Sean Whitfield - NURS 3540 - Module #12 - Complete PDF

NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Module 12 Active Learning Guide - Chapters 31, 32 Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of older adults. Research Highlights contain a summary o...

NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Module 12 Active Learning Guide - Chapters 31, 32 Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of older adults. Research Highlights contain a summary of pertinent current research related to chapter topics. Resources for Best Practice provide suggestions for further information for chapter topics and tools for practice. Healthy People boxes refer to goals cited in Healthy People 2030. Clinical judgment and next generation NCLEX examination style questions are located at the end of every chapter. Please review these questions as they are good practice for the exam. I. Economics 1. Discuss sources of income for older adults in the United States. a. Social Security → Social Security is a program primarily designed to provide financial support to people in their retirement years, as well as to those who are disabled, survivors of workers who have died, and dependents. It's a form of social insurance that is funded through payroll taxes. In the United States, this program is managed by the Social Security Administration (SSA) and is funded by contributions from workers and employers under the Federal Insurance Contributions Act. b. Supplemental Security Income → Supplemental Security Income is a United States government program that provides financial assistance to individuals who are aged 65 or older, blind, or disabled, and who have very low income and limited assets. Unlike Social Security benefits, which are based on the recipient's work history and contributions to the Social Security system through payroll taxes, SSI benefits are funded from general tax revenues. SI is administered by the Social Security Administration, but it's important to note that it is distinct from the Social Security retirement, survivors, and disability insurance programs. The goal of SSI is to provide cash assistance to its recipients to meet basic needs for food, clothing, and shelter. Eligibility for SSI not only depends on age, disability, or blindness but also on financial need. This means that applicants must have limited income and resources. The definition of income for SSI purposes includes money earned from work, other benefits such as Social Security and pensions, and support from family and friends. Resources include cash, bank accounts, stocks, U.S. savings bonds, land, vehicles, personal property, life insurance, and anything else that could be converted to cash and used for food or shelter. c. Private Retirement → Private retirement plans are savings mechanisms that are not provided by the government but are instead established and managed through private entities such as employers, financial institutions, or individuals themselves. These plans are designed to help individuals save and invest for their retirement years, supplementing or, in some cases, serving as the primary source of retirement income beyond any public pension benefits like Social Security. There are several types of NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide private retirement plans, each with its own set of rules regarding contributions, investments, taxes, and withdrawals. Here are some of the most common types: 2. Discuss Social Security as a source of income for older adults. Should people expect Social Security to be the primary source of their income in old age? Whether Social Security should be expected to serve as the primary source of income in old age depends on individual circumstances, expectations for the standard of living in retirement, and the future of the Social Security program itself. However, financial planners and experts often advise that Social Security should not be relied upon as the sole or primary source of income in retirement for several reasons: Insufficient to Cover Expenses: Social Security benefits are designed to replace only a portion of a worker's pre-retirement income. The exact percentage varies depending on earnings and the age at which one starts to receive benefits, but it typically ranges from about 40% to 70% for most workers. For many people, this would not be enough to maintain their standard of living in retirement, especially considering the rising costs of healthcare and long-term care. Cost of Living Adjustments (COLAs): While Social Security benefits are adjusted for inflation through Cost of Living Adjustments, these adjustments may not fully keep pace with the actual increase in living costs, particularly in healthcare, which is a significant part of many retirees' budgets. Financial Health of the Social Security Program: The long-term financial health of the Social Security program has been a subject of concern. Projections have indicated that without changes to the program, the Social Security Trust Fund may be depleted in the near future, potentially leading to reduced benefits. However, it's important to note that this does not mean Social Security will disappear, but adjustments may need to be made. Changing Retirement Landscape: The retirement landscape has shifted significantly over the past few decades, with fewer employers offering traditional pension plans and more responsibility being placed on individuals to save for their retirement through defined contribution plans like 401(k)s and individual retirement accounts. What are the eligibility requirements for Social Security? Retirement Benefits Age: You can start receiving retirement benefits as early as age 62, but doing so may result in a reduced benefit. Full retirement age (FRA) varies depending on your birth year, ranging from age 65 to 67. You can also delay receiving benefits past your full retirement age to increase your monthly benefit, up to age 70. Disability Benefits Work Credits: The number of work credits needed for disability benefits depends on your age when you become disabled. Younger workers may qualify with fewer credits. Generally, you need 40 credits, 20 of which were earned in the last 10 years ending with the year you become disabled, though younger workers might need fewer. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Medical Criteria: You must meet the SSA's definition of disability, which is a condition expected to last at least one year or result in death and that prevents you from performing substantial gainful activity. Survivors Benefits Work Credits: The number of credits needed for your family members to be eligible for survivors benefits depends on your age when you die. The younger a person is, the fewer credits they need for family members to qualify. However, no one needs more than 40 credits (10 years of work) for their survivors to be eligible. Relationship: Widows or widowers, divorced spouses, children, and dependent parents may be eligible for survivors benefits based on their relationship to the deceased worker. Supplemental Security Income While not technically part of the Social Security benefits funded by payroll taxes, SSI is managed by the Social Security Administration and provides benefits based on financial need rather than work history. Age/Disability: SSI is available to individuals who are 65 or older, blind, or disabled. Income and Resources: Applicants must have limited income and resources. 