I shudder to contemplate this as a solution. My 75 yo mother died, unnecessarily, of pulmonary emboli following transfer to a nursing home to rebuild strength after a hospital stay. There is no real medical care in a nursing home, I recognized the symptoms and severity of her condition and contacted her physician directly, only to be told that docs need only visit patients every 30 days (she had been there 4 days). He had an ah ha moment and called for an ambulance once I described the symptoms. Nurses were not involved.
1
When my father died in hospital at age 88 he developed bed sores and said he felt like he was in a dungeoun. He was on a waiting list for a hospice facility because he had contracted MRSA on a prior admission. My dillemma was to allow him to be neglected in the nursing home where he resided or in hospital. 1 in 3 people Skilled Nursing are harmed by their care according a federal report last year. There is so much hype and cant about campaigns for improvement and so little enforcement of regulation that it is hard to trust what is true. A year before he died he had hospice for 6 months in the nursing home and his condition improved. Just two hours a day of consisitent care from an aide made a huge difference, but the director of nursing said they wouldn't tell me if they administered morphine. "All hospice patients get morphine so it's not a change of condition!" Hospice which is by original philosophy supposed to be caring for families too, is a different beast in a nursing home. The facility is their client not the patient or fhe family. I had difficulty reaching the nurse who promised to call me regularly.
Later in the hospital a nurse told me that they wouldn't call me if his condition deteriorated and death was imminent. "It's not our job." For all of that if you can keep your loved one in one place, closely monitor his condition for utmost comfort and receive hospice services (not provided by the skilled nursing facility this still strikes me as the best.
Later in the hospital a nurse told me that they wouldn't call me if his condition deteriorated and death was imminent. "It's not our job." For all of that if you can keep your loved one in one place, closely monitor his condition for utmost comfort and receive hospice services (not provided by the skilled nursing facility this still strikes me as the best.
1
My experience in western Ohio was almost totally opposite but may have been abnormal. That said, there is something strange going on in this comment. I'm guessing this person was not the father's medical POA, the father was not realistic, and that morphine was a good comfort option. Quality of care from the nursing facility I would not address. I would agree that having the hospice aide to do personal care every day was a major contributor to comfort.
As a student nurse I have witnessed the adverse effects of hospitalization on elders, highlighted in Aid and Comfort Staying Put (April 24). I agree that the modern hospital is not a safe place for long term care. Complications such as antibiotic resistant infections, debilitating bedsores, sentinel falls, and depression are real and frighteningly common. While nursing homes may help lower health care costs, they are not immune to patient safety issues. Nursing homes are associated with similar complications due to poor nurse-patient ratios and lack of regulation.
As an alternative to these options, especially when health is declining, I would like to promote the concept of hospice care. Choosing hospice is commonly though of as giving up. This inaccurate stigma has influenced the average hospice stay to be less than a week, when it can actually be 6 months or more. Not only does hospice allow the patient to be at home free of nosocomial infection and stressful new environments, but the nurse’s primary job is to provide comfort to the patient and family. Knowing when to choose hospice instead of hospitalization can be difficult but making these decisions early is critical to maximize an elder’s quality of life.
As an alternative to these options, especially when health is declining, I would like to promote the concept of hospice care. Choosing hospice is commonly though of as giving up. This inaccurate stigma has influenced the average hospice stay to be less than a week, when it can actually be 6 months or more. Not only does hospice allow the patient to be at home free of nosocomial infection and stressful new environments, but the nurse’s primary job is to provide comfort to the patient and family. Knowing when to choose hospice instead of hospitalization can be difficult but making these decisions early is critical to maximize an elder’s quality of life.
1
As a nursing student and community health educator in Oakland Ca, I have worked with older adults in both hospital and nursing home settings, and I know that nursing homes have the potential to provide affordable quality health care if given the resources to do so. One imperative issue that you highlighted and contributes to nursing homes inability to provide optimum care is the lack nursing staffing. It seems Hebrew home in Riverdale and Gurwin have found ways to provide high quality and innovate nursing home care to its residents despite the federal regulations on nursing hours. I have grave concerns about the quality of care older adults are receiving in hospitals settings, and support the notion that the answer to meeting basic health needs includes policy change around nursing home resources. California needs to reconsider adopting the mandate 24/7 nursing coverage in nursing homes. I commend you for shining the light on this health concern.
1
I am a nurse, I have worked in many facilities. LPN's are trained to do all aspects of IV Therapy, plus there are now IV teams from Pharmacies that come in and do it. LPN's are not allowed to do blood transfusions. I have seen residents with dementia, come back from a short time at the hospital so combative and disoriented that it took quite a while to calm them down. Very few facilities have RN's on duty 24 hours. But they are generally only a phone call away. And it is true that the workload for any nurse is getting heavier and heavier. But that is thanks to the type of residents they have and also to government cutbacks\
2
The new model of care that is described in the article is laudable. While hospitals will do their best to prevent nosocomial infections and other “never events”, the fact is that the hospital is a dangerous place to be. If care can be streamlined by allowing elderly patients to receive their IV antibiotics and blood transfusions in a nursing home this could prevent some of the adverse outcomes associated with being hospitalized. However, before we start transitioning all elderly patients to nursing home care, it is important to keep patient centered care in mind. Not all nursing homes have the resources that are needed to provide hospital-level care, especially with their patient to nurse staffing ratios, and the fact that providers may not be as accessible as they would be at the hospital. Patients and families should be fully informed about the benefits and risks of both the hospital and nursing home environments, and should be permitted to make their own decision regarding which environment they prefer.
