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The skilled nursing facility (SNF) or nursing home is not a popular institution in the United States. In an often-quoted study, 30% of surveyed hospital patients stated that they would “rather die” than be transferred to an SNF. This is sobering when we consider that 43% of Americans over the age of 65 are likely to spend time in nursing homes. Although nursing homes continue to operate under a medical model of care, there is a growing movement to change the “culture” of nursing homes so that they are less institutional and more homelike. For example, “homelike” nursing homes encourage their inhabitants to eat, sleep, and wake up when they wish, and to visit with pets, children, friends, and family. This section primarily addresses the regulatory requirements of nursing homes.
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SNF care is often divided into the categories of short-term and long-term care, yet the regulatory requirements remain the same for both types. When a nursing home is used as a site for short-term rehabilitation (physical, occupational, and speech therapy), the institution is reimbursed only for 720 minutes of skilled rehabilitation per week. In contrast, the acute rehabilitation center (ARC) is a high-acuity, posthospital institution designed to provide a minimum of 2 hours of intensive rehabilitation each day. The ARC is not covered in this chapter partly because its exercise requirements are not tolerated by most older adults, and partly because Medicare rarely reimburses for more than a few weeks of care, making it a site of almost exclusively short-term care. It is important, however, to be aware of the difference between acute rehabilitation (ARC) and subacute rehabilitation (SNF) in the context of stroke, because aggressive, early rehabilitation leads to earlier improvements in functional status. An older adult who would benefit from ARC but who cannot yet tolerate the minimum requirements may be admitted temporarily to a nursing home and then transferred to an acute rehabilitation setting with the goal of return to long-term institutional or home care.
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In terms of long-term care, the nursing home is the most well known, but not the only form of institutional care. The “culture change” movement has given rise to newer, more home-like forms, the most well-studied of which is the Greenhouse model. A Greenhouse is home to 10 or 12 nursing-home eligible older adults with caregivers who function outside of the conventional roles of nursing. In a Greenhouse, caregivers, or Shahbazim, are as likely to be found cooking or gardening with residents as to be found providing traditional bed and body care.
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The financial structure of the nursing home is currently undergoing a shift as a consequence of decreases in Medicaid reimbursement. Medicare part A continues pay for posthospital care only. A Medicare-qualifying stay at a nursing home occurs within 30 days of a 3-day hospital stay and requires either skilled nursing (typically IV medications or daily wound care) or rehabilitation 5 days a week. The Medicare part A benefit can be invoked even if the patient is initially discharged home, or after discharge from a skilled nursing facility, if that patient suffers a functional decline within the first 30 days of return to home. Medicare part A can also be invoked for a hospice patient who suffers a nonrelated illness or injury, such as a cancer patient who fractures a femur. Medicare covers the cost of care for the first 20 days and then requires that the patient pay a copayment for the remaining 100 days of coverage. Once this benefit has been exhausted, the patient must remain out of hospital for 3 months before a new benefit period can be invoked. Long-term care costs, in contrast, are not reimbursed by Medicare. Adults who lack adequate long-term care private insurance are required to “spend down” until they qualify for Medicaid. Severe cuts in Medicaid funding in states such as California are resulting in long-term care bed crises, in which it is becoming increasingly difficult for older adults to find institutional homes. Alternate payor sources include private long-term care insurance, VA coverage for certain service-connected veterans, and the resident elders and their families.
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The clinical structure of the nursing home is rigidly defined, even though the federal regulations themselves are relatively vague. The creation of the Minimum Data Set (MDS) has led to improvement in the quality of care without creating parallel improvements in quality of life. Care is managed through an interdisciplinary team consisting of the following members:
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Nursing: Registered nurses (RNs) provide nursing assessments as well as pass medications, manage intravenous access and provide skilled treatments. Licensed vocational nurses (LVNs), with 2-year training, are licensed to pass medications and provide some treatments, but do not receive the formal training in clinical assessment of RNs. Certified nursing assistants (CNAs or NAs) have completed a 40-hour certification program, and provide almost all of the activities of daily living (ADLs) care required by elders living in the home.