3. Discuss how health care for older adults is financed in the United States. Medicare Medicare is a federal program that provides health insurance to people aged 65 and older, some younger people with disabilities, and people with EndStage Renal Disease (permanent kidney failure requiring dialysis or a transplant). It consists of several parts: Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Most people don't pay a premium for Part A because they or their spouse paid Medicare taxes while working. Part B (Medical Insurance): Covers certain doctors' services, outpatient care, medical supplies, and preventive services. Part B requires a monthly premium. Part C (Medicare Advantage Plans): A type of Medicare health plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits. Many Medicare Advantage Plans also offer prescription drug coverage. Part D (Prescription Drug Coverage): Adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare PrivateFeeforService Plans, and Medicare Medical Savings Account Plans. This coverage is provided through insurance companies and other private companies approved by Medicare. Medicaid Medicaid is a state and federal program that provides health coverage to people with very low income, including some low income adults over the age of 65, particularly those in nursing homes or those who need home and community based services. Medicaid can also help pay for NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide costs that Medicare does not cover, such as long term care. Eligibility for Medicaid varies by state. Private Insurance Many older adults maintain some form of private health insurance, either through retirement plans from their former employers or by purchasing individual policies. These can include Medi gap policies, which are supplemental insurance policies that cover costs not covered by Medicare, such as co-payments, coinsurance, and deductibles. Out of Pocket Payments Despite the coverage provided by Medicare, Medicaid, and private insurance, older adults often face out of pocket expenses for health care services not fully covered by these programs. These can include deductibles, co payments, and services not covered by insurance, such as certain long term care services. 4. Differentiate between Medicare and Medicaid. Medicare Purpose: Medicare is a federal program that provides health insurance primarily to people aged 65 and older, regardless of income. It also serves younger individuals with certain disabilities and people with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Eligibility: Eligibility for Medicare is primarily based on age (65+) or specific disabilities or conditions, not income level. Coverage: Medicare is divided into parts that cover different aspects of healthcare: Part A covers hospital insurance, including inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care. Part B covers medical insurance for doctor visits, outpatient services, medical supplies, and preventive services. Part C (Medicare Advantage) offers an alternative way to receive your Medicare benefits through private insurance companies approved by Medicare. Part D provides prescription drug coverage. Cost: Medicare recipients typically pay premiums for parts B and D, deductibles, and coinsurance. Part A is usually premium free for individuals (or their spouses) who have worked and paid Medicare taxes for a certain period. Administration: Medicare is administered by the federal government through the Centers for Medicare & Medicaid Services (CMS). Medicaid Purpose: Medicaid is a joint federal and state program that provides health coverage to eligible low income adults, children, pregnant women, elderly adults, and people with disabilities. It is designed to assist people with limited income and resources. Eligibility: Medicaid eligibility is primarily based on income, and it varies by state. The Affordable Care Act expanded Medicaid coverage in many states to include all adults with income up to NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 138% of the federal poverty level, but not all states have chosen to expand their Medicaid programs. Coverage: Medicaid covers a broad range of health services, including doctor visits, hospital expenses, nursing home care, home health care, and services that Medicare may not cover, like personal care services and long term care. Cost: Medicaid costs to the patient are typically minimal, with some states requiring small co payments for certain services. In many cases, Medicaid beneficiaries pay nothing for covered services. Administration: Medicaid is administered by individual states within federal guidelines. This means that specific coverage and eligibility requirements can vary significantly from one state to another. How are Medicare and Medicaid funded? Medicare Funding Medicare is funded through two main trust funds held by the U.S. Treasury, which are specifically designated to pay for the program's expenses: 1. Hospital Insurance (HI) Trust Fund: This fund pays for Medicare Part A benefits, which include hospital care, skilled nursing facility care, hospice care, and some home health care. It is primarily funded by payroll taxes levied on employees, employers, and the self-employed. These are known as FICA (Federal Insurance Contributions Act) taxes. In addition to payroll taxes, the HI Trust Fund also receives income from taxes on Social Security benefits, interest on its investments, and Part A premiums from those not eligible for premium-free Part A. 2. Supplementary Medical Insurance (SMI) Trust Fund: This fund finances Medicare Part B, which covers doctor visits and outpatient care, and Part D, which provides prescription drug coverage. The SMI Trust Fund is funded through a combination of funds authorized by Congress, premiums paid by Medicare enrollees, and interest on its investments. The general revenue contribution ensures that Medicare can provide comprehensive outpatient and drug coverage and reflects the program's commitment to shared financing between the government and beneficiaries. Medicaid Funding Medicaid is jointly funded by the federal government and the states. The program's structure allows for flexibility within federally set guidelines, with states administering their own Medicaid programs within these parameters: 1. Federal Contributions: The federal government pays a percentage of each state's Medicaid expenses, known as the Federal Medical Assistance Percentage (FMAP). This rate varies by state, primarily based on the state's per capita income, with poorer states receiving a higher federal match. The FMAP ranges from 50% to 76%, with the federal government paying a larger share in states with lower per capita incomes. 2. State Contributions: States fund the remainder of Medicaid costs not covered by the federal government. State funding comes from general state revenues, including taxes and other NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide sources. States have some discretion in setting the eligibility criteria, benefits, and provider payment rates within federal guidelines, which can affect the total cost of the program for each state. 