Hebrew Home in Riverdale and Gurwin are examples of what nursing homes should be: high quality, innovative, and focused on the best practices for their residents! They are both not-for-profit religious organizations whose purpose is care and services - not making money. So the facts in this article come as no real surprise. If you or a loved one needs nursing home care, the local not-for-profit is the place to start looking.
Reading the letters below highlights some of the challenges in long term care. Some cite the high cost of care while other berate many nursing facilities because they have large numbers of CNAs. The sad truth is that society cannot have it both ways - when people need 24-hour care, you need highly trained staff to provide that care (see Hebrew Home and Gurwin), otherwise the care will suffer while the residents are barely maintained for the last months of life. Thank goodness there are still leading organizations in senior care like those mentioned in this article.
Reading the letters below highlights some of the challenges in long term care. Some cite the high cost of care while other berate many nursing facilities because they have large numbers of CNAs. The sad truth is that society cannot have it both ways - when people need 24-hour care, you need highly trained staff to provide that care (see Hebrew Home and Gurwin), otherwise the care will suffer while the residents are barely maintained for the last months of life. Thank goodness there are still leading organizations in senior care like those mentioned in this article.
3
I bet top five officers are not racling in like officers at other non- profit org.
Non - Profits need overall so they can pay well to actual workers.
Non - Profits need overall so they can pay well to actual workers.
I think this article is misleading. Not all nursing homes provide care that is safer and less stressful than hospitals. In fact, many do not. The ratio of educated nursing staff (RNs and NPs) is too low to provide adequate assessments and treatments for the increased acuity. One RN and 2 nursing aides for 30 patients is common today and just not enough to provide good basic level of care, including bathing, dressing, toileting, giving medications, ambulating, and assistance with eating. Families need to do their research and ask tough questions before admitting their loved one to a nursing home. If I need nursing home level of care, it is time for a cocktail to heaven.
2
Well, this will trend will also kill these folks, but at least in familiar territory -- which I guess constitutes some type of gain.
I agree with poster above who discusses staffing and experience. Nursing homes / rehab centers are staffed with minimum wage workers who are so busy sitting at the desk talking w/other staffers, and comparing photos on their phones, the patient is the last person they are concerned with. Feed, bathe(maybe) and medicate (late, or incorrectly). Realize painting broad strokes here, but my 67-year old brother died 6 weeks ago, completely unnecessarily, of preventable complications of an untended infection, in a 'skilled care nursing and rehab facility.' We have lodged complaint with our State Dept. of Health Services, and they will be investigating. That doesn't save my brother, however.
Told my husband just last night -- between our long-term care policies and judicious allocation of funds/planning for same, the most important component to keeping one of us alive after an illness or health intervention /event would be home care by private help. Enter any type of 'nursing facility' and average mortality is one year. And I'm okay, for myself, with that should I even get as far as 85. But 60, or 67, like my brother ... it's no place to be, ever. You are, literally, dead meat.
I agree with poster above who discusses staffing and experience. Nursing homes / rehab centers are staffed with minimum wage workers who are so busy sitting at the desk talking w/other staffers, and comparing photos on their phones, the patient is the last person they are concerned with. Feed, bathe(maybe) and medicate (late, or incorrectly). Realize painting broad strokes here, but my 67-year old brother died 6 weeks ago, completely unnecessarily, of preventable complications of an untended infection, in a 'skilled care nursing and rehab facility.' We have lodged complaint with our State Dept. of Health Services, and they will be investigating. That doesn't save my brother, however.
Told my husband just last night -- between our long-term care policies and judicious allocation of funds/planning for same, the most important component to keeping one of us alive after an illness or health intervention /event would be home care by private help. Enter any type of 'nursing facility' and average mortality is one year. And I'm okay, for myself, with that should I even get as far as 85. But 60, or 67, like my brother ... it's no place to be, ever. You are, literally, dead meat.
2
There’s a disconnect here. Home infusion therapy for antibiotics, cancer chemotherapy, nutritional care, etc. have been on the rise for 25 – 30 years. The article suggests this is new approach to medical delivery. The only thing new about it is that hospitals are transferring patients from the emergency room to home care, without an inpatient stay.
The shift to home care indicates that much of what takes place in hospitals is only based at the hospital because of historical practices and requirements for insurance reimbursement. It also demonstrates that hospitals are being forced to delink their services from centralized, facility based care to dispersed settings, including patient homes, due to changes in technology, insurance reimbursement, consumer attitudes, and changes in the mix of patient needs. In the future, changes in technology and reimbursement will make patient diagnosis, treatment monitoring, and care even less facilities that offer immediate proximity to laboratory, surgery, multi-disciplinary clinical skills, and emergency capabilities. The genie left the bottle some time ago.
