Reinventing the Nursing Home: Getting the Kind of Long-term Care We Want

Robert L. Kane, MD

University of Minnesota

School of Public Health

What is the Problem?

Too often posed as a question of financing

Infrastructure is central Those with funds cannot find the care

they want

The Problems with Current Thinking about LTC

Nursing home is at the center Alternatives to NH paradigm

Negative attitudes Nothing can be done Decline is inevitable Good care does not make a difference

Types of LTC Clients

Physically dependent Cognitively dependent Rehabilitative End of life Coma/vegetative state

Sensitivity to environment

What determines who should be cared for where?

Patient preferences Available support Cost

Personal Societal

Societal dicta Risk taking

The Building Blocks of LTC

Personal care Housing Medical Care

Especially chronic disease care

Rare to find all three done well simultaneously

PersonalCare.

Housing

Chronic Disease Care

Can’t Rely on a Name

Personal Care

ADLs, IADLs Supervision Supportive services Structured observations Reliability Respect Personalized

Housing

Minimal quarters/amenities Supportive environment Control of access Varying levels of affluence Congregation as needed or desired Location

Medical Care

Chronic disease management Proactive primary care Responsive Coordination with social care

Prerequisites for Making Good Decisions

Real options Time Information

Benefits Risks Costs

Clarity about goals What is most important to maximize Consensus within family

Guidance/Structure

Limited Treatment Options

Goals Clarification

Consumers and providers must share the same goals

Medical and social providers must share the same goals

Goals and priorities may change depending on who is paying for the care

A Lot Depends on Interpretation

Potential LTC Goals

Maintaining or improving function Maintaining or improving quality of life Safety Autonomy Not being a burden End of life care

May have to set priorities

Merging Medical and Social Care

Shared goals Social goals generally around

compensatory care Assessment to find problems Services to meet identified needs

Medical goals more therapeutic Making a difference

Potential for common ground

Developing Individualized Care Plans

Each client/patient should be identified in terms of their needs for personal care, housing and medical care

There are many ways to meet each combination of needs

The plan should reflect the client’s (and family’s) preferences

Role of Risk

Older people should not be denied the right to take risks Ageism

Risks involve informed decisions Need to understand the benefits and

risks of an action

Severity, i.e.,

cognition, function,

prognosis.

Preferences, i.e., safety, autonomy, privacy, culture, atmosphere, aesthetics

Personal Care Needs

Health/ Clinical/ Medical Care Needs

Housing Needs

Measuring Success in LTC

Success is measured in terms of slowing the rate of decline

This concept can be applied to measures of both quality of care and quality of life

The problem is that the comparison to see the improvement is generally invisible

ObservedObserved

ExpectedExpected

OutcomeOutcome

TimeTime

Evidence of Successful LTC

Housing issues

Minimal levels Personal private space Bedroom Toilet

More amenities as affordable Small clusters

Personal Care

Skills Care Observation and action

Systematic observation Clinical Glidepaths

Respect Concern Compassion

Medical Care

Chronic care management Proactive primary care Track status and intervene early

Avoid iatrogenesis Drugs Catheters

Respect and incorporate social care Interact with family

Need Relevant Information

Information Technology

Problems with too much as well as too little information.

Need to focus attention on salient data

Validated protocols Professionals Care givers

Just in time information Structured information

Clinical glidepaths

Clinical Glidepath

A Clinical Glidepath is a way to observe one or more parameters of a patient’s condition on a regular basis to be able to compare the observed state with the expected state.

It is a tool to improve communication between patients and primary care providers.

If the patients stays within the expected course, nothing need be done.

But if the patient’s clinical course deviates, this change should trigger immediate closer attention to ward off a problem while it is early.

o

o

o

X

Clinical Glidepath

Expected Course

How You Implement Is Important

Policy Issues LTC is not simply a payment question

Private payers cannot find the care they want Use payment to re-enforce service goals but not to

create them Pay for services not housing

Levels the playing field; eliminates the distinction between NHs and HCBS

Provide housing as needed and affordable Encourage coordination of medical and social care

Start with shared goals Families are central to LTC

Policies should support family care