3. Enhanced Federal Funding for Certain Populations and Services: For specific populations and services, especially those added under the Affordable Care Act's Medicaid expansion, the federal government offers a higher reimbursement rate than the standard FMAP. For example, for states that have expanded Medicaid eligibility to include more low-income adults, the federal government covers 90% or more of the costs for these individuals. Who can receive services under Medicare and Medicaid? Medicare Eligibility 1. People aged 65 and older: Individuals who are 65 or older and are either U.S. citizens or permanent legal residents of the U.S. for at least five continuous years are eligible for Medicare. They or their spouse must also have worked long enough in a job where they paid Medicare taxes (usually about 10 years). 2. Younger individuals with disabilities: People under 65 who have been receiving Social Security Disability Insurance (SSDI) benefits or certain Railroad Retirement Board disability benefits for 24 months are eligible for Medicare. 3. People with End-Stage Renal Disease (ESRD): Individuals of any age with ESRD, which is permanent kidney failure requiring dialysis or a transplant, are eligible for Medicare. 4. People with Amyotrophic Lateral Sclerosis (ALS): Individuals diagnosed with ALS, also known as Lou Gehrig’s disease, are eligible for Medicare as soon as their disability benefits start. Medicaid Eligibility 1. Low-income adults: In states that have expanded Medicaid coverage under the ACA, most adults under the age of 65 with income levels up to 138% of the federal poverty level (FPL) may qualify for Medicaid. 2. Children and pregnant women: Medicaid provides enhanced coverage options for children and pregnant women, often at higher income thresholds than other adults. The Children’s Health Insurance Program (CHIP) also assists with coverage for children in families with incomes too high for Medicaid but too low to afford private insurance. 3. Individuals with disabilities: People who receive SSDI benefits or have significant health needs may qualify for Medicaid based on disability, regardless of age. 4. Seniors: Older adults who are 65 and over and meet income and asset criteria may qualify for Medicaid, which often helps cover costs not fully paid by Medicare, such as long-term care. 5. Certain other groups: Medicaid coverage may also be available to specific groups such as certain lowincome families, qualified pregnant women and children, and recipients of Supplemental Security Income (SSI), depending on the state. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide The dual-eligible population, individuals who qualify for both Medicare and Medicaid, receive comprehensive health coverage from both programs. Medicare typically serves as the primary payer for hospital and medical services, while Medicaid can cover additional services and costs not fully covered by Medicare, such as long-term care services and Medicare premiums, deductibles, and co-payments. 5. Compare the types of health care services available under Medicare Parts A, B, C, and D. Medicare Part A (Hospital Insurance) Coverage Includes: Inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Cost: Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes while working. There are deductibles and coinsurance for hospital stays Medicare Part B (Medical Insurance) Coverage Includes: Doctor's visits, outpatient care, medical supplies, preventive services (like vaccines, screenings, and yearly "Wellness" visits), and some home health care. Cost: There is a monthly premium for Part B, which can vary based on your income. Additionally, there is an annual deductible, after which you typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment. Medicare Part C (Medicare Advantage) Coverage Includes: An alternative way to receive your Medicare benefits. Medicare Advantage Plans are offered by private companies approved by Medicare. These plans combine Part A and Part B, and often Part D. They may offer extra benefits that Original Medicare doesn't cover, like vision, hearing, and dental. Cost: Costs vary by plan and may include monthly premiums (in addition to the Part B premium), deductibles, co-payments, and coinsurance. The specifics depend on the plan chosen and the services used. Medicare Part D (Prescription Drug Coverage) Coverage Includes: Prescription drugs. This coverage is offered through Medicare-approved private insurance companies. Each plan can vary in cost and drugs covered. Cost: Part D plans charge monthly premiums, which vary by plan. There's also an annual deductible and co-payments or coinsurance for medications. Costs can be lower if you qualify for Extra Help from Medicare. 6. Go to www.healthcare.gov and discuss the governmental mandates that affect health care for older adults. Medicare-Related Mandates 1. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): This law changed how Medicare rewards clinicians for value over volume, streamlining various reporting programs into a single framework to help ensure that patients receive higher quality care. It impacts older adults by potentially improving the quality of healthcare services they receive. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 2. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003: Introduced Medicare Part D, which provides seniors and disabled individuals with subsidized access to prescription drug insurance coverage, addressing a significant gap in Medicare coverage. 3. Annual Wellness Visits: Initiated by the ACA, Medicare covers an annual wellness visit without a deductible or copay, allowing for the creation of a personalized prevention plan. This helps in early detection and prevention of diseases among older adults. Medicaid-Related Mandates 1. Medicaid Expansion under the ACA: While not specifically for older adults, the expansion of Medicaid eligibility to include more low-income individuals and families can indirectly benefit older adults, especially those under 65 who may not yet be eligible for Medicare but need healthcare services. 2. Long-Term Care and Home and Community-Based Services (HCBS): Medicaid is a crucial source of funding for long-term care, including nursing home care and HCBS, for older adults and people with disabilities. Various mandates and waivers (like the HCBS waivers) allow states to provide more comprehensive services to keep older adults in their homes and communities instead of institutions. Affordable Care Act Provisions 1. Pre-Existing Condition Protections: The ACA prohibits insurers from denying coverage or charging higher premiums based on pre-existing conditions. This is crucial for older adults, especially those not yet eligible for Medicare, ensuring they have access to health insurance. 2. Closing the Medicare "Donut Hole": The ACA included provisions to close the coverage gap (known as the "donut hole") in Medicare Part D prescription drug coverage, making medications more affordable for Medicare beneficiaries. 