The shift to home care indicates that much of what takes place in hospitals is only based at the hospital because of historical practices and requirements for insurance reimbursement. It also demonstrates that hospitals are being forced to delink their services from centralized, facility based care to dispersed settings, including patient homes, due to changes in technology, insurance reimbursement, consumer attitudes, and changes in the mix of patient needs. In the future, changes in technology and reimbursement will make patient diagnosis, treatment monitoring, and care even less facilities that offer immediate proximity to laboratory, surgery, multi-disciplinary clinical skills, and emergency capabilities. The genie left the bottle some time ago.
3
Unfortunately, the home care model requires families to provide the majority of care at a time when most people have to work. The caregiver stress is untenable.
1
In the geriatric medicine world, we are on the front lines of the growing tendency to push acuity downward. What I mean by that is that patients who used to be in ICUs are now on the medical surgical wards. Those that used to be in regular medical wards are now in nursing homes, and those that used to be nursing home level are now in assisted living where there might be a nurse for a few hours a day if you are lucky. For many older people, in particular those who are frail/nursing home eligible, the acute care hospital can be a dangerous place. It is full of multidrug resistant organisms, policies that require that patients not be allowed to get up until they have been "cleared" by physical therapy (never mind that that person walked well prior to admission), and staff that may or may not realize that frail elders need different care than the standard adult patient. We take great pride in providing excellent care for our long term care residents (in a faith-based, nonprofit nursing home) but I have long since stopped being amazed at the types of conditions we are asked to manage in the SNF and the extraordinary expectations of families and our acute care "partners". A decade ago, many of our patients would have been admitted to acute care, but now we do our best to keep them "at home" with us, when we can, and when it is congruent with the goals of care of the families (many of whom are the drivers of admissions to acute care).
4
I agree with some others here that we should take extra care when even considering the use of IV fluids and medications, not to mention transfusions, in the frail elderly. This is true regardless of care setting.
Sometimes however, a patient's delirium or other troublesome symptom will respond well to a little gentle hydration. In those cases I like to use a technique that is unfortunately little used outside of veterinary medicine. It's called hypodermoclysis, and it involves the placement of a very small needle under the skin.
In subcutaneous hydration the fluid can even be hung without a pump. In any case the fluid runs very slowly, passively, and is absorbed into the body. It's uncomplicated and requires little training. And, done correctly, the risk of infection or complication is exceedingly low, much lower than the risks posed by IV’s. Many medications can be delivered this way as well.
It's not for everyone of course, but I use subcutaneous hydration in homebound patients when it will improve the quality of life. It is the essence of palliative care. More long term care facilities should consider it as a therapeutic tool, to avoid hospitalization and other unnecessary interventions.
Sometimes however, a patient's delirium or other troublesome symptom will respond well to a little gentle hydration. In those cases I like to use a technique that is unfortunately little used outside of veterinary medicine. It's called hypodermoclysis, and it involves the placement of a very small needle under the skin.
In subcutaneous hydration the fluid can even be hung without a pump. In any case the fluid runs very slowly, passively, and is absorbed into the body. It's uncomplicated and requires little training. And, done correctly, the risk of infection or complication is exceedingly low, much lower than the risks posed by IV’s. Many medications can be delivered this way as well.
It's not for everyone of course, but I use subcutaneous hydration in homebound patients when it will improve the quality of life. It is the essence of palliative care. More long term care facilities should consider it as a therapeutic tool, to avoid hospitalization and other unnecessary interventions.
4
It may be very wise to try to reduce trauma to the elderly by making additional resources available in nursing home care.
However, what concerns me about all nursing home and long term care is the cost, which can be astronomical and quickly deplete resources.
However, what concerns me about all nursing home and long term care is the cost, which can be astronomical and quickly deplete resources.
The article alludes only briefly to one of the pitfalls of providing care for patients with more serious illnesses in nursing homes -- the frequent absence of registered nurses.
It neglects to say what is more glaringly lacking -- the presence of doctors. In many cases, they are only required to see patients weekly, unlike hospitals where patients are seen daily.
More advanced health care in nursing homes might be good at times, provided the patients don't have unexpected complications -- and the trained caregivers are actually present.
It neglects to say what is more glaringly lacking -- the presence of doctors. In many cases, they are only required to see patients weekly, unlike hospitals where patients are seen daily.
More advanced health care in nursing homes might be good at times, provided the patients don't have unexpected complications -- and the trained caregivers are actually present.
7
I am troubled by this trend since the nursing homes or "rehab" facilities that I have experienced are understaffed with less educated employees. It is another way to curb costs but patients and their families need to be aware of the risks. In addition, staffing ratios of registered nurses and nurse practitioners need to be regulated.
12
This coming from a nurse who has worked hospital and insurance case management. Medicare would never pay for a 5+ day hospital stay for just blood transfusions. Who are we kidding?
If something can be done outpatient or observation - that's how it's going to go. Even when folks stay overnite - if it does not meet inpatient criteria - it's classified as observation.
Having transfusions done inpatient instead of outpatient is not a matter of kindness - it's a matter of reimbursement. If only a transfusion is needed, an inpatient hospital stay and be reimbursed is not going to fly. Period.
