possible complications in their life.They also tend to leave end-of-life decision to someone else, and their decisions tend to change as they advance in age and as their condition deteriorates. Our findings suggest that medical professionals and care managers always support their patients’ decisions, allowing for the views of the informal caregivers on whom elderly people rely for decision-making.     

An inpatient bed for acute nursing home admissions

BACKGROUND: Some older patients are admitted directly to nursing homes without a comprehensive assessment. OBJECTIVE: To determine whether a hospital assessment bed might provide better assessment, treatment and a more appropriate placement for selected older people. Setting a single bed in an elderly care unit of a district general hospital. SUBJECTS: Older people who general practitioners thought needed nursing home care but whose social workers felt might benefit from inpatient assessment. MAIN OUTCOME MEASURES: Type of treatment needed (acute care, rehabilitation, palliation, long-term care) and placement (home, nursing home, residential home or hospital). RESULTS: of 34 patients assessed, 22 (65%) needed further clinical assessment or care and 26 (75%) left hospital for places other than nursing homes. CONCLUSIONS: Inpatient assessment is a successful way of assessing the needs of some older people who would otherwise have been admitted directly from their homes to nursing homes.     

Nursing home directors' attitude toward medical decision-making and medical care for elderly people with dementia

Medical decision-making involving elderly people with dementia often troubles care providers in Japan. Meanwhile, little attention has been paid to the routine medical care of nondementia illnesses in such patients. To understand the current situation surrounding the issue, we conducted a postal survey with nursing home directors across the nation. A self-administered questionnaire was sent to 1,117 randomly selected nursing homes, one third of all such facilities in Japan, and 502 (44.9%) responded. Of the respondents, 291 (58.0%) said more than a half of their residents have difficulties in daily life because of dementia. Less than 20% of the facilities said that they routinely confirm residents' preferences in writing when they are admitted concerning each of the following items; terminal care, medical information disclosure, leaving a will, funerals and application for the guardian system. 206 (41.0%) facilities have difficulties in finding a hospital for the elderly with dementia when necessary. The Mann-Whitney U test showed no significant relation between facilities' characteristics and their difficulties in finding a hospital that would admit demented patients. At present, a number of nursing homes confirm their residents' preferences only some time after they are admitted. However, the way of confirming seems inappropriate under the circumstances in which more than a majority of residents have difficulties in daily life due to dementia. Though more than a half of nursing homes have difficulties in finding a hospital that would admit dementia patients, no significant relation was found between the difficulties and the facility-hospital relation. The problem seems to lie in the acceptance mechanism of hospitals.     

Hypernatremic dehydration in nursing home patients: an indicator of neglect

In order to determine the antecedents of hypernatremic dehydration the authors reviewed the records of 56 patients with this condition at two public hospitals, one of which includes a large chronic care facility. Twenty-nine patients developed hypernatremic dehydration while at nursing homes. All cases came from proprietary nursing homes, although proprietaries account for only 88 per cent of nursing home beds in the community studied (P less than 0.05). There was a cluster of patients from two nursing homes. Sixteen patients admitted from home all showed evidence of inadequate care prior to admission. Eleven patients became hypernatremic while in acute care hospitals. No patient in the public chronic care facility developed hypernatremic dehydration during the period studied. The average serum sodium concentration of patients transferred from nursing homes was significantly higher than that of patients who developed hypernatremic dehydration at home or in acute care hospitals. It is concluded that hypernatremic dehydration in an institutionalized patient may be an indicator of inadequate care, which should prompt further investigation of the living conditions of the patient.     

Attitudes toward and use of subsequent nursing home services among a national sample of older adults

This study was designed to examine the relationship between attitudes toward nursing homes and subsequent nursing home utilization, and assess the impact of prior nursing home utilization on subsequent attitudes among a national sample of older Americans. Multivariate estimation procedures for complex survey designs were performed on the National Long-Term Care Survey data set. Although prior nursing home use did not directly affect subsequent attitudes toward nursing homes, having favorable attitudes about nursing homes increased the odds of using subsequent nursing home services by 1.5 and increased the total nursing home length of stay by 17%. Implications of this research for public policy and long-term care treatment planning are discussed.     

Level of care and complications among geriatric patients discharged from the medical service of a teaching hospital

To assess the effects of hospitalization on the subsequent placement and supportive care of elderly patients, the medical records of 233 consecutive patients aged 75 years or older, admitted to the medical service of a university hospital, were reviewed. The level of care on admission and at discharge, hospital-associated complications, and demographic data were abstracted for each patient. At discharge, 1 per cent returned to a nursing home, 6 per cent were newly placed in a nursing home, 65 per cent returned to the same level of care as on admission, 10 per cent returned home with an increased level of care, and 18 per cent died or were discharged to another acute care facility. Complications occurred in 30 per cent of patients but did not correlate with age, increased level of care at discharge, or increased rate of nursing home placement. Few elderly patients were discharged to nursing homes, and most returned home without arrangements for increased care.     

A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes

OBJECTIVES: to evaluate the effectiveness of a policy of making hip protectors available to residents of nursing homes. DESIGN: a cluster randomised controlled trial of the policy in nursing and residential homes, with the home as the unit of randomisation. SETTING: 127 nursing and residential homes in the greater Belfast area of Northern Ireland. PARTICIPANTS: 40 homes in the intervention group (representing 1,366 occupied beds) and 87 homes in the control group (representing 2,751 occupied beds). INTERVENTIONS: a policy of making hip protectors available free of charge to residents of nursing homes and supporting the implementation process by employing a nurse facilitator to encourage staff in the homes to promote their use, over a 72-week period. MAIN OUTCOME MEASURES: the rate of hip fractures in intervention and control homes, and the level of adherence to use of hip protectors. RESULTS: there were 85 hip fractures in the intervention homes and 163 in the control homes. The mean fracture rate per 100 residents was 6.22 in the intervention homes and 5.92 in the control homes, giving an adjusted rate ratio for the intervention group compared to the control group of 1.05 (95% CI 0.77, 1.43, P = 0.76). Initial acceptance of the hip protectors was 37.2% (508/1,366) with adherence falling to 19.9% (272/1,366) at 72 weeks. CONCLUSIONS: making hip protectors available to residents of nursing and residential homes did not reduce the rate of hip fracture. This research does not support the introduction of a policy of providing hip protectors to residents of nursing homes.