Long-Term Care Medicine (eBook)

Preface 8
Contents 10
Contributors 12
Part 1 An Introduction to Long-Term Care 15
Chapter 1: Home Care 16
Introduction 16
Home Care 17
The Physician House Call 17
Preparing for the House Call 18
Billing for House Call Services 19
Agency Home Health Care 20
Requirements for Agency Home Health Care 20
Members of the Team 22
Skilled Nursing Care 22
Physical Therapist 23
Speech Therapist 23
Occupational Therapist 23
Aide in Attendance 23
Physician Reimbursement for Home Health Care Services 24
The Future of Home Health Care 25
Pearls for the Practitioner 25
Websites 26
References 26
Chapter 2: Assisted Living and Residential Care 28
Introduction 28
Assisted Living History 29
Definition of Assisted Living 30
Facility Characteristics 31
Resident Characteristics 32
Physicians and Other Providers 33
Financing 33
Physician Billing 35
Assisted Living Care 35
Direct Care Services 35
Medication Management 35
Resident Rights 37
Staff Training 37
Facility Operations 37
Barriers to Care 37
Optimal Medical Care 40
Physician Practice 40
Transitions of Care 41
Technology 41
Suggestions on Improving Care 42
Summary 47
Pearls for the Practitioner 47
Websites 48
References 48
Chapter 3: Nursing Facilities 50
The Interdisciplinary Team 51
Regulations: OBRA ‘87 51
Nursing Facility Regulations 58
CURRENT USES OF THE MDS INCLUDE 59
Regulations: State Operations Manual 59
Quality Initiative: Medicare Five Star Program 61
Financing 62
Medicare Part A 63
Medicare Part B 63
Medicare Part C 63
Medicare Part D 64
Medicaid 64
Transitions of Care 64
Future Changes 65
Summary 65
Pearls for the Practitioner 66
Websites 66
References 66
Chapter 4: The Role of Practitioners and the Medical Director 68
Introduction 68
The Role of the Practitioner 69
The Role of the Medical Director 73
Medical Director Characteristics 73
Origins of the Medical Director Role 73
Key Medical Director Responsibilities 74
Regulatory Foundation 74
Professional Foundations of the Medical Director Role 76
Medical Director Relationships with Practitioners 78
Defining Practitioner Responsibilities 78
The Medical Director’s Relationship with the Facility 79
The Medical Director’s Role in Facility Quality 81
Pearls for the Practitioner 82
Website 83
References 83
Part 2 Common Clinical Conditions in Long-Term Care 85
Chapter 5: Common Clinical Conditions in Long-Term Care 86
Introduction 86
Hypertension 87
Benefits of Treatment 87
Evaluation 88
Treatment Goals 88
Implications for LTC 91
Anemia 91
Impairments 91
Outcomes 92
Definition 92
Signs and Symptoms 92
Causes of Anemia 93
Anemia of CKD 95
Acute or Chronic Immune Activation (ACI) 95
Treatment 95
Heart Failure 96
Evaluation 97
Laboratory Testing 98
Common Precipitants of Heart Failure in LTC Patients 99
Process of Care Considerations 99
Management 100
Cautions 100
Digoxin 101
Refractory HF 101
Chronic Obstructive Pulmonary Disease 101
Identification of COPD 101
Diagnosis of COPD 102
Management of COPD 103
Acute Exacerbations 105
Diabetes 107
Treatment Selection 110
Insulin 110
Sliding-Scale Insulin 111
Suggestions for Adjusting Insulin Therapy Based on Glucose Patterns 112
Goals of Treatment 112
Hypoglycemia 114
Monitoring 115
Assessment of Glycemic Control 115
Assessment of Facility Management of Diabetes 115
Hypothyroidism 115
Screening for Thyroid Dysfunction 116
Appropriate Use of Thyroid Function Tests 117
Causes of Hypothyroidism 119
Primary Hypothyroidism 119