If something can be done outpatient or observation - that's how it's going to go. Even when folks stay overnite - if it does not meet inpatient criteria - it's classified as observation.
Having transfusions done inpatient instead of outpatient is not a matter of kindness - it's a matter of reimbursement. If only a transfusion is needed, an inpatient hospital stay and be reimbursed is not going to fly. Period.
7
The comment about subcutaneous administration of fluid is important. This method has been used for decades in Canada, much of Europe and other parts of the world both in long term care and at home. For some reason. I have found that, in the United States, it has been regarded as to be used only in hospice or palliative care which is far from the truth. It is safe, painless, effective and cheap. It does not require a nurse for administration. Providing water to drink, is of course, preferable but many elders either cannot drink without coughing and discomfort, but, most importantly, lose the sense of thirst with advancing age. To see how simple hypodermoclysis can be, if you wish, go to http://www.youtube.com/watch?v=7LB_0W9lSrI to see a family member start the procedure by inserting the needle in my thigh (I was teaching the method).
7
The RN shortage is a cost-savings shortcut in nursing homes that should be simply disallowed by medicare. Yes, the inpatient admission from a nursing home is a toss of the dice when it comes to getting a problem fixed, avoiding a whole new infection found only at the hospital, and the near certain decline of the patient due to stress and inactivity. The fee-for-service system plays itself out in repeated useless tests, a surgery hunt, and pet project referrals by doctors. No physicians or nurses really coordinate care. None. Nobody. The patient's wheelchair simply winds through the labyrinth of a fee-for-service cafeteria where whatever can be billed (according to regulators)....will be. For most elderly this is a frightening experience where they remain objectified, conveyor-belted and most of all, uninformed. After all, what forward thinking nurse would counsel the patient that, "All is OK, we are just going to wear you out for a few days of waiting in line for tests that you do not need. Sorry you are not feeling better yet." The patient is very much alone on the carousel getting somewhat less than the best treatment in the world. And yes, they are quite happy to return to the nursing home, any nursing home.
9
As an Ombudsman for long term care residents Nursing Homes are suited for many hospital procedures but many facilities have to be upgraded. The article surely does not represent those Nursing Homes that care for the indigent. The goal above all else should be to raise Quality of care for all residents.
7
When I am 89, wheelchair bound and suffer from mild to moderate dementia, I hope to make it very clear to my family that I don't want blood transfusions for anemia or IV fluids because my appetite is sub-par. When will we realize as a society that we are not immortal, death is natural and all these interventions just prolong the inevitable and do little to improve one's quality of life. We must learn to let go and say good-by to those we love.
71
Amen to that, Mary. IV antibiotics??? Dialysis??? My husband and I are going to write the best advanced directives we can--and not get into the medical nightmare at the end of our lives.
Also...is there anyone who's visited a nursing home lately and thought that the residents were maintaining their muscle tone? This is delusional. People spend hours, days in wheel chair, their beds. If all you can say is that being in the nursing home is better than being in the hospital, God help you. Do you realize that is like comparing the 8th and 9th circles of Hell????
Also...is there anyone who's visited a nursing home lately and thought that the residents were maintaining their muscle tone? This is delusional. People spend hours, days in wheel chair, their beds. If all you can say is that being in the nursing home is better than being in the hospital, God help you. Do you realize that is like comparing the 8th and 9th circles of Hell????
8
Be sure to tell your family members exactly what your wishes are. Better yet, give them all a copy of your advanced directives and hold a family meeting to review them! If you're incapacitated, all it takes to be treated against your wishes is one family member who accuses the others of "killing Gramma" by following your directives. And choose your durable power of medical decision making carefully.
1
Mary,
That will be great-- for you. Maybe that isn't this gentlemans choice. Maybe he has the quality of life he would like in his condition and he is content to live in a place where he is cared for and loved. It is so very hard to make these decisions when our parents age. I am sure that we all know that death is natural.
Next time you utter words like this again, think about how an insurance company may say that about you as you are suffering from some sort of a disease-- "Well, death is inevitable....." Or, if a person is hit by a car "Don't bother--- death is inevitable"
Why don't you have a tad bit more empathy for others and how they decide to handle very personal issues within their own family.
That will be great-- for you. Maybe that isn't this gentlemans choice. Maybe he has the quality of life he would like in his condition and he is content to live in a place where he is cared for and loved. It is so very hard to make these decisions when our parents age. I am sure that we all know that death is natural.
Next time you utter words like this again, think about how an insurance company may say that about you as you are suffering from some sort of a disease-- "Well, death is inevitable....." Or, if a person is hit by a car "Don't bother--- death is inevitable"
Why don't you have a tad bit more empathy for others and how they decide to handle very personal issues within their own family.
1
Reading this article drives home the fact that as a society we continue to be ill-prepared for confronting the impermanence of life.
Consumers need a more realistic understanding of what medical care can and cannot do to ameliorate aging. Geriatric care is (or should be) by nature, a shift away from attempts at curing aging and toward comfort care and quality of life enhancement for elderly patients.
