Interacting with Long Term Care Systems

Miriam Rodin, M.D., Ph.D. & Cheryl Woodson, M.D.

Institutional long term care - Nursing homes

Caring for patients who are transferred between nursing homes and hospitals can be frustrating to hospital-based physicians. Understanding the strengths and weaknesses of long term care facilities will lessen this frustration and improve your ability to use this care site appropriately.

Transferring patients into the hospital:

• Nursing homes cannot assess and stabilize acutely ill patients because there are no physicians, laboratory, pharmacy or radiology on site in a nursing home. Their only option is to transfer.
  
• The nursing home transfer sheet has some medically useful items. The medication list reflects what the physician thinks are the current diagnoses. You need not agree. The diagnoses written in the space labeled "Diagnoses" are really the PMH.
  
• Most nursing homes have Fax machines. The nursing home chart should have an annual ECG, most recent labs, consultations, progress notes, and information about next-of-kin/guardian and advance directives. Have the nursing home supervisor Fax them, day or night.
  
• Look at the functional assessment. To qualify for Medicare reimbursement, nursing homes are required to update functional assessments (called Minimal Data Set--MDS). If the nurse checked "independent in gait and toileting," then incontinence and inability to walk are not this patient's usual state of health. The MDS will state whether the patient normally wears glasses, dentures or a hearing aid.
  
• Look for signs of good care: well trimmed finger and toenails, decubiti that are debrided and dressed, short hair and minimal beard growth on men, absence of thick scale on skin and scalp, relatively clear ear canals.
  
• Superficial bruising is common and fairly extensive ecchymoses can develop in aged skin without rough handling. But large sheet burns, decubiti of different ages and stages and unexplained fractures and dislocations should prompt inquiry first to the nursing home Director of Nursing. If further inquiry is necessary, ask for assistance from the hospital Department of Social Services.
  
• Nursing homes are required to report communicable diseases to the Departments of Public Health. If you admit a patient with TB, MRSA, C. difficile, shingles, scabies or lice, you must notify the sending nursing home of this. This will not prevent your sending a stable patient back to the nursing home.

Transferring patients out to a nursing home:

• Nursing homes are not hospitals. They provide skilled nursing care (IV medications, feeding tubes, wound care, chronic ventilator care) and restorative care (physical, occupational and recreational therapies) for people who need time to recover from an illness. This is usually covered by Medicare and private insurance. They also provide custodial care (safety and supervision, feeding, bathing, dressing and toileting) for people who will not be able to return home. This is not paid for by Medicare or insurance.
  
• Nursing homes can maintain blood-borne, contact or enteric precautions if they know what is needed. Almost none can provide respiratory isolation. You can discharge a patient to the nursing home with HIV, C. difficile or MRSA, but not with active TB until the sputum is cleared.
  
• Every nursing home is required to know the PPD and treatment status of all residents and staff. Verify a positive PPD with the director of nursing at the nursing home. If the conversion is new, they are required to re-test all nursing home contacts. There is no upper age limit for INH prophylaxis of a new PPD conversion.
  
• Most nursing homes can manage IVs, respiratory treatments, oxygen therapy and complex wound care once the patients are stable. Call well ahead of the planned discharge date to let them know what is needed.
  
• Ask the nursing home for the name and phone number of the physician who will care for the patient and try to call him or her to give information.
  
• When you dictate the discharge summary, ask that a copy be sent to the nursing home.

Non-institutional long term care - Home health care

Almost any service that can be provided in a nursing home and many services that are provided in the hospital can be arranged at home with the help of the Discharge Planning nurses or a geriatrics social worker.

To assess home health needs, ask whether the person can execute the care plan you prescribe (medication, dressing changes, etc.) and manage their activities of daily living 24 hours a day, 7 days a week. If they cannot, you and the consultants decide how many hours of help, what level of professional services, and what financial resources are required. This information, when matched with patient's/ family's wishes and resources, determines the care site. It is critical that you gather this information as soon as possible so that resources can be solidly in place before the desired day of discharge!

The physician's partners in providing good care at home are the patient and caregivers, professionals from home health agencies and community/social service
providers. The information you provide to the discharge planning nurses and home health intake persons will greatly improve quality of care.

The Continuity of Care form is your consultation form and it must include:

• A full list of diagnoses, medications and treatments. There should be a diagnosis for every medication listed.
  
• Goals for each requested service. Why are you requesting skilled nursing or physical therapy? What do you expect they will accomplish?
  
• Communication parameters, i.e., call MD for blood glucose >300 or <100, BP >180/90 or <120/70.
  
• Clear indication of which physician will assume responsibility after discharge, how to reach him or her and any special communication aids (best times to call, pager numbers, office numbers, availability of associates who can handle home health questions, e.g., nurses or office administrators, most efficient means of handling paperwork).

The financial aspects of physician practice in home care are rapidly evolving. Most recently, in January 1995, regulations were instated that allow for reimbursement of physician time spent in telephone interaction with home health agency professionals. Currently, the regulations permit reimbursement for 30-60 minutes per patient per month when the patients receive Medicare-certified services and have been seen by the physician within 6 months. This does not apply to conversation with patients and family members and other specific documentation is required. As regulations continue to change, information about new resources and responsibilities can be updated through a newsletter published by the American Academy of Home Care Physicians (410/ 730-1623). The American Medical Association has published two sets of guidelines for physician home care practice that are available from the AMA's Department of Geriatric Health (312/ 464-5355).