Sunday, March 31, 2013

Reflections of Nursing Homes and more

It's been quite a few years since B and I were involved in traveling and oversight of many contracted nursing homes in the Albany, NY and outlying area.  B, an extraordinary master level's nurse is long retired and I have long since moved into an entirely different position (dabbling with data and technology).  Despite the lapse of time, I am taking this opportunity to share some thoughts and reflections in regards to nursing homes and related issues of aging.

Some terms and concepts to be aware of:

Nursing Home or Nursing Facility - In this post, nursing home refers to skilled nursing facilities, not facilities such as adult homes where services to assist with activities of daily living (absent of skilled nursing services).

Restorative care versus custodial care.  In general, restorative care is targeted to "restore function," that is to say that the goal is discharge to more independent living.  Similarly, custodial care reflects treatment where the patient is not anticipated to improve to the extent of permitting more independent living (they will continue to require skilled nursing).

Advanced Directives - These are written, instructions by the individual as to their preferences for care (often end of life care) that are prepared in advance of an event (e.g. coma) that prevents the individual from being able to actively be involved in decisions relating to their care.  This may include specific instructions such as to whether resuscitation should be provided or whether tube (artificial) feeding should be provided.

Health Care Proxy - This is a written document identifying who should make health care decisions for you in the event that you are not able to.

Now some reflections from my observations:

The importance of local friends and family (moreover, family who are friends... so really this is friends and friends...).  Family is always an interesting dynamic.  I experienced a social work peer of Indian (the country) descent who related she could not understand why so many American families would not take care of their elderly parents.  Indeed, you will find a wide divergence of "growing up" experiences and familiar relationships in America.  When you cannot effectively advocate for yourself, you need good friends who will.  Regular visitation by friends is your best assurance of optimal care.  (Sadly, but truthfully, your family member who lives on the other end of the country is not going to help you much in regards to your day to day nursing home care.)

Advanced Directives and a Health Care Proxy will help to clarify your preferences.  This coupled with a true friend is your best defense.  My hope is to check out in the recliner with the remote and a beer within reach, but just in case that doesn't work out, it is important to make sure wishes are known AND you have a loyal friend who will promote your wishes.  I recall an ethics consult that I was involved with where a feeding tube had been inserted for continued feeding, contrary to the patient's wishes stated in an advance directive.  When I asked the nurse why the advance directive had not been honored, her response was "well, it wasn't his time yet."  Fortunately, there was a family involved who made noise to move the care in the direction of the patient's wishes; however, I note this as an illustration of how the values of the care provider may impact care.  (This may be a particular consideration with "faith based" nursing facilities where religious renderings may run contrary to patient identified preferences for end of life care).

While the basic service may be the same, nursing homes are NOT the same.  Medicare provides some data that can be used to compare nursing homes.  This is a good starting point, but I would not recommend making a decision based on this information alone.  As stated in my first (and most important) reflection, nothing beats the active involvement of a friend, specifically a friend who is willing and able to VISIT the nursing facility.  Additionally, personal preferences should be considered and this may involve balancing priorities.  Beyond basic care measures, nursing homes have different personalities such as urban versus rural or faith based or other.  One of the more interesting decisions I observed was a daughter who wanted her father in a nursing home close to her home versus a great opportunity in a terrific rural nursing home that was about an hour away.  Anticipate that there will be trade offs and be open to fresh ideas.

Medicare, Medicaid, Long Term Care Insurance:  These are common, but potentially confusing payment sources for nursing home care.  For those in the Albany area, I strongly recommend Albany Law School's Senior Law Day.  This is a free event and the sponsor prohibits "selling" so you will get the information without any hidden agendas.  (In fact, if you go and are interested in services from a presenter, you will need to take the initiative to write down and sometimes ask for their contact information because they will not "push" their business card on you - they are prohibited from doing so).

In general, Medicare is a likely payer for restorative nursing care services while Medicaid is a more likely payer for custodial care type nursing care.  I am skeptical of Long Term Care insurance - let me emphasize that this is MY opinion based solely through MY eyes.  (If you are expecting the noncommittal dribble common of many blogs... Newsflash, it's called "My Turn Quips" for a reason).  Remember, life is for the living; if you are spending too much time worrying about end of life, take action... consult an attorney to resolve you estate worries AND find something more productive to do with your life.  Excessive worry is an indicator that you have too much spare time.

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