It would be beneficial if more doctors learned how to have honest discussions with declining, elderly patients and/or their families about the consequences of medical care aimed at preventing what we all confront and creating unnecessary suffering in the process.
Consumers need a more realistic understanding of what medical care can and cannot do to ameliorate aging. Geriatric care is (or should be) by nature, a shift away from attempts at curing aging and toward comfort care and quality of life enhancement for elderly patients.
It would be beneficial if more doctors learned how to have honest discussions with declining, elderly patients and/or their families about the consequences of medical care aimed at preventing what we all confront and creating unnecessary suffering in the process.
41
Nicely said, and appropriate. But the medical care of the elderly, whether needed or not, is an INDUSTRY that generates enormous amounts of money. That money is a huge disincentive to honest discussions.
3
Reimbursement needs to catch up with patient preferences, patient well-being, and overall system cost savings. Let's do the right thing repeatedly and things will get better.
6
While providing certain care in nursing homes that was previously done in hospitals may at times be possible and desirable, a more important and vexing question involves the wisdom of doing some of what we do to begin with, and here enters the dilemma. Decisions regarding medical interventions need to be weighed carefully, so that the patient actually benefits from the treatment.
For example, someone who is in the actual dying process may not benefit from the administration of IV fluids, which may simply prolong the number of days in which this person may languish before death. Sometimes NOT doing something is actually the best choice, which in many circumstances is a much more complex decision than simply ordering multiple tests and giving antibiotics and other treatments which may not benefit, can be uncomfortable and may even harm the patient.
While providing more services in nursing homes may be economically attractive at first glance, the long term consequences of this approach needs to be considered, and we need to be mindful that what we do actually is helpful to the patient, not necessarily what uninfomed family members may imagine is best or that things are done simply because they may be readily available.
Our health care system is very big on action and technology, with some miraculous and other mixed results, but many times what is really needed is something that requires little capital: careful consideration.
For example, someone who is in the actual dying process may not benefit from the administration of IV fluids, which may simply prolong the number of days in which this person may languish before death. Sometimes NOT doing something is actually the best choice, which in many circumstances is a much more complex decision than simply ordering multiple tests and giving antibiotics and other treatments which may not benefit, can be uncomfortable and may even harm the patient.
While providing more services in nursing homes may be economically attractive at first glance, the long term consequences of this approach needs to be considered, and we need to be mindful that what we do actually is helpful to the patient, not necessarily what uninfomed family members may imagine is best or that things are done simply because they may be readily available.
Our health care system is very big on action and technology, with some miraculous and other mixed results, but many times what is really needed is something that requires little capital: careful consideration.
44
I agree, Dr. T., that sometimes Don't Do Something, Just Stand There (and monitor the situation) is the best response. The ability to do a procedure in a nursing home doesn't mean that it should be done. But it still seems preferable, if patients and families agree to an intervention (and it's still their decision, after weighing the information that medical professionals should provide), to do it outside a hospital whenever possible.
10
There are a lot of medical services that could be carried out at a location lower in the healthcare structure if we would just let go of some old assumptions, but it will require rethinking the training and deployment of professional staff and the structure of financial incentives.
The government has to take the lead in doing this because that's the only possible way for it to work, but the ideas can come from anywhere. We need to be open to sensible improvements, while being careful not to simply open floodgates of funding for new services. Hard to do, very hard to do, but necessary. It requires having smart people in mid-level policy positions.
The government has to take the lead in doing this because that's the only possible way for it to work, but the ideas can come from anywhere. We need to be open to sensible improvements, while being careful not to simply open floodgates of funding for new services. Hard to do, very hard to do, but necessary. It requires having smart people in mid-level policy positions.
6
When the demographics demand that we alter Medicare and Medicaid reimbursements to compensate family members and home health aids for the least expensive means of providing care to the elderly, nursing homes are clawing about for patients to replace those who will be cared for at home. What do they look for? Hospital patients? Ridiculous! These patients can also be treated at home given the technology available today.
A pertinent question may be, when will we recognize the capacity of Registered Nurses to manage many home care patients independently? This would in no way diminish a physician's role in diagnosing and ordering treatment. It could eliminate administrative costs if RNs were able to provide nursing services, and bill for nursing services, independent of any other entity: hospitals, nursing homes, or others. Nurses are already responsible for implementing "standing orders" to provide treatments, medications, and diagnostic tests and monitoring. Given available technology, a group of Registered Nurses, could manage the home care of large numbers of patients and provide the supervision/guidance to aides or family remotely. This, with vast savings to the overall costs of providing such care in a nursing home or hospital. Warehousing the elderly has no evidence based positive outcomes for the patients.
A pertinent question may be, when will we recognize the capacity of Registered Nurses to manage many home care patients independently? This would in no way diminish a physician's role in diagnosing and ordering treatment. It could eliminate administrative costs if RNs were able to provide nursing services, and bill for nursing services, independent of any other entity: hospitals, nursing homes, or others. Nurses are already responsible for implementing "standing orders" to provide treatments, medications, and diagnostic tests and monitoring. Given available technology, a group of Registered Nurses, could manage the home care of large numbers of patients and provide the supervision/guidance to aides or family remotely. This, with vast savings to the overall costs of providing such care in a nursing home or hospital. Warehousing the elderly has no evidence based positive outcomes for the patients.