3. Preventive Services: The ACA requires most health plans, including Medicare, to cover a set of preventive services like screenings for cancer, diabetes, and hypertension at no cost to the patient. This mandate helps in early detection and management of conditions prevalent among older adults. 7. Discuss the major components of the Affordable Care Act (ACA) and how they affect older adults. 1. Pre-existing Condition Coverage Impact: Before the ACA, health insurance companies could refuse coverage or charge higher premiums to individuals with pre-existing conditions, which disproportionately affected older adults due to the increased likelihood of having chronic health conditions. The ACA prohibits this practice, ensuring that older adults cannot be denied coverage or charged more due to their health status. 2. Medicaid Expansion Impact: The ACA provided states with the option to expand Medicaid coverage to include more low-income individuals, including older adults under 65 who do not yet qualify for Medicare. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide This expansion significantly increased healthcare access for older adults who were previously uninsured due to income constraints. 3. Medicare Part D "Donut Hole" Closure Impact: The ACA included provisions to gradually close the coverage gap ("donut hole") in Medicare Part D prescription drug plans. This gap had required beneficiaries to pay 100% of drug costs after reaching a certain threshold until catastrophic coverage kicked in. The closing of this gap has reduced out-of-pocket drug costs for older adults on Medicare, making medications more affordable. 4. Preventive Services Impact: The ACA requires most insurance plans, including Medicare, to cover preventive services at no cost to the beneficiary. This includes screenings for conditions like cancer, diabetes, and heart disease, which are more prevalent among older populations. By promoting early detection and preventive care, the ACA has potentially improved health outcomes for older adults. 5. Medicare Payment Reforms Impact: The ACA implemented various reforms aimed at improving the quality of care in Medicare, such as reducing hospital readmissions and promoting value over volume in provider payments. These reforms are designed to improve healthcare outcomes for Medicare beneficiaries, including older adults, and ensure more efficient use of healthcare resources. 6. Creation of Health Insurance Marketplaces Impact: For older adults under 65 who are not yet eligible for Medicare, the ACA established health insurance marketplaces (exchanges) that offer a platform to compare and purchase health insurance plans. Subsidies available through the marketplaces can make premiums more affordable for older adults with low to moderate incomes. 7. Extension of Dependent Coverage Impact: While not affecting older adults directly, the ACA's provision allowing young adults to stay on their parents' health insurance plan until age 26 may indirectly benefit older adults by ensuring their children have access to health coverage. 8. Annual Wellness Visit and Personalized Prevention Plan Impact: Medicare beneficiaries are entitled to an annual wellness visit and personalized prevention plan services at no cost under the ACA. This benefit encourages older adults to engage in preventive care and health monitoring. 8. Discuss some alternative plans for financing your health care. (Indian health Services, Care for veterans, TRICARE, long – term Care Insurance. Indian Health Services (IHS) Who It Serves: The IHS provides healthcare services to American Indians and Alaska Natives. Coverage: It offers a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes in 37 states. Services include primary care, hospital and specialist services, preventive health care, dental care, and optometry, among others. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Financing: The IHS is federally funded and provides healthcare directly to its beneficiaries. Patients may receive care at no cost, but the services are somewhat limited by funding levels and may not cover all healthcare needs or expenses. Care for Veterans Who It Serves: Veterans Affairs (VA) health care is for military veterans. Coverage: The VA provides a broad spectrum of medical, surgical, and rehabilitative care to its enrollees. This can include hospital, outpatient medical, dental, pharmacy, and prosthetic services, as well as supportive services such as rehabilitation, home health, and hospice care. Financing: The VA health care system is federally funded. Eligible veterans might receive these benefits at low or no cost, depending on various factors, including their service history and income level. TRICARE Who It Serves: TRICARE is the health care program for uniformed service members, retirees, and their families. Coverage: TRICARE provides comprehensive coverage, including health plans, prescriptions, dental plans, and special programs tailored to the military community's unique needs. Financing: TRICARE is government-funded but requires some out-of-pocket costs, such as annual enrollment fees, deductibles, and co-pays, which vary depending on the plan, the beneficiary's status (active duty, retired, etc.), and other factors. Long-Term Care Insurance Who It Serves: Individuals who require long-term care due to aging, chronic illness, disability, or other conditions. Coverage: Long-term care insurance typically covers services that Medicare, Medicaid, and traditional health insurance do not, such as assistance with activities of daily living (bathing, eating, dressing), home health care, respite care, and nursing home care. Financing: Long-term care insurance is privately purchased through insurance companies. The cost of premiums varies depending on the age at purchase, the extent of coverage, and other policy details. This insurance helps manage the high costs associated with long-term care services and supports, which can deplete savings and assets. II. Ethical Issues 1. What ethical principle is associated with consent? The ethical principle most closely associated with consent is "autonomy." Autonomy refers to the right of patients or individuals to make informed decisions about their own healthcare. It is a fundamental principle in medical ethics and underpins the practice of obtaining informed consent from patients before proceeding with any medical treatment or intervention. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Informed consent is a process through which healthcare providers must ensure that patients are fully informed about the benefits, risks, alternatives, and potential outcomes of the proposed medical intervention or treatment. This process respects the patient's right to selfdetermination and their ability to make decisions based on their values, preferences, and understanding of their health condition and treatment options. The principle of autonomy emphasizes respect for the individual and their capacity to make reasoned decisions about their own health and body. It also highlights the importance of communication and dialogue between healthcare providers and patients to ensure that consent is truly informed and freely given, without coercion or undue influence. Other ethical principles that play a role in the broader context of consent include: Beneficence: Acting in the best interest of the patient. Non-maleficence: Avoiding harm to the patient. Justice: Ensuring fairness in the distribution of healthcare resources and treatments. 