Living Arrangements Based on Levels of Care.
Nursing Home Care
In clinical practice, long-term care (LTC) has become synonymous with nursing home care. LTC for adult clients with medical-surgical problems can occur either in the home or in facilities such as nursing homes, subacute units, chronic care facilities, or rehabilitation centers. In general, long-term care implies that clients receive care for a prolonged period of time, usually weeks or months. A small percentage of clients may remain in a facility indefinitely, perhaps a lifetime. Nursing home care can be very expensive, with annual costs between $30,000 and $45,000 in the
Nursing homes in the
Types of Nursing Homes
Nursing homes can be divided into residential care homes, nursing facilities, skilled nursing facilities, and chronic care facilities. Some nursing homes are part of retirement communities, and others have specialty units, such as dementia, ventilator, or subacute units.
Residential facilities include domiciliary homes, care homes, rest homes, assisted-living facilities, and group homes. Some of these facilities are small and much like boarding homes before the advent of Medicare (Ignatavicius, 1998). Others are large communities managed by national corporations. Many of the larger complexes are life care or continuing care retirement centers that offer a continuum of services, from independent living to skilled care. The typical resident in a residential facility is fairly independent and is able to perform most or all self-care activities. Employees in these facilities are usually unlicensed staff. Formerly called intermediate care facilities, nursing facilities (NFs) provide a custodial, maintenance level of care. Certified, licensed NFs receive Medicaid funding for the care of residents who cannot perform activities of daily living independently. Each state has specific guidelines for reimbursement. Skilled nursing facilities (SNFs, pronounced “snifs”) provide care that requires licensed health care professionals, such as nurses and therapists. Only a small portion of most nursing home residents are categorized as skilled and therefore eligible for Medicare reimbursement. Examples of skilled care include new tube feedings, daily rehabilitative care for postoperative fractured hips, and care of stage 3 and stage 4 wounds. Chronic care facilities provide care for long-term, chronically ill clients, such those with severe head injuries or those who need chronic ventilator support. These facilities are often managed by county or state governments.
Documentation in Long-Term Care
Documentation in nursing homes is highly regulated by both federal and state governments. The Minimum Data Set (MDS) is a federally mandated assessment form that is completed for all residents regardless of the level of care or reimbursement system. This document is an interdisciplinary tool completed by each member of the health care team. The team develops an interdisciplinary care plan for all actual or potential resident problems. Depending on the resident’s level of care, this plan is updated every 30 to 60 days, or more often as the resident’s condition changes.
Hospice and Respite Care Services
Respite care is a service that is receiving increasing attention. It is aimed primarily at caregivers’ needs. Many older people at home are cared for by a spouse or other family member. The demands of such care can be exhausting unless the caregiver gets some relief, or respite—thus the name of this service (see Chapter 37). Respite care may be available through an agency that provides volunteers to relieve caregivers, giving them time off regularly or permitting a periodic vacation. Some skilled nursing facilities or board and care homes provide an extra room to give temporary institutional housing for the elderly while caregivers take a break.
Elderly clients may also need a change from the constant interaction with their caregivers.
Hospice care may be offered through an institution, such as a hospital or home health agency, or it may be a freestanding facility existing solely as an inpatient hospice. Hospices and other agencies providing hospice care offer services that enable dying people to stay at home with the support and services they need. The purpose of hospice care is to make the dying process as dignified, free from discomfort, and emotionally, spiritually, and socially supportive as possible. Some community health nursing agencies offer hospice programs staffed by their nurses. It is a service that has been well received by elders, meets important needs, and is growing in use. Hospice and respite care are two services most needed and used by the families of clients with AD.
Organization of palliative care
•In any setting
•Based on guidelines and [nursing] standards
•Continuity of care
•Team approach
•Multidisciplinary
•Coordination of care
•Specialized care
•Level of care needed [low, medium, high care]
Levels in palliative care
Depending on complexity:
–Low care [care workers, volunteers, nurse as a consultant]
–Medium care [nurses, care workers, volunteers]
–High care [nurses, volunteers]
In our understanding finding a new balance of Cure and Care in a nursing home means promoting independence in dependence.
Factors:
–Autonomy and dignity
–Attitudes of healthcare professionals
–Exposure of staff to healthy older people
–Education and training
–Information provision
–Cultural expectations
Spirituality, Advance Directives, and Preparing for Death
A final need of the elderly, and one that is receiving increasing attention, is that of preparing for a dignified death. Elisabeth Kubler-Ross (1975) described death as the final stage of growth and one that deserves the same measure of quality as other stages of life. Many older people fear death as an experience of pain, humiliation, discomfort, or financial concern for their loved ones. Planning for a dignified death is an important issue for many older people. For most, this includes choosing, if possible, where and under what circumstances death will occur; being free of financial worries; knowing that their affairs and their family members are taken care of; having the opportunity to receive spiritual counseling; and dying in peaceful surroundings, preferably at home with the support of loved ones (Cicirelli, 2002; O’Brien, 2003).
Some elders make arrangements with a funeral home of their choice, selecting interment or cremation, a memorial service or a celebration of life gathering, music to be played, and other personal details rather than leaving these choices to their families. Others place less emphasis on the rituals, as was demonstrated by one elder who left these choices to her children by telling them, “Surprise me!”
Summary
Levels of care are dependent of the product
Levels of care are dependent of the organization
Levels of care are dependent of the concept / vision of the organization
Levels of care are dependent of
Most important is the level of care who is dependent of the wish of the ‘client’
Hospice “De Winde” in the Netherland city of Enshede.
The dining room in the “De Winde” Hospice gives the possibility for socialization of its clients: having coffee or some parties together, inviting friends and relatives inside.
Relaxation room is a part of holistic care: a place for meditation, prayer.
There is a peaceful environment in the yard of the hospice.
Boards with photos of all the staff members of the hospice give clients and their relatives possibility to be familiar with them.
The rooms in the hospice don’t look like hospital rooms: it’s a house. Clients are encouraged to bring their own staff from their home.
Allender, J. A., Spradley, B.W. (2001). Community Health Nursing: Concepts and Practice (5th edition). Lippincott Williams & Wilkins; 5th edition (January 15, 2001). 799 pages. ISBN-13: 978-0781721226. Chapter 30, Pp. 719-726.
Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition)
Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition)
Allender, J. A., Spradley, B.W. (2004). Community Health Nursing: Promoting and Protecting the Public’s Health (6th Edition) Lippincott Williams & Wilkins, 2004. – 992 p.
Additional readings:
Age-friendly Primary Health Care Centres TOOLKIT // World Health Organization, 2008.
Cicirelli, V.G. (2002). Older adults’ views on death.
Ebersole, P., & Hess, P. (2004). Toward healthy aging (6th ed.).
WEB SITES on Aging
American Diabetes Association, Facts and Figures: http://www.diabetes.org
Assisted Living Federation of
National Institute on Aging. http://www.nia.nih.gov
