You are listening to ReachMD radio on XM160, The Channel for Medical Professionals. Welcome to Advances in Long-Term Care Medicine produced incorporation with the AMDA. Your host is Dr. Eric Tangelos, professor of medicine at the Mayo Clinic in Rochester, Minnesota and a certified medical director.
What are the advantages to each type of long-term care facility and how can physicians best evaluate facilities before referring patients. Joining us to discuss recommending long-term care facilities to patient is Dr. Charles Crecelius, Clinical Instructor of Internal Medicine in Geriatrics at Washington University School of Medicine in St. Louis.
DR. ERIC TANGELOS:
Chuck, welcome to the program.
DR. CHARLES CRECELIUS:
Thank you Eric.
DR. ERIC TANGELOS:
We have a national audience today and the topic that we are going to discuss certainly has different definitions across each state and sometimes with instates but give us your best shot at this alphabet soup and explain the differences between a nursing home, SNF, a med A part facility nursing home and assisted living facility, congregate living CCRC, it's all yours.
DR. CHARLES CRECELIUS:
Thank you. It is a real alphabet soup out there sometimes. Overall, there is a million and a half nursing home residents and about a million assisted living residents. Nursing home is divided into two different types of patients, first the skilled nursing facility or med A patients. Those are patients that are coming out of the hospital, you know, who are being paid to get better basically. The insurance company typically Medicare is paying their room and board, physical therapy, medications, the whole lot in order to get better, be restored, and return to a higher level of function. The other class of patients in nursing homes is the traditional nursing home patients, the person who is used I think is sitting in a rocking chair. We really do not have those patients anymore. We do have chronically ill people with multiple medical problems but who are stable and don't need any restorative care but do need a lot of assistance to get by in life. From there, we go on to assisted living. Those are those patients who are used I think of being at nursing home but not really for the most part have a lot of functional abilities or cognitive abilities. They can get by in life with some help, maybe they need some medications given to them, maybe need help getting up in the morning, getting dressed, getting their clothes on. They may have some degree of dementia but can get by in life and have good social skills. Assisted living is not paid for at the present time in most states. A few states have Medicaid programs that pay for assisted living but by and large assisted living is a private pay situation. Lastly, we have various degrees of congregate living. Congregate living in general is a group of older people living together. They don't have a payment, so it's all private pay. They don't have a formal structure for as in assisted living from getting assistance in place. A CCRC or Continuous Care Retirement Community is a combination of all these. Typically, people have moved into a senior citizen housing and will have the whole lot in front of them. If doing well, they may begin the assisted living. If they get ill, they may need to move out from the nursing home temporarily or permanently but that is the general ball we are actually dealing with.
DR. ERIC TANGELOS:
You want to make any comment about the concept of day hospitals that even exist in the United States?
DR. CHARLES CRECELIUS:
Day hospitals, day programs do exist, especially for dementia care, they sometimes exist within the nursing home or a congregate living facility situation. In general, they take care of people with dementia, sometimes it's mental disease. There may be some specialty programs for people with certain neurologic disease even for MS. The most common though is dementia care that is private pay and the most part they sort of serve as a bridge for people to be able to stay at home with some help for their family to avoid having to make a permanent move out of the residence.
DR. ERIC TANGELOS:
Now, my long-term care patients certainly have gotten older over the last 20 years, they have gotten more frail, more complicated but there doesn't seem to be a lot of growth in nursing homes proper, you want to comment about that?
DR. CHARLES CRECELIUS:
Yes, in general, America is aging, getting older. There are more people that should be entering nursing homes but what has happened instead is people are leaving nursing homes who have inability to get out, people used to live in nursing homes with minor disabilities, bad arthritis, maybe a little bit of mental impairment are now more likely to be living in an assisted living or other non-nursing facility, that is a good thing, nursing homes really are geared to more and more ill patients, many of our patients in nursing homes despite he is a med A or a SNF patient are frankly sick than some of the people in the hospital we used to see.
DR. ERIC TANGELOS:
One of the big differences between nursing homes and assisted living I think might be home health, the home health benefit.