Central (Secondary) Hypothyroidism 119
Clinical Evaluation 119
Treatment of Clinical Hypothyroidism 120
Subclinical Hypothyroidism 121
Management of Subclinical Hypothyroidism 121
Nonthyroidal Illness 121
Vitamin B12 Deficiency 122
When Should B12 Deficiency be Suspected? 123
Diagnosis 123
Treatment 124
Skin Disorders 124
Scabies 124
Transmission and Diagnosis 125
Controlling the Outbreak 126
Treatment [36] 126
Herpes Zoster 127
General Measures 127
Vaccination 128
Treatment 128
Pearls for the Practitioner 128
Websites 129
References 129
Chapter 6: Acute Change in Condition 133
Introduction 133
Asymptomatic Bacteriuria and Urinary Tract Infections 134
Guidelines for Diagnosing a Urinary Tract Infection or Urosepsis 134
Urinalysis and Urine Culture 137
Fever 137
Treatment of Urinary Tract Infections 139
Pneumonia 140
Diagnosing Pneumonia 141
Where to Treat Patients with Pneumonia 142
Pneumonia vs. Pneumonitis 143
Treatment of Nursing Home-Acquired Pneumonia 144
Interface with Acute Care 146
Barriers to Effective Transitions 148
Opportunities to Improve the Interface in Acute Care 148
Transition of Care from the Nursing Facility to the Hospital 149
Summary 150
Pearls for the Practitioner 151
Websites 152
References 152
Chapter 7: Health Maintenance and Prevention 154
Introduction 154
Physical Activity and Fall Prevention 155
Osteoporosis Management and Prevention 157
Vitamin D Deficiency 158
Vaccinations 159
Pneumococcal Vaccine 159
Influenza Vaccine 160
Herpes Zoster Vaccine 160
Tuberculosis Screening 160
Cancer Screening 161
Cervical Cancer Screening 162
Breast Cancer Screening 162
Colon Cancer Screening 163
Prostate Cancer Screening 163
Pearls for the Practitioner 163
Websites 164
References 165
Chapter 8: Integrating Palliative Care into Practice 167
Introduction 167
Illness Trajectories 168
Principles of Palliative Care 168
Symptom Assessment and Management 169
Anorexia 172
Dyspnea 173
Nausea and Vomiting 174
Constipation 175
Delirium 177
Pain Management 178
Opioid Analgesics 182
Eligibility Guidelines for Hospice 187
End-of-Life Care 190
Pearls for the Practitioner 192
Websites 193
References 193
Chapter 9: Weight and Nutrition 195
Introduction 195
IMPACT OF AGING, DISEASE, AND MEDICATION 196
Assessment of Nutritional Status 200
Additional Laboratory Assessment and Monitoring 201
Weight Management 202
Nutritional Intervention 204
Fluids 204
Supplements 204
Appetite Stimulating Medicines 205
Indications and Use of Feeding Tubes 206
Ethical and Legal Issues 208
Pearls for the Practitioner 209
Websites 210
References 210
Chapter 10: Wound Care 212
Introduction 212
Risk Factors for Wound Development 213
Types of Wounds 218
Pressure Ulcers 218
Diabetic Wounds 218
Ischemic Wounds 219
Venous Wounds 219
Prevention 219
Staging 220
Management 221
Treatment 221
Complications 224
Documentation 225
Summary 226
Pearls for the Practitioner 226
Websites 227
References 227
Part 3 Psychosocial Aspects of Long-Term Care 230
Chapter 11: Dementia, Delirium, and Depression 231
Introduction 231
Dementia in Long-Term Care 231
Definition of Dementia 231
Evaluation of Dementia 234
The Importance of Dementia Screening 234
Medication Management and Cognitive Impairment 235
Evaluation of the Resident with Cognitive Impairment 235
Implications of a Diagnosis of Dementia 236
Progression of Dementia 236
Treatments for Dementia 237
Challenging Behaviors in Dementia 237
Treatment of Behaviors in Dementia 238
