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Robert Kane Presentation March 6-7 2009
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Reinventing the Nursing Home: Getting the Kind of Long-term Care We Want
Robert L. Kane, MD
University of Minnesota
School of Public Health
What is the Problem?
Too often posed as a question of financing
Infrastructure is central Those with funds cannot find the care
they want
The Problems with Current Thinking about LTC
Nursing home is at the center Alternatives to NH paradigm
Negative attitudes Nothing can be done Decline is inevitable Good care does not make a difference
Types of LTC Clients
Physically dependent Cognitively dependent Rehabilitative End of life Coma/vegetative state
Sensitivity to environment
What determines who should be cared for where?
Patient preferences Available support Cost
Personal Societal
Societal dicta Risk taking
The Building Blocks of LTC
Personal care Housing Medical Care
Especially chronic disease care
Rare to find all three done well simultaneously
PersonalCare.
Housing
Chronic Disease Care
Can’t Rely on a Name
Personal Care
ADLs, IADLs Supervision Supportive services Structured observations Reliability Respect Personalized
Housing
Minimal quarters/amenities Supportive environment Control of access Varying levels of affluence Congregation as needed or desired Location
Medical Care
Chronic disease management Proactive primary care Responsive Coordination with social care
Prerequisites for Making Good Decisions
Real options Time Information
Benefits Risks Costs
Clarity about goals What is most important to maximize Consensus within family
Guidance/Structure
Limited Treatment Options
Goals Clarification
Consumers and providers must share the same goals
Medical and social providers must share the same goals
Goals and priorities may change depending on who is paying for the care
A Lot Depends on Interpretation
Potential LTC Goals
Maintaining or improving function Maintaining or improving quality of life Safety Autonomy Not being a burden End of life care
May have to set priorities
Merging Medical and Social Care
Shared goals Social goals generally around
compensatory care Assessment to find problems Services to meet identified needs
Medical goals more therapeutic Making a difference
Potential for common ground
Developing Individualized Care Plans
Each client/patient should be identified in terms of their needs for personal care, housing and medical care
There are many ways to meet each combination of needs
The plan should reflect the client’s (and family’s) preferences
Role of Risk
Older people should not be denied the right to take risks Ageism
Risks involve informed decisions Need to understand the benefits and
risks of an action
Severity, i.e.,
cognition, function,
prognosis.
Preferences, i.e., safety, autonomy, privacy, culture, atmosphere, aesthetics
Personal Care Needs
Health/ Clinical/ Medical Care Needs
Housing Needs
Measuring Success in LTC
Success is measured in terms of slowing the rate of decline
This concept can be applied to measures of both quality of care and quality of life
The problem is that the comparison to see the improvement is generally invisible
ObservedObserved
ExpectedExpected
OutcomeOutcome
TimeTime
Evidence of Successful LTC
Housing issues
Minimal levels Personal private space Bedroom Toilet
More amenities as affordable Small clusters
Personal Care
Skills Care Observation and action
Systematic observation Clinical Glidepaths
Respect Concern Compassion
Medical Care
Chronic care management Proactive primary care Track status and intervene early
Avoid iatrogenesis Drugs Catheters
Respect and incorporate social care Interact with family
Need Relevant Information
Information Technology
Problems with too much as well as too little information.
Need to focus attention on salient data
Validated protocols Professionals Care givers
Just in time information Structured information
Clinical glidepaths
Clinical Glidepath
A Clinical Glidepath is a way to observe one or more parameters of a patient’s condition on a regular basis to be able to compare the observed state with the expected state.
It is a tool to improve communication between patients and primary care providers.
If the patients stays within the expected course, nothing need be done.
But if the patient’s clinical course deviates, this change should trigger immediate closer attention to ward off a problem while it is early.
o
o
o
X
Clinical Glidepath
Expected Course
How You Implement Is Important
Policy Issues LTC is not simply a payment question
Private payers cannot find the care they want Use payment to re-enforce service goals but not to
create them Pay for services not housing
Levels the playing field; eliminates the distinction between NHs and HCBS
Provide housing as needed and affordable Encourage coordination of medical and social care
Start with shared goals Families are central to LTC
Policies should support family care
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