DR. CHARLES CRECELIUS:
Ya, the home health benefit can apply in a variety of settings. You don't get home healthcare benefits in home ever, that this doesn't exist. Some assisted livings do use extensive amount of home health care in order to meet the needs of their patients. Home health services can include medication review, therapy services, nursing monitoring for chronic stabilized diseases such as congestive heart failure. Some of these services are provided within the assisted living themselves as part and parcel, sometimes this medication administration in an Medicare governed service, home health care would provide that. Some can be covered at a medicare part B as part of the stay.
DR. ERIC TANGELOS:
So with all that background information how do you go about recommending long-term care facility to a patient or their family?
DR. CHARLES CRECELIUS:
You have to do a little background information, in your local area you should get to know several of the nursing homes and know their pros and cons. There is a lot of good sources information. One of the first is finding a local medical director. Every nursing home in the United States has a medical director that oversees the care rendered there. Don't know the facility pretty well and know their strengths and weaknesses, you may know some attending physicians that go there commonly asking them may help. For your skilled patients that are leaving the hospital going to the nursing home, the hospital social worker will be of help for you. The hospital social worker may not be as aware of the nursing homes chronic care patients. People who are going to need to stay there the rest of the lives, they would be better off talking to the attending physicians and the nursing home staff. Most doctors have been into a nursing home at some time in their career, talking with the local staff, the administrator, visiting the facility when you see your patient is a very good way to get to know the facility. You can also go to Medicare's website www.medicare.gov and on the home page you will find nursing home compare. Website has a lot of statistics in it, staffing ratios, quality measures, inspection report, and starting December 18, 2008, they are going to have a 5-star rating system. It has been debated how accurate it will be but at least it will be some guide to tell you if you are dealing with a relatively good home or homes it may have for mild difficulty.
DR. ERIC TANGELOS:
If you are just tuning in, you are listening to the Advances in Long-Term Care Medicine on ReachMD, The Channel for Medical Professionals. I am your host Dr. Eric Tangelos and joining me to discuss recommending long-term care facilities to patients is Dr. Charles Crecelius, Clinical Instructor of Internal Medicine in Geriatrics at Washington University School of Medicine in St. Louis. So, we have 5-star ratings coming for nursing homes. Can you compare or can you better match patient and their family personality wise to a facility or do you just take what is available?
DR. CHARLES CRECELIUS:
You really need to look the facility. It is said if you have walked into one nursing home you have seen one nursing home and just like hospitals may have their specialties, cardiac care, neurologic care and the like nurse homes also tend to subspecialize. Many now specialize them postacute care, taking people out of the hospital and rehabilitating them. Some do very well with dementia care may even have a separate unit for different levels of dementia. Some are just general nursing homes that take care of a variety of patients with chronic diseases. You really have to get to know the facility to get a feel of really what that facility is good at and you have to have more than a superficial impression. You may walk in a nursing home and find a somewhat loud and noisy nursing home at times and think my goodness this is not really where I want to be but you may find that exactly in-home with taking care of very sick people in the hospital, healing pressure ulcers, getting people rehabilitated from hip fractures, getting people out of congestive heart failure back home. A noisy home isn't necessarily a bad home, it may just be a very busy home. So always scratch beyond the surface and see what the strengths and weaknesses are of that home.
DR. ERIC TANGELOS:
Well, nursing home compare might give us an objective measure but what can you suggest to our listeners with regards to how you assess strengths and weaknesses of any given facility?
DR. CHARLES CRECELIUS:
One of the best ways is simply the experience you and others have had. Do they get the job done? If it is a patient who needs rehabilitation, do they manage them to get back home if they have chronic diseases, are they cared for meaningfully, are the families satisfied with their care and correspondently all is it will be able to have problems in nursing homes that are chronically ill and declining. Do the nursing home at least try and listen to the family, talk with the staff, talk with the doctor, let them know what is going on, basically of a good communicator. Nursing homes that communicate with the doctor, with the patients and with the families are typically better nursing homes.
DR. ERIC TANGELOS:
Is there anyway for us to assess the physician staffing or the capabilities of a medical director at a given facility?
