Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

CHAPTER FOUR: NURSING FACILITIES

CHAPTER HIGHLIGHTS

Introduction

 Nursing facilities used to be called “nursing homes”

 They include those certified by Medicare as Skilled Nursing Facilities (SNF) and what

used to be called Intermediate Care Facilities (ICF), the primary difference being the

amount of nursing care provided.

How nursing facilities developed

 Nursing homes grew out of early charity-based forms of care for people without family to

care for them or other sources of help.

 They came into their own when the federal government became involved with assisting

the needy with passage of the Social Security Act in 1935 and the Medicare and

Medicaid amendments in 1965.

 They suffered through a lingering poor public image.

Philosophy of care

 Medical vs. Social Model – Nursing facilities find themselves sitting solidly astride the

line between acute care and long-term care.

 A Multidisciplinary Approach – They utilize a combination of medical, social, residential,

and other allied professionals to provide needed services, blending those disciplinary

specialties to develop and implement care plans for individual consumers.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Family Involvement – Another distinguishing characteristic of long-term care in general,

and nursing facilities in particular, is the degree to which family members are involved in

the care of the primary consumer.

Ownership of Nursing Facilities

 More for-profit than nonprofit

 More than half owned by national multi-facility chains

Occupancy

 The occupancy rate for nursing facilities has declined from a high of 89.0 percent in 2007

to 86.0 percent to 2013.

 This may be due to competition from community-based services.

Services Provided

 Nursing

 Physical therapy

 Occupational therapy

 Speech therapy

 Medical and dental services

 Medications

 Laboratory and x-ray services as needed.

Special Care Units – many facilities created special care units to meet the needs of a wider

variety of residents. They may be:

 Based on a Specific Diagnosis or Disability

 Alzheimer's Disease

Chapter 4 2

Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Mental Health & Mental Retardation

 Brain Injury

 AIDS

 Based on Age

 Pediatric

 Young Adults

Consumers Served

 By age:

 Mostly elderly

 By care Needs:

 Admitted because of functional disabilities, resulting from a number of medical or

physical conditions

 May include both physical and mental disabilities

 By gender Mix:

 Three-quarters women

Market Forces Impacting Nursing Facilities

 Need-Driven Vs. Choice-Driven Admissions – most residents do not choose to be

admitted, but must be due to their conditions.

 Family/Physician Initiated Admissions – admission is usually not at the request of the

resident but by family or a family physician.

Chapter 4 3

Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Hospital Readmissions – under the Affordable Care Act's Hospital Readmissions

Reduction Program, hospitals that readmit "excessive" numbers of Medicare patients

within 30 days of discharge now face significant penalties.

 Location Relative to the Resident’s Family – facilities are often chosen so the resident

can be close to family members.

 Alternative Types of Care (or Lack of) – some are admitted to nursing facilities because

of a lack of other alternatives (e.g., community-based care).

Regulations

There are three primary categories of regulations:

 Affecting Residents – Regulations concerning care and quality of care

 Affecting Employees – regulations protecting employees from unfair treatment

 Affecting Building Construction and Safety – regulations assuring proper construction

and maintenance of facilities.

Financing Nursing Facilities

 Medicaid is the largest source (two-thirds)

 It covers the medically indigent

 Medicare is the next largest

 It provides limited coverage

 Other sources include insurance and out-of-pocket

Staffing/Human Resource Issues

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Nature of the Work Force – nursing facilities utilize a staffing mix that combines both

highly trained and relatively untrained staff.

 Must provide both clinical and non-clinical care

 Government regulations, particularly OBRA and Medicare, specify the numbers of

staff on duty on each work shift and the mix of personnel categories making up that

staff.

 Nursing

 Certified Nurse Aides

 Medical Coverage

 Other Specialists

 Recruitment/Turnover Issues

 Aging of the workforce – the population group available to provide care is getting

smaller due to aging

 Relatively low pay – the amount allowed by Medicaid (the primary payment source)

is not adequate

 Competition from other sectors – staff can make more working elsewhere, even in

fast-food restaurants

Legal/Ethical Issues

 Day-To-Day Quality of Life Issues

 Desire for privacy, personal autonomy

 Individual vs. group choice is an issue

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 End of Life Issues

 Many residents live out their last days in a nursing facility

 Competency and choice are issues

Management of Nursing Facilities

 Management Qualifications:

 Must be licensed by states

 Some variation in state regulations

 Management Challenges & Opportunities:

 Balancing Cost and Quality – never enough resources

 Integration of Differing Levels of Service – many are part of a multi-level facility

providing several types of care, possibly including assisted living, home health care

and/or subacute care in addition to skilled and nursing care.