21
But I definitely would not want it at any of the nursing homes in which I volunteered or was employed. Just look at the ridiculously low requirement for number of hours of "nursing care" (read nursing assistant) per resident per day which varies by state. In addition to nursing assistants the care basically is provided by LPNs. Many of the nursing assistants and LPNss are wonderful, caring people but if nursing homes are going to be doing procedures and providing care once done only in hospitals, they need similarly skilled staff. RNs in decent numbers and doctors who do more than give a passing glance at charts...How likely is that to be when more than two-thirds of the nursing homes are for-profit and the not-for-profits have to at least break even? Don't hold your breath...
13
No one of any age who is in their right senses wants to be in an acute care hospital unless there is absolutely no other alternative!! Something like a blood transfusion should not require hospitalisation!
11
actually, there is some risk of reaction to a transfusion and the range of risks includes sudden death - incidence is very low but if it happens to you or your loved one, you can end up disabled or dead. Unless a patient is clearly a DNR then it is reckless to do a transfusion with a patient who is more than a couple of minutes away from CCU. And if patient IS clearly a DNR, then perhaps the transfusion is not so much for the patient's benefit as that of staff or family or provider who can't let go (I won't presume to ascribe a financial incentive to order transfusions on moderately demented clients who have a DNR and are not able to live in the community.) Everyone dies at some point.
This is the critical statement in the article, "Many (actually MOST) of the nation's Medicare-certified nursing homes don't employ round the clock registered nurses." Very often the only RN employed is the DON (Director of Nursing). Often the ADON (Assistant Director of Nursing) is NOT an RN. Your loved ones are attended to by CNA's (who get 12 hours of schooling). They are unable to recognize when a patient is acting like they may be ill or have a UTI or are dehydrated. ("Oh,old people just don't like to drink.", a quote from a CNA.)
My MIL always got much better, more alert & talkative when she went to the hospital, usually for UTI's and got several days of IV fluids and IV antibiotics and good food, and all the water she wanted to drink.
PLEASE until nursing homes are better regulated and frequently observed by authorities and have laws that they must have several RN's on duty 24/7, let the patients go to hospitals for regulated care by professionals.
My MIL always got much better, more alert & talkative when she went to the hospital, usually for UTI's and got several days of IV fluids and IV antibiotics and good food, and all the water she wanted to drink.
PLEASE until nursing homes are better regulated and frequently observed by authorities and have laws that they must have several RN's on duty 24/7, let the patients go to hospitals for regulated care by professionals.
18
Nursing homes need all kinds of improvements, jenben, but the certified nursing assistants (CNAs) who provide most of the hands-on care are required to have 75 hours training, by federal law, not 12. They're required, after certification, to have 12 hours of additional training each year.
And while there are no solid numbers on how many nursing homes don't have round the clock RNs, it is probably not the majority. A 2012 analysis by the Association of Nurse Assessment Coordination came up with an estimate of 11.4 percent.
But yes, they should all have nurses 24/7, especially if we're going to try to do more procedures in the nursing home, instead of the hospital. Rep. Jan Schakowsky (D.-Illinois) introduced legislation to require that last year; it went nowhere, but she'll reintroduce it this year. It's called the Put a Registered Nurse in the Nursing Home Act. Write your congressperson!
And while there are no solid numbers on how many nursing homes don't have round the clock RNs, it is probably not the majority. A 2012 analysis by the Association of Nurse Assessment Coordination came up with an estimate of 11.4 percent.
But yes, they should all have nurses 24/7, especially if we're going to try to do more procedures in the nursing home, instead of the hospital. Rep. Jan Schakowsky (D.-Illinois) introduced legislation to require that last year; it went nowhere, but she'll reintroduce it this year. It's called the Put a Registered Nurse in the Nursing Home Act. Write your congressperson!
1
It is best for the public at large to keep patients inflicted with dementia out of the hospital. My 17 year old son had a severe Traumatic Brain Injury. After months in ICU he was transferred to a pulmonary unit and put in a room with a 90 something man named Leo. Leo was confused but ambulatory. He unplugged things including monitors.
It took 72 hours to negotiate with our health insurance and the hospital to put my son in a private room for his safety. I was allowed to stay in my son's hospital room in an upright chair keeping guard, very frightening.
It took 72 hours to negotiate with our health insurance and the hospital to put my son in a private room for his safety. I was allowed to stay in my son's hospital room in an upright chair keeping guard, very frightening.
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Looking at my dad's photo in this article, he may appear asleep, overly medicated, or deep in prayer. What is not apparent is a great deal of life inside of him. He might turn towards me and ask if my son still has the same girlfriend. Or if my daughter likes her new job. All relevant questions. All showing a deep love and concern for his family.
I have come to admire the many residents on the dementia unit and look forward to my visits at the Hebrew Home. I chat with Ivy League educated women who had long, rewarding careers. I am touched by a man's love and devotion for his wife as he shares his meals with her every day. Her smile is so bright and nourishes him as well.
