Geriatric InterclerkshipLocations of Care: Living

Arrangements

Sarah McGee MD, MPHAssociate Professor of Medicine

Director of Education Division of Geriatric MedicineUniversity of Massachusetts

April 30, 2012

Where do you want to live?

Independent Living

Dependent Living

We Imagine it Will Be Like…

We Imagine it Will Be Like…

What we see…

Patient needs Resources

ADLs Spouse/FamilyIADLs FriendsPhysicalCommunityEmotional ChurchSpiritual Financial

Determinants of location of care and living arrangements

How to evaluate patients for “best fit” of various living

arrangements

• Functional Assessment• Quality of life and quality of care• Safety versus autonomy• Getting to know the person, not

just the patient/disease• What is most important to them?• Insurance/cost

Independent Living

Own home or apartment Congregate or senior housing

may have: help with some household upkeep congregate meals activities staff

specific home health services available through outside agencies

Naturally Occurring Retirement Communities (NORC)

Assisted Living

• “A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with ADLs are available as needed to people who still live on their own in a residential facility”

– Center for Medicare and Medicaid Services

2007 975,000 residents 38,000 facilities (25-120 units)

2009 $3022/mo ave cost for pvt unit ($10K-$50K/yr range)

Assisted Living Facilities of America National Center for Assisted Living

Assisted Living

Assisted Living

Means different things in different regions or states

Lack of consensus on what is the best model, social vs medical

Types of patientstoo frail to stay at homemay have mild to moderate dementiaoften required to toilet themselves and do some of own ADLs

Most do not have 24 hour nursing on site One hour of personal care/day

Assisted Living

Half the price of a nursing home, but what services are you getting?

Liability is hurting development of the industry

Much less regulation than nursing homes right now

Aging in place is a big issue

Most Assisted Living Facilities will provide:

•Health care management and monitoring •Help with activities of daily living such as bathing, dressing, and eating •Housekeeping and laundry •Medication reminders and/or help with medications •Recreational and social activities •Security •Transportation•Emergency call system in each unit

Assisted Living

Aging Together

201015,622 facilities (MA 429)1.66 million beds (MA 48,484)1.4 million residentsAv LOS 875 daysAv cost $198/day

(Alaska $687, MA $329)

%≥65 yo in NH? www.longtermcare.gov www.statehealthfacts.org

Long Term Care in Nursing Homes

Long Term Care in Nursing Homes

How do you qualify for nursing home care?

How do you end up in a nursing home?

Have we always hadnursing homes?

4.18.0

8.1

34.7

16.2

9.2

19.1

0.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Percent of existing facilities originally

constructed

Priorto1900

1900-1950

1950-1960

1960-1970

1970-1980

1980-1990

1990-2000

2000+

Percent of NFs Original Construction by Decade

Long Term Care in Nursing Homes

Abuse in 1960s, 1970s led to

Reforms in 1980s (OBRA ’87) led to

Government regulation

Can Nursing Homes Be the Best Alternative?

Long Term Care in Nursing Homes

How is it changing?Can we make it a more positive

alternative?Resident-centered care

Geriatrics is a Team Sport

Interprofessional teams enhance the comprehensive care of complex patients

Teams are not hierarchicalEach person on the team is valued for

his or her unique role and what they bring to the care of the person

Teams include informal caregivers (family, friends)

Team Members

CNA (certified nursing assistant)

physical therapist dietician chaplain primary care

provider (MD, NP, PA)

psychologist activity director registered nurse occupational

therapist speech therapist social worker

Geriatric Care TeamsRegardless of the Setting…

Resources

• Geriatric Interdisciplinary Team Training– http://www.umassd.edu/gitt/

• Medicare and Medicaid– www.Medicare.gov – www.longtermcare.gov– www.cms.gov

• Assisted Living Facilities of America– www.alfa.org

• National Center for Assisted Living – www.ncal.org

• National Council on the Aging (NCOA)– www.healthyagingprograms.org