 Coordination with Other Facilities, Organizations – it is no longer possible/feasible to

stand alone.

Significant Trends and Their Impact on Nursing Facilities

 Rising Acuity Levels – as acute care hospitals try to save money, higher acuity patients

are sent to nursing facilities.

 Managed Care – has become a primary form of reimbursement and comes with strings

attached.

 Other Reimbursement Trends:

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Prospective Payment

 Private LTC Insurance – not a large enough source of reimbursement

 Payment Bundling – the ACA created a system of payment bundling where a single

entity would receive a sum of money to cover the costs of an episode of care spanning

two or more providers

 Rising Liability Insurance Costs – threaten the survival of providers

 Consumer Choice – the single, most important trend today is the demand by consumers

for more choice in their care

Chapter 4 7

Chapter 4 Nursing Care Facilities

Learning Objectives

1. Define and describe nursing facilities 2. Identify sources of financing for nursing

facilities 3. Identify and describe regulations affecting

nursing facilities

Learning Objectives (continued)

4. Identify and discuss ethical issues affecting nursing facilities

5. Identify trends affecting nursing facilities in the near future and describe the possible impact of those trends

What is a Nursing Facility?

Includes:  Facilities licensed by the states offering

room, board, nursing care and some therapies

 Those certified by Medicare as skilled nursing facilities (SNF) and what used to be called intermediate care facilities (ICF)

How Nursing Facilities Developed

 Early charity-based forms of care  Poor public image  Increased regulation  Significant improvement  Still under scrutiny

Philosophy of Care

 Medical vs. social model • “care not cure”

 Multidisciplinary approach  Family involvement

Ownership of Nursing Facilities

 Largely for profit (68%)  Nonprofit (25%)  Government owned (6%)  Growth in multifacility chains (55%)

Services Provided  Nursing  Physical therapy  Occupational therapy  Speech therapy  Medical and dental services  Medications  Laboratory and X-ray services  Room and board

Special Care Units By diagnosis or disability:

• Alzheimer’s disease • Mental health and intellectual disabilities • Brain injury • AIDS

By age: • Pediatric • Young adult

Those Served

 Elderly – over 90%  Female – two-thirds, male – one-third  Both physical and mental disabilities

• Two-fifths have dementia • Many have depression

Activities of Daily Living (ADLs)

 Bathing  Dressing  Eating  Toileting  Transferring

* Average resident needs help with 4 ADLs

Market Forces

 Need-driven admissions  Family- and physician-initiated admissions  Hospital Readmissions  Location relative to resident’s family  Alternative types of care (or lack of)

© 2010 Jones an Brtlett Publishers, LLC

Regulations

Purpose of regulations: Care is safe and of high quality Care is not unnecessarily expensive Services are uniformly accessible Rights of workers are protected

Types of Regulations

 Affecting residents  Affecting employees  Affecting building construction

and safety

Financing Nursing Facilities

Reimbursement sources: Medicaid – 66% Medicare – 13% Private pay and other sources – the remainder

Medicare Coverage

Restrictions: Covers only skilled nursing care Must follow 3-day hospital stay Limited to 100 days per “benefit period” Requires co-payment for days 21–100

Staffing and Human Resource Issues

 Nursing  Certified nurse aides (CNAs)  Medical coverage  Other specialists

• Often on contract basis

Legal and Ethical Issues

Responsibility to: Protect residents’ rights Act ethically

Types of Legal and Ethical Issues

 Day-to-day quality-of-life issues: • Autonomy (choice) • Privacy

 End-of-life issues: • Advance directives

• living will or power of attorney

• Patient Self-Determination Act of 1990 • Cognitive ability?

Management Qualifications

 Licensed by the states  Differing state regulations cover:

• Education requirements • Hands-on experience • Continuing education

• NAB

Management Challenges and Opportunities

 Balancing cost and quality  Integration of differing levels of service  Coordination with other facilities and

organizations

Significant Trends

 Rising acuity levels  Managed care  Prospective payment  Private long-term care insurance  Payment bundling  Rising liability insurance costs  Consumer choice

Summary

Nursing facilities have a long history but are evolving, as is the overall system. They have gone from being the dominant form of long-term care to one of many provider types.

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