C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 173
within 30 days before needing skilled nursing care.
Clients who meet the criteria are eligible for 100 days of assistance with the costs. There is no charge for the first 20 days; for the next 80 days, Medicare pays all but
$119.00 a day (United States Department of Health and Human Services).
Some older adults have private insurance policies that assist with Medicare co-payments. If not, or if clients continue to require skilled care beyond 100 days, they must bear the cost personally until they are considered indigent. After clients have exhausted their own finan- cial resources and those of their spouse, they may apply to the state for Medicaid or its equivalent.
Intermediate Care Facilities
A nursing home also may be licensed as an intermediate care facility. This type of agency provides health-related care and services to people who, because of their mental or physical condition, require institutional care but not 24-hour nursing. Clients who require intermediate care may need supervision because they tend to wander or are confused. They need assistance with oral medications, bathing, dressing, toileting, and mobility.
Medicare does not provide reimbursement for inter- mediate care. Clients assume the costs. For impoverished residents, state welfare programs, such as Medicaid, will pay. Some nursing homes do not accept Medicaid clients, however, because states fix the fees for reimbursement at much lower amounts than Medicare and private insur- ance provide.
Basic Care Facilities
A third type of nursing home is a basic care facility(agency that provides extended custodial care). The emphasis is on providing shelter, food, and laundry services in a group setting. These clients assume much responsibility for their own activities of daily living such as hygiene and dressing, preparing for sleep, and joining others for meals. Intermediate and basic care may be provided at a skilled nursing facility but usually in separate wings.
Determining the Level of Care
The level of care is determined at admission. Each client is assessed using a standard form developed by the Health Care Financing Association called a Minimum Data Set for Nursing Home Resident Assessment and Care Screening.
By federal law, the Minimum Data Set (MDS) is repeated every 3 months or whenever a client’s condition changes.
The MDS requires assessment of the following:
• Cognitive patterns
• Communication and hearing patterns
• Vision patterns
• Physical functioning and structural problems
• Continence patterns in the last 14 days
• Psychosocial well-being
• Mood and behavior patterns
• Activity pursuit patterns
• Disease diagnoses
• Health conditions
• Oral and nutritional status
• Oral and dental status
• Skin condition
• Medication use
• Special treatments and procedures
Problems identified on the MDS are then reflected in the nursing care plan.
Selecting a Nursing Home
When the need arises, family members are often ill pre- pared for selecting a nursing home. A discharge planner can assist with arranging nursing home care. Brochures on selection are available from the American Association of Retired Persons, the Commission on Aging, and each state’s public health and welfare departments. Websites also provide valuable information. See Client and Family Teaching 11-1.
Areferralis the process of sending someone to another person or agency for special services. Referrals generally are made to private practitioners or community agencies.
Table 11-3 lists some common community services to
174 U N I T 4 ● Performing Basic Client Care
which people with declining health, physical disabilities, or special needs are referred.
Considering Referrals
Considering referrals is part of good discharge plan- ning. For example, a nurse, case manager, or agency dis-
charge planner may help refer clients for home health care. Because planning, coordinating, and communicat- ing take time, personnel initiate referrals as soon as pos- sible once a need is identified. Early planning helps to ensurecontinuity of care(uninterrupted client care despite the change in caregivers), thus avoiding any loss of progress that has been made.
Home Health Care
Home health careis health care provided in the home by an employee of a home health agency (Fig. 11-8). Pub- Selecting a Nursing Home
The nurse teaches the client or family to do the following:
• Find out the levels of care (skilled, intermediate, or basic) that the nursing home is licensed to provide.
• Review inspection reports on each home. This information is available from the state’s public health department on a fee-per-page basis.
• Ask others in the community, including the family physician, for recommendations.
• Visit nursing homes with, and again without, an appointment. Go at least once during a meal.
• Note the appearance of residents and how staff members respond to their needs.
• Observe the cleanliness of the surroundings and any unpleasant odors.
• Request brochures that identify medical care, nursing services, rehabilitation therapy, social services, activities programs, religious obser- vances, and residents’ rights and privileges.
• Clarify charges and billing procedures.
• Analyze if the overall impression of the home is positive or negative.