My dad looks forward to the kasha knish I bring him, and eats it with relish, but he is unable to manipulate a fork very well due to his blindness. The article noted that he 'wasn't eating and drinking much' for a period of time and required IV fluids. A feeding tube had even been suggested. Outrageous! Depriving my dad of the enjoyment of tasting food would have diminished his quality of life rather than improve it. And it was not necessary. All that was needed was someone to help him get his food from his plate to his mouth and place a cup in his hand to drink.
The exceptional people that care for our parents deserve our admiration and support. Resources should be directed to provide more qualified and caring healthcare workers to improve the day to day lives of our aging parents.
I have come to admire the many residents on the dementia unit and look forward to my visits at the Hebrew Home. I chat with Ivy League educated women who had long, rewarding careers. I am touched by a man's love and devotion for his wife as he shares his meals with her every day. Her smile is so bright and nourishes him as well.
My dad looks forward to the kasha knish I bring him, and eats it with relish, but he is unable to manipulate a fork very well due to his blindness. The article noted that he 'wasn't eating and drinking much' for a period of time and required IV fluids. A feeding tube had even been suggested. Outrageous! Depriving my dad of the enjoyment of tasting food would have diminished his quality of life rather than improve it. And it was not necessary. All that was needed was someone to help him get his food from his plate to his mouth and place a cup in his hand to drink.
The exceptional people that care for our parents deserve our admiration and support. Resources should be directed to provide more qualified and caring healthcare workers to improve the day to day lives of our aging parents.
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would you be willing to pay more of your own money to justly compensate the nursing home workers? not medicare, not insurance, but your money?
6
Many families such as mine personally contribute not only money but time. And if it were possible to choose how tax dollars are spent, I could think of many less worthwhile ways public funds are used than to improve the quality of life of aging Americans that fought for our country, taught our children, and contributed decades of taxes.
7
I've had 4 relatives in 5 nursing homes in 3 states. After the first relative had to go on Medicaid because she only had social security, we got our other relatives to sign up for Long Term Care Ins. So the other three were Private Pay, using long term care ins. and savings. Not only were the nursing homes paid $60,000 - $70,000 a year, but because of rationing, there were insufficient diapers and towels , so we also provided diapers, towels , adult wipes, Bottom Butter, Eucerin, body wash and shampoo (because the nursing home used industrial strength cleansers), bottled water, Boost, apple and grape juice, apple sauce, bananas, plastic cups, utensils, etc..
The last nursing home had a Family Council, so with other patient's family members, we paid for and served holiday and CNA appreciation day meals for all members of staff. And decorated patient's doors for birthdays and holidays.
I also spent 4 days/15 hours a week at the nursing home and paid Debbie $10.00 an hour to help with my MIL's care for 3 days/10 hours for each week. We worked hard to keep Mom hydrated, happy, and informed staff when we noticed she was sick.
So how did that all work out? They dropped Mom on her head and she died of a subdural hematoma.
The last nursing home had a Family Council, so with other patient's family members, we paid for and served holiday and CNA appreciation day meals for all members of staff. And decorated patient's doors for birthdays and holidays.
I also spent 4 days/15 hours a week at the nursing home and paid Debbie $10.00 an hour to help with my MIL's care for 3 days/10 hours for each week. We worked hard to keep Mom hydrated, happy, and informed staff when we noticed she was sick.
So how did that all work out? They dropped Mom on her head and she died of a subdural hematoma.
1
I couldn't agree more with this post. I am constantly having discussions with my older patients and their children about the benefits of keeping Mom or Dad out of the hospital, to the extent that that is possible. When I was a nurse in subacute rehab, if we called a physician about a patient, we would inevitably be told, "Send him/her out". In other words, send the patient to the hospital. Inevitably, the patient would have lots of useless and expensive tests and returned to the facility, definitely worse for wear.
An old technique for rehydration, subcutaneous fluid administration (hypodermoclysis) has regained favor in recent years. If a geriatric patient has mild to moderate dehydration, this method of fluid administration is effective and avoids the use of an IV (an all its attendant risks). http://www.ncbi.nlm.nih.gov/pubmed/17971137
Of course, as the post points out, registered nurses are required for some procedures, including blood transfusions. Therein lies the problem for many nursing homes.
An old technique for rehydration, subcutaneous fluid administration (hypodermoclysis) has regained favor in recent years. If a geriatric patient has mild to moderate dehydration, this method of fluid administration is effective and avoids the use of an IV (an all its attendant risks). http://www.ncbi.nlm.nih.gov/pubmed/17971137
Of course, as the post points out, registered nurses are required for some procedures, including blood transfusions. Therein lies the problem for many nursing homes.
8
Thanks for the info on subcutaneous fluid administration.
I realize now that the vet taught us how to do that for our cat.
But the simplest solution to avoid dehydration in the first place would be to teach CNA's about the importance of hydration and to make sure they put the resident's drinking glasses WITHIN THEIR REACH at their 3 meals each day, and to refill their empty glasses.
Often the CNA's would take the resident's in their wheelchairs to the Dining Room about 3:00pm, (dinner was served at 5:00pm), and leave them there without anything to drink until dinner time. Even though my favorite, Edith, would yell at anyone passing by, "HEY! I'M THIRSTY!"
