Psych Aging Final

long term care issues

nurshing home placements and insitutionalization, financing of mental health and medical services for seniors

Why long term care issues matter Reason #1

uPersonal / Family.  A decision we make for our loved ones.  Institutional best practices is one of the oldest topics within gerontology

• part of education

• may work in senior housing industry

• place a loved one in a nursing home

• facing a nursing home placement yourself

Reason #2

uPolitical / National.   “The right of dignity in sickness and in health”

• John F Kennedy 

• we owe them the right of dignity

Reason #3

uGlobal / International.  It’s a major issue facing the world

• population aging is a global issue facing the world

nursing homes

a medical institution that provides comprehensive care in a single setting for people who need daily care and support services

2 types of nursing homes

uSkilled nursing facilities.   Provide intensive nursing care. 

uIntermediate care facilities.  Provide health related services for older adults who do not require hospital or skilled nursing facility care.

nursing home realities

1.  Most nursing homes are a business with a business model

2.  Nursing home residents have medical needs

3.  Some nursing homes offer temporary placements (for rehab)

4.  Standards of Care are monitored

5.  Deficiencies are cited

deficiencies are cited. 6 types 

uquality of care

ulack of accident prevention (harm or immediate jeopardy to residents)

ucontinence (control over elimination of urine and feces)

uquality of an individual's life

uquality of the life of the staff

uthe use of physical and chemical restraints

two legislative landmarks

1. Nursing Home Reform Act (NHRA) passed in 1987.  Requires specific services, which are summarized next

2.  The 1998 Nursing Home Initiative (NHI)

Nursing Home Reform Act (NHRA)

uMust be licensed in accordance with state and local laws.

uMust have a governing body legally responsible for policies and the appointment of a qualified administrator. 

uMust have 1 or more physicians on call at all times, and there must be 24 hour nursing care services.

uThe facility must admit eligible patients without discrimination.

The 1998 Nursing Home Initiative (NHI)

proposed a series of steps used to improve enforcement of nursing home quality including altering the timing of nursing home inspections to include both weekends and evenings as well as weekdays, providing more frequent inspections of previous violators, and imposing immediate sanctions on nursing homes found guilty of a second offense

4 main types of residential care facilities

1) Board and care homes

2) Group homes

3) Assisted living facilities

4) Adult foster care

board and care homes

group living arrangements for older adults that cannot live on their own and need some nursing services 

group homes

- provide independent, private living in a house shared by several older adults

assisted living facilities

- licensed and professionally managed housing complexes with independently living older adults in their own apartments, some have health services available on site

adult foster care

when a family provides care in their home to an older adult.

financing long term care realities

uThe need for long-term care for seniors is increasing.

uThe cost of this care is increasing nationally at an alarming rate.

long term care costs: how much

1.  Nursing homes

2.  Assisted living facilities

3.  Registered nurses and LPCs

4.  Home health workers

who pays?

1.  Families:  private pay and long-term care insurance

2.  The Federal Government:  Medicare & Medicaid

Medicare

• A federal funding agency, started as title XVIII of the U.S. Social Security Act passed and signed by President Lyndon B. Johnson in 1965.

• It was a pay as you go system when it was passed.

• Medicare's funding comes from payroll taxes, premiums, general revenue from income taxes, and some payments from the states

Medicare program 4 parts

• Medicare Part A:   hospital insurance

• Medicare Part B:  benefits for people age 65+ who pay a monthly premium based on income

• Medicare Part C:  “Medicare advantage” coverage through private health plans

• Medicare Part D:  prescription drug benefits

Medicaid Program

• Title XIX, a federal and state matching entitlement program that provides medical assistance for individuals and families with low incomes

• It is essentially public assistance for the poor in need of medical and health related services.

• Those covered by Medicare who are not otherwise poor may require Medicaid when their benefits have run out and they cannot afford to pay their medical expenses.

reasonable alternatives to nursing home or residential care placement include:

uHome health services

uGeriatric Partial Hospital facilities

uAccessory dwelling units (aka “mother-in-law” apts)

uSubsidized housing (e.g., Bishop Ott)

uContinuing Care Retirement Communities (CCRCs)

waht you should know in aging in place

1.  It pays to retrofit your home

2.  Think small

3.  Make it accessible

4.  Consider the big picture

5.  Tap your equity

6.  Assistive robotics

criteria for clinical death

uNo spontaneous movement in response to stimuli

uNo spontaneous respirations for at least 1 hour

uTotal lack of responsiveness to even the most painful stimuli

uNo eye movements, blinking, or pupil responses

uNo postural activity, yawning, swallowing, or vocalizing

uNo motor reflexes

uA flat EEG for at least 10 minutes

uNo change in any of these criteria when they are tested again 24 hours later

cortical death

uThe absence of higher order cortical activity but lower brainstem activity persists

uWith cortical death, the person might be considered a “vegetable”

uCortical death is not used as a legal definition anywhere in the US at this time

social and psychic death

uOccurs when people are isolated or abandoned by others, being shunned or written off by family / friends;

uPeople with terminal illnesses are often treated this way

uRole of the hospice movement: Death with Dignity

death anxiety across the lifespan

1.Younger adults

2.Middle aged adults

3.Older adults

death anxiety in older adults

1.Less emphasis on life

2.Death isn’t unfair

3.Anticipatory rehearsal

5 functions of a funeral

1) helps survivors

2) strengthens social cohesiveness

3) gives survivors an opportunity to communicate their feelings about the deceased

4) forces the realization that a loved one is dead

5) helps put the death within a meaningful context

Kulber Ross book

on death and dying, 5 stages of dying (denial, anger, baragaining, depression, acceptance)

Patient Self-Determination Act

uPatient has active role in end-of-life decisions and care

uAdvance Directive / “Living Will”

uDurable Power of Attorney for Health Care

Hospice Care, when life expectancy is less than 6 months (Physician ordered)

uMedical and Supportive Services

uPalliative care (ease pain and discomfort)

uMeeting social, psychological, and spiritual needs

comfort care staff

uPhysicians, RNs, Certified nursing assistants

uMedical social workers

uHospice chaplains

uBereavement professionals

uHospice-trained volunteers