• Poor caregiver health is another reason for entry into LTC.⁴ Sixty-one percent of family caregivers of people with AD report high or very high levels of emotional stress; 33% report symptoms of depression; and 43% report high to very high physical stress.³

Types of long-term care

LTC has become a critically important area of patient care for the nation because many of the frailest and most vulnerable elders use LTC options to help meet health or personal needs. LTC can be defined broadly as medical or nonmedical care that is provided in the community, congregate housing, residential care facilities (e.g., assisted living), and nursing homes.

Long-term care can be defined broadly to include medical or nonmedical care that is provided in the community, congregate housing, residential care facilities (e.g., assisted living), and nursing homes.

Table 11-1 summarizes the most common types of LTC. As is evident from Table 11-1, LTC serves many older adults in a variety of settings. Indicators of the breadth of LTC services are these statistics from 2010:

TABLE 11-1

Types of Long-Term Care ¹^,⁷^,⁸^,^37–40

ADLs, Activities of daily living; LPN, licensed practical nurse; MSW, master’s level social worker; NH, nursing home; OT, occupational therapy; PT, physical therapy; RN, registered nurse; RT, recreational therapist; SLP, speech-language pathology; SNFs, skilled nursing facilities; RC/AL, residential care/assisted living communities.

• There were 1.4 million occupied beds in 16,071 nursing homes across the United States.¹ All told, 3.8 million persons were served by nursing homes, because many had short facility stays for post-acute care.⁶

• An additional 1.23 million older adults were living in residential care or assisted living facilities.¹

• An estimated 42 million family caregivers were providing unpaid care.¹

• A total of 3.4 million Medicare beneficiaries received home health care,⁷ and 2.5 million Medicaid participants received home- and community-based services or home health services.¹

Nursing homes

Nursing homes house two types of residents: (1) short-stay, post–acute care residents, who were admitted for rehabilitation, usually after a hospitalization, and (2) long-stay residents who are receiving chronic disease care or palliative care. About 4% of Medicare enrollees older than age 65 had a nursing home stay in 2009, with the rate highest among persons aged 85 and older (14%).² Nursing home residents are mostly white (88%), female (66%), and elderly (median age 82.6).⁸ The racial make-up of the nursing home population should become more diverse in the future as the population of older adults changes in the United States.² Nursing home residents commonly have multiple chronic illnesses; dementia is one of the most prevalent at 46%.¹ Depressive symptoms, sensory impairment, pain, and functional impairment are also common. In addition, most LTC residents have functional limitations. For example, in 2009, 68% of all nursing home residents had three or more activity of daily living (ADL) limitations (bathing, dressing, eating, getting in/out of chairs, toileting) and 95% had at least one instrumental activities of daily living (IADL) limitation (using the telephone, housework, meal preparation, shopping, managing money).²

Residential care / assisted living (RC/AL) communities

Residential care and assisted living communities have a variety of names, depending on state regulations, including assisted living residences, board and care homes, congregate care, enriched housing, homes for the aged, personal care homes, and shared housing. In 2010 there were 1,233,690 units in 58,938 RC/AL residences, most of which were private, for-profit settings.¹^,⁹ Half were small (4-10 beds), but these facilities served only 10% of the overall RC/AL population. The majority of residents (52%) lived in large (26-100 bed) or (29%) in extra-large (>100 beds) facilities.⁹ Nearly all RC/AL communities provide basic health monitoring, incontinence care, social and recreational activities, special diets, and personal laundry services.⁹ Most also offer transportation to medical appointments and case management, whereas social services, counseling, and physical and occupational therapy tend to be offered only by large RC/AL communities or indirectly through home care agencies.⁹ Residents are typically white (91%), female (70%), age 75 and older (81%), and have a median length of stay of 22 months.¹⁰ Over a third (38%) of residents receive assistance with three or more activities of daily living, of which bathing and dressing were the most common; and another 36% receive assistance with one to two ADLs.¹⁰ These demographic descriptors indicate that considerable overlap exists between the population of RC/AL communities and nursing homes.

CASE 2 Albert Thompson (Part 1)

Albert Thompson is an 89-year-old nursing home resident with advanced Parkinson’s disease and mild dementia. A nurse calls you because she noticed that he hardly ate or drank anything for dinner. She reports that a certified nursing assistant (CNA) obtained Mr. Thompson’s vital signs, and that his temperature was 100.4, blood pressure 110/60, pulse 80, and respirations 18. When you try to ask further questions, the nurse is unprepared. She has not assessed the patient herself. She does not have his current medication or problem list. She seems to be frazzled and mentions she has only been working in the building for 3 weeks. She suggests strongly that you send the patient to the emergency department (ED).

1. What additional information would you most like to have? What steps can be taken short of sending this patient to the ED for evaluation?

2. Because you are also the medical director of this facility, what steps can you suggest to better prepare nurses to assess and manage patients with physicians over the telephone?