2. Define and discuss decision-making capacity. Decision making → The cognitive process of reaching a decision. Decision-making capacity includes the ability to communicate a clear and consistent choice. This communication can be verbal or non-verbal but must indicate a specific preference. Understanding The individual must be able to comprehend the information relevant to the decision at hand. This includes understanding the nature of their condition, the proposed interventions, and the potential risks and benefits of each option. Appreciation Beyond mere understanding, appreciation requires that the individual can recognize the personal significance of the information provided, particularly how the potential outcomes relate to their own situation and values. Reasoning This component involves the ability to compare options, consider consequences, and reason through the potential outcomes of different choices. It reflects the individual's capacity to engage in a logical process of decision-making. Autonomy and Decision-Making Capacity The principle of autonomy underpins the importance of decision-making capacity in healthcare. Respecting an individual's autonomy means acknowledging their right to make choices about their own life and body, provided they have the capacity to do so. When assessing decisionmaking capacity, healthcare providers must balance the need to respect patient autonomy with the ethical obligations of beneficence (acting in the patient's best interest) and non-maleficence (avoiding harm). NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Assessing Decision-Making Capacity Assessing decision-making capacity is primarily the responsibility of healthcare providers and involves a careful evaluation of the components mentioned above. It's important to note that capacity is task-specific and decision-specific; a person may have the capacity to make certain decisions but not others, depending on the complexity of the information and the cognitive demands of the decision-making process. Additionally, decision-making capacity can fluctuate over time, particularly in individuals with conditions that affect cognitive function. Legal Considerations In cases where an individual is determined to lack decision-making capacity for certain decisions, legal tools such as advance directives, guardianships, or powers of attorney can be utilized to ensure that decisions are made in the individual's best interest, reflecting their values and preferences as much as possible. 3. Discuss issues of consent related to older adults. Describe ways an older adult can authorize another to make legal decisions for him or her. Issues of Consent with Older Adults 1. Assessing Capacity: The primary concern is accurately assessing an older adult's capacity to give informed consent. This involves evaluating their ability to understand information related to decisions, appreciate the consequences of their choices, reason through their options, and communicate their wishes. 2. Risk of Coercion: Older adults might be more vulnerable to coercion or undue influence from family members, caregivers, or others who might stand to benefit from certain decisions. Safeguarding against this requires vigilance by healthcare providers and legal professionals. 3. Balancing Autonomy and Protection: Healthcare professionals often must navigate the delicate balance between respecting an older adult's autonomy and intervening to protect them when they lack the capacity to make safe decisions for themselves. Ways an Older Adult Can Authorize Another to Make Legal Decisions 1. Durable Power of Attorney (POA): A durable power of attorney is a legal document that grants another person (the agent) the authority to make decisions on behalf of the person who created the power of attorney (the principal), should the principal become unable to make decisions. A POA can cover financial matters, healthcare decisions, or both, depending on how it's structured. 2. Healthcare Proxy or Healthcare Power of Attorney: Specifically designed for healthcare decisions, this document allows an older adult to appoint someone to make medical decisions for them if they become incapacitated. The appointed NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide agent makes decisions based on the older adult's wishes, which are often documented in an advance directive. 3. Advance Directives: Advance directives, including living wills, allow individuals to express their wishes about end-oflife care and other healthcare decisions in advance. While not directly authorizing another to make decisions, these directives guide healthcare providers and appointed agents in decisionmaking. 4. Guardianship or Conservatorship: In situations where an older adult has not designated someone to make decisions and is found legally incapable of making their own decisions, a court may appoint a guardian or conservator. This is a more drastic measure, typically used when other methods of decision-making support are not in place. The guardian or conservator has the legal authority to make decisions on behalf of the older adult, within the scope determined by the court. 5. Trusts: For financial matters, an older adult can set up a trust, transferring assets into the trust to be managed by a trustee for the benefit of the older adult or other beneficiaries. This can be an effective way to manage an older adult's finances, with built-in safeguards and oversight. 4. Obtain an advance directive document from the Internet or from your instructor and complete the document to reflect your present wishes should you become incapable of making personal health care decisions. How did you feel about completing this document? 5. Compare the difference between a conservator and a guardian. Guardian Scope of Responsibility: A guardian is typically responsible for making personal decisions on behalf of the protected individual (known as the ward). These decisions can cover a wide range of non-financial aspects, including healthcare, education, and living arrangements. Appointment and Authority: Guardians are appointed by a court to oversee the personal and, in some cases, financial welfare of minors or adults who have been legally determined to lack the capacity to manage their own affairs. In cases where the guardian also manages financial matters, they might be referred to as a "guardian of the estate." Duties: The guardian's duties are generally focused on ensuring the ward's health, safety, and welfare. This includes decisions about medical treatment, where the ward lives, and other aspects of daily life and personal care. Conservator Scope of Responsibility: A conservator is appointed to manage the financial affairs of an individual who is unable to do so themselves due to incapacity or disability. This includes managing assets, paying bills, and handling investments. