Chapter 7
Geriatrics - Nursing Homes and Home Care

Where elders live

About 5 % of people over 65 live in nursing homes. But about 43 % of us can expect to spend some time there. There are other institutions such as assisted living, intermediate care and long term hospitals where people live rather than at home as well.

1. What are the reasons people live in nursing homes

A. People live in nursing homes because of functional disability, not particular diagnoses. Most nursing home residents have impairments in 2 or 3 of the Physical Activities of Daily Living and that determines their stay.

B. The events that actually precipitate admission are usually:

1. Behavior problem associated with dementia
2. Incontinence
3. Inability to self toilet or transfer
4. Falls
5. Pressure sores
6. Failure to rehabilitate to self care after a CVA

C. That said, the important conditions common in nursing home populations include:

1. Dementia - about half of nursing home residents and usually an important cause of disability leading to admission but not always the sole cause.
2. Congestive Heart Failure
3. Arthritis
4. CVA
5. Parkinson's Disease

D. Nursing home residents fall into two separate groups:

1. Those who stay for a short time (less than 6 months). This is over half of all nursing home residents. These in turn, fall into two groups:

*Group 1. People who come to a nursing home to finish a hospital stay, undergo rehabilitation or deal with short - term medical care needs. The nursing homeused as a hospital step-down.

*Group 2. People who come into the nursing home and die shortly thereafter.

2. Those who stay for a long time. They average about 5 years stay and most of them die either in the nursing home or after a short hospital stay.

E. Because of these two populations, some odd things result. The average nursing home stay is 300 days but the median nursing home stay is 90 days! Most people who in nursing home at any one moment are among the long termers, it seems like most people are there for a long time, but it's not so.

F. About half of nursing home residents are demented, but it isn't clear if that's always the reason they are there. It appears that behavior problems such as wandering, violent behavior or calling out are causes of nursing home placement.

G. Of the short-termers, most are either post - operative or have congestive heart failure or COPD or other severe medical conditions. A number of the ones who die quickly after admission are otherwise the same as long-term stayers but don't survive being in the nursing home.

H. There is great disparity in the use of nursing homes by various demographic groups:

1. Women use nursing homes about twice as much as men.
This is probably because older women are much more likely to be single than men and because women more readily take on personal care of their spouses. In addition, women survive longer on average after admission to the nursing home.

2. Whites use nursing homes about twice as much as people of color.
This is probably because of a combination of greater reliance on family resources and distrust of institutions Reliance on family for personal care is a social norm since among many cultures of color, until recently, institutional resources simply weren't available.

2. Nursing Homes

There are about 16,000 nursing homes in the US. Average capacity is just over 100 so there are about 1.7 million nursing home beds. The nursing home industry is very heavily regulated; more so than hospitals. Nursing home care and administration is very challenging for this reason. Many want to tell nursing homes how to do their job, but few want to actually do it.

A. Who pays for nursing homes?

1. Medicare pays for about 5% of all nursing home costs. (This number is probably changing). This is important because many people assume medicare covers nursing homes, but it dos not.

2. Medicaid pays for about 60% of nursing home costs.

3. Private insurance pays for a fraction of one percent of nursing home costs.

4. Out-of-pocket pays for the rest. What usually happens is that a person comes in, pays until they have no more money and then medicaid takes over. Medicaid is administered by the states, so the eligibility and rules governing how much the spouse gets to keep etc. are specific to each state and very complicated. The average elderly person has enough money for 6 months of private pay.

B. Nursing Home Medical Directors

1. See American Medical Director's Association for more information: they have courses and accreditation among other things.

2. Medical directors of nursing homes is a job which is often offered to new doctors. If you decide to accept the job, you should know that it entails more than meets the eye and that pressure is being put on nursing homes for it to entail even more. For that reason, you should get paid for it. Do not do it as a favor with the understanding you will get referrals. It's too important and time consuming.

C. Home Care

1. Home Care is the fastest growing segment of elder care but that may be coming to an end. The reason is that the federal gov't is initiating means to control costs and growth in this area.

2. Home care agencies are just getting to be regulated more. Some of them have medical directors, but not all (as is the case with nursing homes.) Some are approved by JCAHCO and some are not. In large cities there are many such agencies, and in smaller areas there may be only one.

3. Try to get to know home care people you work with, especially if you do home visit care.

4. The home care agencies must have physician certification of need for home care services. Don't sign these unless you are sure that what you're signing is correct. There is an effort to root out fraud and abuse of home care services.

Go To Chapter 8

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