Medical care provider practice patterns long-term care

Because exposure to LTC remains limited in medical school and residency programs, expertise in LTC medical practice is typically obtained through experience, a geriatric fellowship program, or through courses offered by the American Medical Directors Association (AMDA). AMDA has a certification program that uses an experiential model in which practicing physicians who are providing LTC and medical director duties can be certified by completing educational requirements through participation in a geriatric fellowship program, continuing medical education, AMDA-sponsored courses in medical direction, and/or other continuing education programs.

Nursing homes are required by law to have a medical director; RC/AL communities are not, but a few do have them. The medical director is a physician who oversees and guides care in a LTC facility.¹¹ The primary functions are summarized in Table 11-2.

TABLE 11-2

Functions and Duties of a Nursing Home Medical Director

DON, Director of nursing; QAPI, quality assessment and performance improvement.

Adapted from AMDA. The nursing home medical director: Leader and manager (White Paper A11). Columbia, MD: AMDA; 2011. Available at http://www.amda.com/governance/whitepapers/A11.cfm.

The American Medical Directors Association has a certification program that uses an experiential model in which practicing physicians who are providing LTC and medical director duties can be certified.

Physicians who practice in nursing homes do so within a variety of practice models. The traditional model has been as an adjunct to an office-based practice. In the last decade new practice models have arisen: the LTC-only practice and the house-call practice. With these, there has been a call to recognize that nursing home medicine is emerging as a specialty in its own right, similar to the hospitalist.¹² Physicians working in this specialty have been referred to as SNFists, nursing home physician specialists, or LTC specialists. The nursing home physician specialist spends a substantial portion of time in the delivery of nursing home care and is proficient in nursing home regulations and the medical management of common syndromes faced by nursing home residents.

The nursing home physician specialist spends a substantial portion of time in the delivery of nursing home care and is proficient in nursing home regulations and the medical management of common syndromes faced by nursing home residents.

Nurse practitioners (NPs) provide primary care to nursing home residents as nursing home employees, as members of primary care practices, or as employees of health maintenance organizations. NPs are registered nurses who have a master’s degree and obtain certification through a national certifying examination or through state certification mechanisms. The NP scope of practice varies by state. In 10 states no physician involvement is required; however, 40 states give NPs the authority to prescribe only with physician oversight.¹³ Federal nursing home regulations require collaboration with a physician in all states.

Physician assistants (PAs) function in much the same way as NPs in nursing homes. They are non-nurse providers whose training typically consists of 1 year of basic science classes and 1 year of clinical rotations. PAs must practice under the supervision of a physician, but they have the authority to prescribe in all 50 states and the District of Columbia.¹⁴ The PA scope of practice varies by state and is largely determined by the physician; most commonly, a physician can delegate to PAs anything that is within the physician’s scope of practice and the PA’s training and experience.¹⁴

Evercare is a Medicare Advantage program specifically for long-stay nursing home residents that extensively uses NPs or PAs. The NPs or PAs work as employees of the managed care company and provide more intensive primary care than is typical. They are assigned to work in specific nursing homes, usually one or two, carrying a caseload of approximately 100 residents.¹⁵ The nursing home residents continue to have their primary care physician, which Evercare pays on a fee-for-service basis, including payment for time spent in family or care-planning conferences (which is not ordinarily reimbursed under Medicare). The NP also educates the nursing home staff through formal and informal in-service training. Because the NP or PA is present in the nursing home frequently under the Evercare model, they monitor residents closely and develop relationships with the staff, which facilitates early identification of acute illnesses. Because they are salaried employees of the managed care company, Evercare NPs and PAs can spend more time in preventive and early intervention direct care that might not otherwise be reimbursed by Medicare. In addition, Evercare can pay the nursing home for “intensive service days,” when an ill resident might otherwise need to be hospitalized. As a result, Evercare sites have fewer hospitalizations and emergency department visits than traditional care models, and Evercare enrollees have higher patient and family satisfaction with the care.¹⁵

Federal regulations require that nursing home residents be seen by the physician for the initial comprehensive visit and then every 30 days for the first 90 days. Thereafter patients must be seen every 60 days and when medically necessary. Other than the initial comprehensive visit, the routine (regulatory) visits can usually be alternated between the MD and NP or PA. Patients in the nursing home are generally seen by their primary care providers in their residence. This is in contrast to the RC/AL communities, in which the practice norm is for the resident to be transported to his or her provider’s office (though models of care where providers come to the RC/AL are growing). Because RC/AL communities are regulated by the states, regulations differ depending on the state of residence, but most commonly only a yearly physician visit is required.

Much of the care delivery in LTC occurs via telephone—more so than in other clinical settings. Many of the telephone calls occur after hours and on weekends to on-call providers who may not be familiar with the patient or the facility. Most telephone calls report a clinical problem. For example, in one study of a typical nursing home, the problems that were most frequently reported by phone were falls, pain, agitation, abnormal blood glucose, and fever, with the calls typically prompting a clinical action, such as ordering a medication or treatment, clinical observation by the nursing staff, or diagnostic studies.¹⁶