DR. CHARLES CRECELIUS:
There are several ways. The medical director should be certified doctor in United States obviously and more importantly should be a certified medical director. There is a training program medical directors can undergo in which they are taught how to provide the administrative support and clinical duties of their job. It's a one-week training course, very intensive but really gets doctors up to speed for their job. So ask if the doctor is a certified medical director or CMD. You may also want to know is the home a closed model. There is some evidence that indicates that homes that use a select group of doctors who are used to working with nursing homes, caring for frail patients, promptly helping with rehabilitative patients, do a better job than those that are just the occasional doctor.
DR. ERIC TANGELOS:
So, if we took an average nursing home about say between 100 and 120 beds and you are to make a quick glance using that kind of logic how many physicians would you want to see front of the facility listed as attending?
DR. CHARLES CRECELIUS:
It could vary somewhat by region to region and by interest and some urban areas were blessed with a lot of geriatricians and so you might see up to 10 doctors, more likely you are going to see 4 to 5 doctors taking care of those patients. You may also want to ask if there are nurse practitioners that are employed by the doctor. Nurse practitioners can be valuable in helping provide day-to-day continuity of the services in helping to take care of acute problems that the doctor may not be able to get to quickly.
DR. ERIC TANGELOS:
So, let's explore the rest of the healthcare team. You started with the nurse practitioners and again were assessing facilities, what are you going to look for or what would you recommend we all look for when we are looking at nurse practitioners or the nursing models or what is available nutritionally in a facility? Tell us.
DR. CHARLES CRECELIUS:
Nurse practitioners are a valuable asset but there is a shortage of healthcare workers in general, so you may not always find them. If they are there, it's a nice addition to be at. You may also want to inquire about the director of nursing. How long has she or he been there is a important question to know. Unfortunately, some homes they are not this good tend to have a high turnover rate and knowing the average length of stay of the administrator, the directive nursing and the direct care staff is very important. You can find from nursing home compare but you can also inquire at the home about staffing ratios, how many nurses are there to the average residents, how many hours per day, how many seeing hours per day. On nursing home compare website, you can actually find this information compared to national norm.
DR. ERIC TANGELOS:
Is there any way to assess the team itself on nursing home compare or are there other methods to do that?
DR. CHARLES CRECELIUS:
The team approach can be indirectly assessed to the quality measures. Quality measures are listed in nursing home compare that relate to both acute patients on med A stays and chronic patients that are staying there long-term, a typical measure would be the number of people in daily pain or the number of high-risk patients with pressure ulcers. These measures can be helpful in determining whether a home is doing a good job and whether they can work in interdisciplinary fashion to improve quality in their home. We have to take this as a bit in a salt though, there will be an occasional home that specializes for example in pressure ulcers and some other measures may look a little off, so don't always take on the face value, if you find a quality measure that seems to be out of sort make sure that is not simply reflection of the kind of patients the home care is for.
DR. ERIC TANGELOS:
Now, when you talk about the quality measures, is this the same as talking about the regulatory environment or are there separate ways to look at the same kind of care issues?
DR. CHARLES CRECELIUS:
They are related to a regulatory issue to some extent but regulations in quality measures are a little different. Regulations simply mean that you are but not providing basic services and were found to be deficient in often just one person's care out of 100 or so. Quality measures relate to all the patients you have and how you are doing as a team in improving the care for many measures, urinary incontinence, pressure ulcers, pain, insomnia, a whole host of them.
DR. ERIC TANGELOS:
Well, I would like to thank my guest from Washington University School of Medicine in St. Louis, Dr. Charles Crecelius. Dr. Crecelius, thank you very much for being our guest this week on Advances in Long-Term Care Medicine.
DR. CHARLES CRECELIUS:
Thank you Dr. Tangelos.
You have been listening to Advances in Long-Term Care Medicine on ReachMD radio on XM 160, The Channel for Medical Professionals. Advances in Long-Term Care Medicine is produced in cooperation with the AMDA. For more information about this or any other show, please visit reachmd.com, which features on-demand podcasts of all of your programming.
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