Unfortunately, only visiting family members would go to the other room to get pitchers and glasses and bring them back for Edith and the other residents.
How about nursing homes having Supervisors who would make sure residents could reach their glasses and were given drinks while waiting in the dining room, and would teach CNA's the importance of hydration.
I realize now that the vet taught us how to do that for our cat.
But the simplest solution to avoid dehydration in the first place would be to teach CNA's about the importance of hydration and to make sure they put the resident's drinking glasses WITHIN THEIR REACH at their 3 meals each day, and to refill their empty glasses.
Often the CNA's would take the resident's in their wheelchairs to the Dining Room about 3:00pm, (dinner was served at 5:00pm), and leave them there without anything to drink until dinner time. Even though my favorite, Edith, would yell at anyone passing by, "HEY! I'M THIRSTY!"
Unfortunately, only visiting family members would go to the other room to get pitchers and glasses and bring them back for Edith and the other residents.
How about nursing homes having Supervisors who would make sure residents could reach their glasses and were given drinks while waiting in the dining room, and would teach CNA's the importance of hydration.
11
The encouragement of the staff is definitely important but from the experience with my father, he just did not drink much. The care givers were providing water in a large mug and lots of reminders. But still he did not drink. Perhaps from losing his sense of thirst but also because he seemed to forget. I did not realize how much his loss of memory affected his life both in his daily routine and his memories.
1
My dad not only asks for water, but it's got to be cold. If not, he asks for ice. And if you have it, how about some seltzer?
Staff has been providing more help at mealtimes and adequate drinks throughout the day. It has made a big difference. A helping hand is certainly preferable to a needle.
Staff has been providing more help at mealtimes and adequate drinks throughout the day. It has made a big difference. A helping hand is certainly preferable to a needle.
2
Sadly if Nursing Homes are understaffed now with caretakers how do you think they will be staffed with nurses 24/7? And as far as a hospital stay it is the insurance that determines how long you will be there. if the hospital can't do anything further for the patient, out he goes. And sometimes it's a game of sorts... symptoms return... back comes the patient. If there is no cure and the condition is terminal then the ping pong game commences. it's all about the money, and those with cadillac insurance plans benefit the most.
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And there's a problem at 3 AM what do you do?? In the past one aroused the on-call MD who might well be at home in a smaller community.. (and there should be residents on call at hospitals in larger areas. One can make things as complicated or as simple as possible -- however, and from personal experience, how does one handle obstreperous patients with mild dementia? who won't do things like bathe or change wet Depends or other??? How does one get the obstreperous elderly in assisted living to be part of an exercise program (and why aren't exercise segments part of children's programming on TV-- or adult programming on PBS) and how do you get the obese to morbidly obese to lose weight and eat healthfully -- here in the institutional setting? Ideas??
6
Hebrew Home, where my mother died, has two RNs per floor 24/7. In choosing a nursing home, to me, that is the primary indicator of good care.
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Maybe. I would look at staff turnover rates first. By the way, to my mind the point of the RN's is not so much what they do but the professional attitude that good RN's model for the rest of the staff.
The phrase nursing home is really a misnomer.
There is barely any on site RN coverage at nights in most nursing homes. There are also staff shortages - just as there are shortages of staff to actually provide necessary hands on care for patients in hospitals. And incidents such as falls are probably as common or more common in nursing homes. Infections with bugs like MRSA are probably less.
But it makes no sense to ferry individuals back and forth, when they can be cared for in place. As noted neither the trip nor the wait in the hospital improves well being. I note that the cost of hospital services didn't add in the ambulance costs - another pricey item on the list, one which may have out of pocket costs as well.
There should be adjustments in Medicare spending to allow the development of more intense care in nursing homes - of flexible alternatives. But it's necessary to beware the unintended consequences of all changes.Just as one report in the Time indicated that some nursing home chains are trying to eliminate long term residents in favor of taking in better paying short term rehab patients, it's necessary to be sure that nursing homes don't slight the ongoing care needs of the long term residents not in need of intensive care.
Whenever there is any financial incentive, it can skew services being provided.
There is barely any on site RN coverage at nights in most nursing homes. There are also staff shortages - just as there are shortages of staff to actually provide necessary hands on care for patients in hospitals. And incidents such as falls are probably as common or more common in nursing homes. Infections with bugs like MRSA are probably less.
But it makes no sense to ferry individuals back and forth, when they can be cared for in place. As noted neither the trip nor the wait in the hospital improves well being. I note that the cost of hospital services didn't add in the ambulance costs - another pricey item on the list, one which may have out of pocket costs as well.
There should be adjustments in Medicare spending to allow the development of more intense care in nursing homes - of flexible alternatives. But it's necessary to beware the unintended consequences of all changes.Just as one report in the Time indicated that some nursing home chains are trying to eliminate long term residents in favor of taking in better paying short term rehab patients, it's necessary to be sure that nursing homes don't slight the ongoing care needs of the long term residents not in need of intensive care.
Whenever there is any financial incentive, it can skew services being provided.
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