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Appointment and Authority: Conservators are also appointed by a court and are specifically focused on the financial aspect of the ward's life. The appointment of a conservator often occurs when the individual has significant assets that need management or when financial decisions need to be made on their behalf. Duties: The primary duty of a conservator is to manage and protect the ward's financial assets. This involves making decisions that are in the best financial interest of the ward, including budgeting, investing, and ensuring that the ward's living expenses and debts are paid. Key Differences Focus of Duties: The main difference between a guardian and a conservator lies in their areas of responsibility—guardians are primarily concerned with personal and healthcare decisions, whereas conservators manage financial affairs. 6. Legal Process and Oversight: Both roles require court appointment and involve oversight by the court to ensure that the guardian or conservator acts in the best interest of the ward. However, the specific procedures for appointment, the reports required, and the oversight mechanisms can vary between guardianships and conservatorships, as well as from one jurisdiction to another. Legal Process for Appointment 1. Petition for Appointment: The process usually begins when someone (often a family member, friend, or social worker) petitions a court to appoint a guardian or conservator for an individual. This requires submitting evidence that the individual cannot effectively manage their personal and/or financial affairs due to reasons like mental incapacity, illness, or disability. 2. Evaluation of the Individual: The court may order a professional evaluation to assess the physical and mental condition of the individual in question, determining their capacity to make decisions. 3. Notice: Generally, the proposed ward is legally notified of the proceedings, ensuring they are aware that a guardianship or conservatorship is being considered. 4. Hearing: A court hearing is held where evidence is presented regarding the individual's capacity. The individual has the right to be present, represented by an attorney, and to present evidence. 5. Decision and Appointment: If the court determines that a guardian or conservator is necessary, it will appoint a suitable person. This decision is based on the individual's best interests, considering the proposed guardian's or conservator's ability to manage the responsibilities effectively. Oversight Mechanisms 1. Reporting Requirements: Guardians and conservators are usually required to submit periodic reports to the court. For guardians, these reports might detail the ward's living situation, health status, and well-being. Conservators typically must file detailed accounts of the financial transactions and status of the ward's assets. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 2. Court Review: The court reviews the reports submitted by the guardian or conservator to ensure they are acting in the ward's best interests. This oversight aims to prevent abuse, neglect, or financial mismanagement. 3. Complaints and Investigations: Courts often have mechanisms to address complaints against guardians or conservators. If allegations of misconduct arise, the court may investigate and take appropriate action, which could include removing the guardian or conservator, appointing a new one, or modifying the guardianship or conservatorship arrangements. 4. Termination or Modification: If the ward's condition improves and they regain the capacity to manage their affairs, or if the guardian or conservator is not acting in the ward's best interest, the court can terminate or modify the guardianship or conservatorship. 7. Differentiate the types of elder mistreatment. 1. Physical Abuse This involves inflicting physical pain or injury upon an elder, such as hitting, slapping, bruising, or restraining by physical or chemical means. It also includes acts of violence such as hitting, beating, pushing, and inappropriate use of drugs and physical restraints. 2. Emotional or Psychological Abuse Emotional abuse occurs when an elder experiences pain or distress through verbal or non-verbal acts. Examples include intimidation through yelling or threats, humiliation and ridicule, habitual blaming or scapegoating, and isolating the elder from friends, family, or regular activities. 3. Sexual Abuse Sexual abuse includes non-consensual sexual contact of any kind with an elder. This can range from unwanted touching to rape. It also covers situations where the elder is unable to give consent due to mental incapacity or fear. 4. Neglect Neglect is the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder. It can be intentional or unintentional, based on factors such as ignorance or denial that an elder needs as much care as they do. Neglect can be by caregivers or self-neglect by the elder. 5. Financial Abuse or Exploitation This involves the unauthorized or improper use of the elder's resources for another's benefit. It includes, but is not limited to, theft, fraud, misuse of an elder's personal checks, credit cards, or accounts, forgery, identity theft, or undue influence to gain control of an elder's money or property. 6. Abandonment Abandonment is the desertion of an elder by an individual who has assumed responsibility for providing care or by someone with physical custody of the elder. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 7. Self-neglect Self-neglect characterizes behaviors of an elder that threaten their own health or safety. It involves an elder living in a way that puts them at risk, such as neglecting personal hygiene, not attending to health care needs, or living in unsafe or unsanitary conditions. Self-neglect does not include situations where a competent elder makes a voluntary decision to engage in acts that threaten their safety as a matter of personal choice. 8. Describe risk factors for elder abuse or neglect. Individual-Level Risk Factors Cognitive Impairment: Older adults with dementia or other cognitive impairments are at a higher risk of abuse and neglect due to their increased dependency on caregivers. Physical Disability: Disabilities that require assistance with activities of daily living (ADLs) increase vulnerability to abuse or neglect. Mental Health Issues: Both the mental health of the caregiver and the elder can be risk factors. Elders with depression or other mental health conditions may be at increased risk. Substance Abuse: Substance abuse by either the elder or the caregiver can significantly increase the risk of mistreatment. Social Isolation: Elders who are isolated from their communities or families are at a higher risk, as abuse can go unnoticed. Relationship-Level Risk Factors Dependency: Dependence of the elder on the caregiver for basic needs or the caregiver’s dependency on the elder for economic support can create conditions ripe for abuse. Family Dynamics: Conflict-ridden relationships or a history of domestic violence can extend into elder abuse. Caregiver Stress: Caregivers under significant stress, whether from financial pressures, caregiving demands, or lack of support, may be more likely to commit abuse or neglect. Community-Level Risk Factors Lack of Social Support: Communities with limited resources for elders and caregivers, including social services, recreational activities, or healthcare, increase the risk of neglect and abuse. Cultural Norms: Societal attitudes and norms that devalue older adults or view them as burdens can contribute to mistreatment. Societal-Level Risk Factors Ageism: Societal discrimination against older adults can lead to a lack of protective policies and can influence the way abuse is addressed by the legal and healthcare systems. Economic Inequality: Poverty and financial stress among elders and their families can increase the risk of financial exploitation and neglect. