Tips for physicians offered; a community program reports its success

In addition to advocating for a cultural change in nursing homes to make them more resident centered, the author of a recent article is the Archives of Internal Medicine urges that physicians be alert to opportunities for delaying nursing home admission, or even for avoiding it altogether.

“Incorporating a resident-centered philosophy can begin even before a nursing home admission, either through better preparation of the patient and family or through avoiding the admission altogether,” writes Mary Anne Johnson, MD, professor of Medicine, Department of Medicine, Division of Geriatrics, at the University of California, San Francisco.

“Most nursing home admissions are unplanned,” Johnson points out. “As a result, the nursing home resident often feels, the nursing home resident often feels abandoned and the family feels guilty.”

Johnson suggests that physicians prepare patients and families for the possibility of nursing home placement when it becomes apparent that the patient will need increasing help with activities of daily living, most often because of declining cognitive or physical function.

HOME HEALTH CARE CAN HELP

“The physician can also partner with social workers or community agencies to assess alternatives to nursing home care,” writes Johnson. Such alternatives include: home health care, assisted-living facilities, adult day care programs, and programs of all-inclusive care for the elderly.

Nursing home placement of elderly patients occurs frequently following hospital discharge, as the result of functional decline during the hospitalization, Johnson notes. “Many nursing homes admissions from the acute care hospital can be prevented. Loss of function has the potential to lead to nursing home admission and could be seen as a failure of the hospital care system,” she declares.

She suggests that physicians help prevent functional decline in their older, hospitalized patients by:

• Prescribing medications carefully and appropriately, avoiding drugs likely to cause delirium, incontinence, or falls
• Writing orders that encourage mobility and exercises
• Educating staff and families on the importance of maintaining function and mobility during hospitalization
• Assessing for and addressing sensory impairments, and ensuring that the patient has all necessary assistive devices.

Information on nursing home alternatives and Medicare/Medicaid eligibility requirements can be found on the Medicare compare website at www.medicare.gov/nhcompare.

PROACTIVE ‘GATEKEEPER PROGRAM AIDS COMMUNITY-DWELLING ELDERS

A 10-year, comprehensive program aimed at keeping older adults in the Cleveland, Ohio, area safe and independent in their own homes has proven to be both successful and cost effective, according to a report published in a recent issue on Home Healthcare Nurse.

The Gatekeeper Program’s goal is to provide “linkages to community resources to delay or prevent institutional care for older adults residing in the program’s service area,” explain the authors.

The intervention and case management program uses trained volunteers from the community – employees of local businesses and organizations – to identify and refer older adults (age, 60 years and older) in need of assistance. Each referral is reviewed by a nurse/social worker team, followed most often by an unannounced joint visit to the elder’s home.

The team assess the older adult’s physical health and psychosocial needs, develops a plan in conjunction with the elder to link him or her to appropriate community resources, then manages the case for an average of 11 months.

Community resources linked most frequently for the program’s clients include:

• Home health agencies
• Transportation services
• Meals on Wheels
• Adult day care
• Physicians

“While other case management programs exist, they are traditional in scope,” note the authors. “Older adults must agree to be referred to those programs for assistance. The Gatekeeper Program does not wait for the referral. Despite making unscheduled initial visits, 95% of older adults contacted agree to be helped.”

The most frequent reasons given by volunteers for referring older adults to the program are: cognitive problems, lack of support, physical impairments, falls, and financial difficulties. These reasons coincide with several known risk factors for nursing home admission, the authors point out.

Program outcomes and cost benefits were analyzed for the period 2001-2008.

Key findings include:

• Emergency department visits decreased by 66% during the first three months following assessment and continued to be significantly lower throughout the first year.
• Hospitalizations decreased by 50%
• Cost savings totaled nearly $14 million.

“The program is unique in that it is proactive and does not assume that the older adult will call for assistance or has a support system in place to call for them,” the authors explain, adding that the program reaches out “to those older adults who might not otherwise be found until they are in crisis.”

Source: Changing the Culture of Nursing Homes,” Archives of Internal Medicine; March 8, 2010; 170(5):407-409. Johnson MA; Department of Medicine, Division of Geriatrics, University of California, San Francisco. “The Gatekeeper Program: Proactive Identification and Case Management At Risk Older Adults Prevents Nursing Home Placement, Saving Healthcare Dollars Program Evaluation,” Home Healthcare Nurse; Barrett DL, Secic M, Borowske D; Gatekepper & Geriatric Services, Southwest General Health Center Middleburg Heights, Ohio.