11-1
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CLIENT AND FAMILY TEACHINGCOMMON COMMUNITY SERVICES
TABLE 11-3
ORGANIZATION SERVICE
Commission on Aging Assists older adults with transportation to medical appointments, outpatient therapy, and community meal sites
Hospice Supports the family and terminally ill clients who choose to stay at home Visiting Nurses’ Association Offers intermittent nursing care to homebound clients
Meals on Wheels Provides one or two hot meals per day delivered either at home or at a community meal site Homemaker Services Sends adults to the home to assist in shopping, meal preparation, and light housekeeping Home health aides Assist with bathing, hygiene, and medications
Adult protective services Make social, legal, and accounting services available to incompetent adults who may be victimized by others
Respite care Provides short-term, temporary relief to full-time caregivers of homebound clients Older Americans’ Ombudsman Investigates and resolves complaints made by, or on behalf of, nursing home residents;
at least one full-time ombudsman is mandated for each state
FIGURE 11-8
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Home health care assessment.C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 175
lic agencies (regional, state, or federal, such as the pub- lic health department) or private agencies may provide home health care.
The number of clients who receive home health care continues to rise, partly as an outcome of limitations imposed by Medicare and insurance companies on the number of hospital and nursing home days for which they reimburse care. Another factor is the growing num- ber of chronically ill older adults in the population in need of assistance.
According to Profiles of Older Americans (American Association of Retired Persons, 2004), approximately 45%
of people 65 years or older and 75% of those 80 years or older have at least one disability. With advancing age, the need for assistance increased from 8% to 35% (Fig. 11-9).
Types of assistance older adults may need include basic activities of daily living (bathing, dressing, eating, and getting around the house), preparing meals, shopping, housework, managing money, using the phone, and taking medications.
Home care nursing services help shorten the time spent recovering in the hospital, prevent admissions to extended care facilities, and reduce readmissions to acute care facilities. Box 11-3 identifies the responsibilities assumed by home health nurses who provide community- based care.
GENERAL GERONTOLOGIC C O N S I D E R A T I O N S
Many older adults fear that admission to a hospital or long-term care facility will eventually prevent their return to independent living. They may therefore minimize symptoms to protect their independent-living situation.
Some older adults have difficulty accepting help from others even though they recognize the need for it. They may resist changes related to how they accomplish familiar tasks. Nurses should consider methods to facilitate required changes and minimize any unnecessary alterations when planning a transi- tion to an institutional setting.
Aging directly correlates with increased incidence of acute disease and exacerbations of chronic conditions.
In 2003, adults 65 years and older accounted for one third of hos- pital admissions.
When admitting, discharging, or transferring older adults, nurses allow additional time because of possible functional impairments.
Pets are an integral social support system and contribute to the general well-being of older adults. Those who live alone may be concerned about the welfare of pets. This should be con- sidered during admission, with arrangements made for care of the pet.
50 45 40 35 30 25 20 15 10 5
0 Bathing/
showering Dressing Eating Getting in/out
of bed/chairs Walking Using toilet Type of ADL
65–74 yr 75–84 yr ≥ 85 yr FIGURE 11-9
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Percentage of people withlimitations in activities of daily living (ADLs) by age: 2003. (From Administration on Aging, Department of Health and Human Services.
[2005].A profile of older Americans.Available at: http://www.aoa.gov/PROF/Statistics/profile/
2005/profiles2005.asp. Accessed September 26, 2006.)
BOX 11-3 ● Responsibilities of Home Health Nurses
❙ Assess the readiness of the client and home environment
❙ Treat each client with respect regardless of the person’s standard of living
❙ Identify health or social problems that require nursing, allied health, or supportive care services
❙ Plan, coordinate, and monitor home care
❙ Give skilled care to clients requiring part-time nursing services
❙ Teach and supervise the client in self-care activities and family members who participate in the client’s home care
❙ Assess the safety of health practices that are being used
❙ Observe, evaluate, and modify environmental and social factors that affect the client’s progress
❙ Evaluate the urgency and complexity of each client’s changing health needs
❙ Keep accurate written records and submit documentation to the agency for the purpose of reimbursement
❙ Arrange for referrals to other health care agencies
❙ Discharge clients who have reached a level of self-reliance