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Legal and Policy Limitations: Inadequate laws or policies to protect older adults, or insufficient implementation of existing laws, can increase the risk of abuse. 9. Describe strategies that may be used to prevent elder mistreatment. 1. Education and Awareness Programs General Public Awareness: Raising awareness about elder abuse, its signs, and how to report it can help in early detection and intervention. Professional Training: Healthcare providers, social workers, law enforcement, and other professionals who interact with older adults should receive training to recognize and appropriately respond to signs of elder mistreatment. 2. Screening and Assessment Regular screening for signs of abuse or neglect should be integrated into healthcare settings. This can help in identifying cases that might not be reported. Comprehensive assessments can help identify those at risk due to cognitive impairments, disabilities, or social isolation. 3. Support for Caregivers Providing support services, respite care, and education to caregivers can reduce stress and prevent potential abuse. Support groups and counseling services can offer emotional support and coping strategies for caregivers. 4. Community Support Services Ensuring that older adults have access to community resources can reduce isolation, a significant risk factor for mistreatment. This includes social activities, transportation services, and meal programs. Legal and financial counseling services can help protect older adults from exploitation and improve their ability to manage their affairs. 5. Strengthening Social Support Networks Encouraging older adults to maintain connections with friends, family, and community members can provide a network of vigilance and support. Programs that promote intergenerational interactions can also help reduce isolation and foster respect and understanding across ages. 6. Legislation and Policy NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Advocating for stronger laws and policies to protect older adults from abuse, neglect, and exploitation is crucial. This includes laws that make reporting suspected mistreatment mandatory for certain professionals. Improving legal responses, including prosecution of abusers and protective orders for victims, can deter potential abusers. 7. Research and Data Collection Investing in research to better understand the causes, types, and consequences of elder mistreatment can inform more effective prevention strategies. Collecting data on elder abuse cases can help in evaluating the effectiveness of laws and interventions. 8. Financial Security Programs aimed at ensuring the financial security of older adults can reduce their vulnerability to exploitation. This includes pension programs, financial literacy education, and protections against fraud. 9. Empowerment and Advocacy Empowering older adults through education on their rights and how to seek help is critical. Advocacy by and for older adults can help ensure their voices are heard in policy-making processes. 10. Discuss the nurse’s legal responsibility in your home state when elder neglect of abuse is suspected. Legal Responsibilities of Nurses Regarding Suspected Elder Abuse or Neglect 1. Mandatory Reporting: In most states, nurses are mandated reporters of elder abuse, neglect, and exploitation. This means that if a nurse suspects that an older adult is a victim of abuse, neglect, or financial exploitation, they are legally required to report their suspicions to the appropriate state or local authorities. The specifics of whom to report to (e.g., adult protective services, local law enforcement) can vary by state. 2. Training and Education: Some states require that nurses and other healthcare professionals receive training on identifying and reporting elder abuse. This education typically covers the signs of abuse, legal responsibilities for reporting, and the procedures for making a report. 3. Confidentiality: While confidentiality between a nurse and patient is a cornerstone of healthcare, the duty to report suspected abuse or neglect takes precedence over privacy concerns in cases of elder mistreatment. State laws usually provide some form of immunity or protection for reporters, assuming the report is made in good faith. 4. Documentation: Nurses should carefully document their observations and the statements of the elder that led to the suspicion of abuse or neglect. This documentation can be crucial for investigations and subsequent interventions. However, nurses must also be aware of and NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide comply with relevant privacy laws and regulations when handling and sharing patient information. 5. Follow-Up: Depending on the state and the situation, the nurse might have responsibilities for follow-up after a report is made, especially if the older adult continues to be under their care. 6. Education and Prevention: Beyond reporting, nurses can play a key role in educating older adults, families, and caregivers about preventing abuse and neglect, recognizing its signs, and understanding the rights of older adults. 11. Describe undue influence. Identify signs of potential undue influence. Undue influence occurs when an individual exerts excessive pressure or influence on another person, typically someone who is vulnerable due to age, illness, cognitive impairment, or dependency, resulting in the victim making decisions that are not in their best interest. Signs of Potential Undue Influence Recognizing undue influence can be challenging, as it often occurs in private and involves subtle manipulation. However, several signs may suggest its presence: 1. Isolation: The influencer may isolate the victim from friends, family, and other support networks to exert more control and minimize outside influence. 2. Dependency: The victim may be made to feel dependent on the influencer for basic needs, emotional support, or companionship. 3. Sudden Changes in Financial or Legal Documents: Unexpected changes in wills, trusts, powers of attorney, or property titles, especially if they disproportionately benefit one person, can be a red flag. 4. Secrecy or Evasiveness: The older adult or the influencer might be secretive or evasive about financial matters, refusing to share details with other family members or professionals. 5. Unusual Financial Transactions: Large, unexplained withdrawals from bank accounts, significant gifts, or transfers of assets to the influencer can indicate undue influence. 6. Changes in Behavior or Emotional State: The victim might show signs of stress, depression, or fear, especially in the presence of the influencer, or express concerns that they are being pressured or controlled. 