Ensuring that dependent older adults with complex health problems receive high quality long-term care has been a long-standing challenge for the health care systems around the world. Currently, the need is greater than ever, considering that older adults battling with a multiple of chronic diseases and functional and/or cognitive disabilities are becoming more prevalent as the elderly population worldwide continues to expand. Nursing home facilities provide 24-hour intensive care for individuals who are commonly physically or cognitively disabled, or both. The delivery of quality of care and maintenance of quality of life in nursing homes are often unsuccessful, however, and has long been a great concern to consumers, providers of care, and policy makers. The evidence that nursing home residents frequently suffer from preventable adverse outcomes (such as negative drug events, bed sores, falls resulting in serious injury, physical and pharmaceutical restraint use, delirium, and elder abuse) continues to grow and increase the risk of morbidity and mortality.
End-of-life care and decisions are an emotional and stressful process for both the patient and surrounding family members. Death is part of life that everyone goes through, yet it remains a traumatic experience. Older adults face end-of-life issues when they choose to receive therapeutic care rather than aggressive treatment, and go into hospice care. In hospice, residents will receive palliative care, where the number one goal is to make sure that the resident’s quality of life is maintained.
The focus of hospice care and coordination should be on the hospice resident. However, the stress and turmoil that family members face should not be ignored. In fact, the American Cancer Society suggests family meetings and respite care to be central services provided by hospices. A July 2014 study published in the Journal of American Medical Directors Association looked into the perceptions that family members of hospice patients experience, when patients go into hospice. The study posed two questions: 1) whether family members of nursing home residents experienced differently compared to family members of community dwelling hospice patients with aspects such as anxiety, depression and quality of life; and 2) what the family members’ perceptions and experiences were with end-of-life care in nursing homes. The researchers conducted interviews with family members residing in both settings and categorized various experiences that the family members described.
The results were informative. First, there were little differences that were described between family members who had patients receiving hospice care in nursing homes, and living in the community. Both settings evoked similar issues, such as depression and anxiety. Regarding the second question, family members described their perceptions on how hospice collaborated with the nursing homes, on the family’s own expectation of care, on communication between the facility and the family, and on resident care issues. About a third of the family members who responded described incidents that may indicate neglect. Family members expressed frustration with how pressure ulcers were treated, or when patients experienced falls at the facility. Overall, families expressed frustration with how many barriers they faced in order to get good end-of-life care for their loved ones, and sought support for family caregivers. The researchers concluded that an assessment of the family’s capacity to care for their loved one was essential so that family members can actively participate in the resident’s care. Furthermore, they suggested that nursing homes develop a system that would encourage family involvement, and actively incorporate family suggestions as part of the resident’s care plan.
Relevant factors that generally lead to placement of elders into nursing homes or long-term care are advanced age, cognitive dysfunctions, and physical disability. The role of acute care hospitalization is little known but also a significant risk factor for long-term institutionalization of elders.
According to a recent study published in the Journal of Gerontology: MEDICAL SCIENCES in August 2011, titled “Risk of Continued Institutionalization after Hospitalization in Older Adults,” three quarters of new nursing home placements were preceded, and presumably precipitated, by a hospitalization with discharge to a skilled nursing facility (SNF). The analysis of national Medicare data from 1995 to 2008 showed that hospitalized patients for acute illness were almost 10 times more likely to reside in a nursing home 6 months later compared to non-hospitalized control patients. The patients who were transferred home were also less likely to be institutionalized in long-term care than those who were transferred to a SNF on hospital discharge.
Based on the results of this study, the article concludes that “an appropriate time to initiate programs to prevent long-term institutionalization is at hospitalization,” and that “[a]nother point for potential intervention is during an SNF stay, which now occurs in almost two thirds of all patients who go into long-term care after hospitalization.” Therefore, efforts for reductions in institutionalization of the elderly in long-term care should focus on elder patients undergoing this transition from hospitalization to subsequent placement into a SNF.
Due to such link between hospitalization and long-term institutionalization, finding the right SNF is particularly important for elder patients’ well-being. Many factors, especially nursing staff levels, can affect the quality of care and the risk of nursing home injuries. Thus patients and family members should carefully compare and choose a SNF that is in compliance with federal and state regulations and laws and provides high quality skilled nursing services.
Of course, a preferable option, if possible, would be home care with the services of a Home Health Agency. This is often a sacrifice for the family who agrees to take in a loved one who needs 24 hour skilled nursing care. The benefit, however, is that the patient is under close family supervision, in a home environment, which can substantially benefit the patient psychologically. This is not to say that all Home Health Agencies are perfect, and you should study their background carefully as well to ensure their compliance history with state and federal. However, given the alarming rate of elder abuse and neglect in California nursing homes, a home health agency is worth looking into.