Nonpharmacologic Treatment 238
Pharmacologic Treatment 239
Delirium 240
Importance of Recognizing Delirium 240
Assessment of Delirium 241
Depression 242
Differentiating Depression from Dementia 243
Diagnosis of Depression 244
Diagnostic Tools 246
Treatment of Depression 247
Summary 249
Pearls for the Practitioner 249
Dementia 249
Delirium 249
Depression 249
Websites 250
References 250
Chapter 12: Ethical and Legal Issues 252
Introduction 252
Principles of Health care Ethics 253
Common Areas of Concern 254
Resident Rights 254
Elder Abuse, Neglect, and Exploitation 255
Driving 259
Mental Capacity, Competence, and Options for Surrogate Decision Making 260
Evaluation of Capacity 263
End-of-Life Issues 265
Ethical and Legal Aspects of Research in Long-Term Care 267
Liability in Long-Term Care 269
Summary 271
Pearls for the Practitioner 272
Websites 273
References 273
Chapter 13: Caring for Families 274
Introduction 274
Attitudes 275
Knowledge 276
Skills 277
Selection of a Family Spokesperson 278
Responding to a Phone Call from an Unhappy Family Member 278
Convening and Conducting a Family Meeting 281
Writing a Progress Note for Families 283
Creating and Using a Genogram 283
When There Are Cultural Barriers 284
Summary 285
Pearls for the Practitioner 285
Websites 285
References 286
Part 4 Special Issues in Long-Term Care 287
Chapter 14: Documentation and Coding 288
Introduction 288
Documenting the Visit 288
History 289
Examination 290
Medical Decision Making 290
Time 291
Coding and Billing for Nursing Facilities 291
Skilled Nursing and Nursing Facility Visits 291
Other Coding Issues in Nursing Facilities 295
Consultations 295
Hospice Care 295
Physicians in Group Practice 296
Multisite Same Day Visits 296
Split or Shared Visits 296
“Incident To” Services 296
Visits by Qualified Nonphysician Practitioners 296
Prolonged Services 298
Services Provided in the NF or SNF That Are Not Reimbursable by Medicare 298
Coding and Billing for Assisted Living Facilities 298
Coding and Billing for Home Visits 298
Pearls for the Practitioner 299
Websites 300
References 300
Chapter 15: Medication Management in Long-Term Care 301
Introduction 301
Polypharmacy 302
Pharmacokinetics 302
Absorption 303
Distribution 304
Metabolism 304
Elimination 305
Pharmacodynamic Changes 305
Preventing Adverse Drug Events in Long-Term Care 306
Use of Antipsychotic Medications 310
Diabetic Medications 315
Analgesics 315
Transition in Care and Medication Errors 316
Medication Selection in the Elderly 316
Special Considerations 317
Hypertension 317
Clinical Situations Meriting Specific Antihypertensive Therapy 317
Beta-Blockers Postmyocardial Infarction 318
Anticoagulants in Nonvalvular Atrial Fibrillation 318
Subclinical Hypothyroidism 318
Gradual Dose Reduction in SNFs/NFs 319
Summary 320
Pearls for the Practitioner 320
Websites 321
References 322
Chapter 16: Rehabilitation and Maximizing Function 325
Introduction 325
Types of Therapy Services 326
Payment for Rehabilitation Therapy 327
Medical Comorbidities and Frailty 327
Prevention 328
Pressure Ulcer Prevention 328
Prevention of Venous Thromboembolism 328
Rehabilitation Approaches 329
Stroke 329
Fracture Care 331
Joint Replacement 332
Amputation and Orthotics 333
Deconditioned State 334
Other Guiding Principles 334
Maximizing Function 334
Pain Management 335
Depression 335
Summary 335
Pearls for the Practitioner 336
Websites 337
References 337
Index 338