Rehabilitation: Physical therapists (PTs) provide gait and balance training and much of the work involved in strengthening the body after a debilitating episode. Physical therapy assistants, who lack the formal training of the PT, work with patients on established workout routines. Occupational therapists (OTs) provide therapy around ADLs and instrumental activities of daily living (IADLs). They often focus on the small motor skills of the hands, and their work is highly dependent upon the functional status of the patient. Occupational therapy assistants can similarly work as OT extenders to help patients complete established exercise sets. Speech and language pathologists, or speech therapists (STs), focus on deficits in both speech and swallowing, and represent a crucial part of acute stroke rehabilitation, as well as in the slower neurodegenerative diseases found commonly in nursing homes. Most short-term care rehabilitation units do not have respiratory therapists working on site, unless they specialize in the care of ventilator-dependent patients.
Nutrition: SNFs are required to provide at least 1 registered dietitian for their residents. The nutritionist provides recommendations for nutritional supplementation as well as individual education and recommendations. In some facilities, the nutritionists partner with the kitchen to develop healthy menus, but this is not one of the federal regulatory requirements.
Pharmacy: Nursing homes require the presence of a pharmacist, but not a pharmacy. Although larger nursing homes may elect to have an onsite dispensing pharmacy, many smaller facilities contract out with local pharmacies that are willing to deliver medications, sometimes urgently or after hours. The pharmacist is required to complete drug regimen reviews in order to prevent polypharmacy complications and to reduce the rate of medication errors.
Social services: The social services at a nursing home can be highly variable and include 2 completely separate sets of professionals. Licensed clinical social workers assist with social, financial, and other systems-based issues, and may provide counseling, depending upon the setting. In contrast, Title 42 also mandates that the nursing home provide “meaningful activities,” and these are done through the work of either recreation therapists or activities staff members. At some nursing homes, there is also chaplaincy support for the spiritual care of the residents.
Medical services: Medical services are mandated in nursing homes, but onsite medical care is highly variable. Physicians are required to provide the nursing home with their call schedule, but they are not required to establish set hours in which to provide face-to-face care. Reimbursement involves a fee-for-service model in most practices. The notable exceptions are some large Health Management Organizations and the VA, in which the physicians work for a salary. Unlike the outpatient setting, the SNF is tightly regulated under both the federal and state governments. Medicare requires that physicians see and admit patients within 72 hours of their arrival at the nursing home, and then every 30 days for the next 3 months. After this period, federal regulations dictate that they must see the patient every 60 days. State regulations vary, with certain states requiring a physician admission exam within 48 hours of patient arrival or requiring monthly visits, only some of which may be performed by a nurse practitioner in a comanaged process.
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This interdisciplinary team (IDT), augmented by administrators, housekeepers, kitchen staff, family, and any other appropriate members, meet together quarterly and annually to discuss the overall health and well-being of each elder residing in the nursing home. These meetings are documented and an individual plan of care created. The care plan determines not only the clinical and social treatment of the patient, but also the Medicare or Medicaid reimbursement.
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In 1987, a major reform was enacted on the federal level. Part of an Omnibus Budget Reconciliation Act, OBRA 87 became the basis for the MDS collected on each patient and as a mechanism for improving quality of care. As part of this regulatory process, nursing homes are subject to annual, unannounced surveys by the state in which they are located. State surveys, which may take place during or after business hours, result in a report that must be posted at the nursing home. In addition, results are converted to a “5 star” rating system that is reported publicly at http://www.medicare.gov/NursingHomeCompare. Along with site-wide health and safety assessments, surveyors examine resident plans of care (POCs, or care plans). For specific areas of concern, Resident Assessment Protocols (RAPs) are required as well (Table 18–1).
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These problems, when identified, must be addressed by the IDT and incorporated into the POC. Care must be taken to explain why it is that a patient is suffering from one of these 18 conditions, as the surveyors will look closely at charts flagged with them. Reporting of every scratch and bruise on nursing home residents is mandated, and intended to prevent elder abuse and ensure that an important injury is not left unnoticed. The Centers for Medicare and Medicaid Services (CMS) has the right to penalize nursing homes including through fines, temporary denial of payment, assigned oversight, or even the removal of nursing home certification to provide care CMS beneficiaries (which effectively forces the nursing home to close). Table 18–2 categorizes the deficiencies.
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