7. Rapid Involvement: The influencer quickly becomes involved in the elder's life, taking on roles of importance such as healthcare decision-maker, attorney-in-fact, or beneficiary in a very short period. 8. Control of Communications: The influencer may control the elder's communications, including mail, phone calls, and visits, often under the guise of helping. 9. Disparity in Mental Capacity: There may be a significant difference in the mental capacity or understanding between the influencer and the elder, with the elder being unable to fully comprehend the implications of decisions or transactions. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 10. Fear of Retaliation: The elder might express or show signs of fear of retaliation or harm for not complying with the wishes or demands of the influencer. 12. Describe the nurse’s role as advocate. 1. Promoting Patients' Rights Nurses ensure that patients are fully informed about their rights to respectful and dignified treatment, privacy, informed consent, and the right to accept or refuse treatment. They play a critical role in making sure these rights are upheld within the healthcare system. 2. Informed Consent Part of advocacy involves ensuring that patients understand their health conditions, the benefits and risks of proposed treatments, and any alternative options. Nurses help translate complex medical terminology into understandable language, empowering patients to make informed decisions about their care. 3. Supporting Decision-Making Nurses support patients in making healthcare decisions that align with their values, beliefs, and preferences. This may involve providing additional information, clarifying misunderstandings, or simply offering emotional support during difficult decisions. 4. Safeguarding Against Discrimination Nurses advocate for equitable treatment of all patients, regardless of race, gender, age, socioeconomic status, or any other factor. They are often at the frontline in identifying and addressing discriminatory practices or biases in healthcare delivery. 5. Acting as a Liaison Nurses frequently act as liaisons between patients and other healthcare professionals. They communicate patients' needs, preferences, and concerns to doctors, therapists, and family members, ensuring that the care plan reflects the patient's wishes. 6. Education Educating patients and families about health conditions, management strategies, and preventive measures is a key aspect of advocacy. Nurses provide the tools and knowledge needed for patients to take charge of their health. 7. Ethical Concerns Nurses confront ethical issues, such as end-of-life decisions or conflicts between patient wishes and family desires. They advocate for respecting the patient's autonomy and ethical principles in healthcare delivery. 8. Policy Advocacy NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Beyond individual patient advocacy, nurses also engage in broader efforts to improve healthcare systems and policies. This can involve participating in professional organizations, contributing to health policy development, or campaigning for changes that enhance patient care quality and accessibility. 9. Empowerment A significant part of advocacy is empowering patients by encouraging self-advocacy. Nurses teach patients how to ask questions, seek information, and express their needs and concerns. 10. Confidentiality and Privacy Ensuring patient confidentiality and privacy is a fundamental part of advocacy. Nurses protect sensitive patient information and advocate for the secure handling of health records. III. Long-Term Care 1. Describe factors influencing a client’s need for long-term care. 1. Age Older adults are more likely to require long-term care due to the natural aging process, increased risk of chronic diseases, and higher likelihood of conditions such as dementia. 2. Chronic Health Conditions Conditions such as heart disease, diabetes, chronic obstructive pulmonary disease (COPD), arthritis, and Alzheimer's disease can necessitate long-term care due to their progressive nature and the functional limitations they impose. 3. Cognitive Impairments Cognitive disorders like dementia and Alzheimer's disease significantly affect an individual's ability to perform daily tasks independently, requiring sustained caregiving and supervision. 4. Physical Disabilities Physical impairments resulting from conditions like stroke, spinal cord injuries, or severe arthritis can limit mobility and the ability to perform ADLs, leading to a need for long-term care. 5. Mental Health Issues Severe mental health disorders, including major depression, bipolar disorder, or schizophrenia, may impair an individual's ability to care for themselves, necessitating ongoing support. 6. Acute Medical Events Events such as falls, fractures, or hospitalizations for acute illnesses can result in a temporary or permanent need for long-term care, especially if they result in decreased mobility or other lasting impairments. 7. Lack of Support System NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Individuals who lack a supportive network of family or friends may require formal long-term care services, as they might not have informal caregivers to assist with daily needs. 8. Socioeconomic Factors Economic constraints can affect an individual's access to healthcare services, nutritious food, and safe living conditions, potentially increasing the need for long-term care. 9. Living Alone Those living alone may be at a higher risk of needing long-term care facilities, especially if they have conditions that could lead to sudden emergencies or gradual decline in the ability to perform daily tasks. 10. Lifestyle Factors Lifestyle choices, such as smoking, excessive alcohol consumption, poor diet, and lack of physical activity, can contribute to the development of chronic conditions and disabilities that necessitate long-term care. 2. Discuss the future of long-term care. How much can Medicaid and Medicare do for the elderly in long-term care? Future Trends in Long-Term Care: 1. Increased Demand: The need for LTC services will grow due to the aging population. This will strain existing resources and require the expansion of LTC facilities and services. 2. Technological Advances: Technology, including telehealth, remote monitoring, and assistive devices, will play a larger role in LTC, potentially allowing more seniors to age in place and receive care in their homes. 3. Integration of Services: There will likely be a trend towards more integrated care models that combine medical care, social support, and LTC services, aimed at providing comprehensive care that can adapt to the changing needs of the elderly. 4. Workforce Challenges: Attracting and retaining skilled LTC workers will be a critical challenge. Improving working conditions, offering competitive wages, and leveraging technology for routine tasks may be necessary. 5. Alternative Financing Models: The rising costs of LTC may lead to the exploration of alternative financing models, including private long-term care insurance, reverse mortgages, and hybrid life insurance products. Role of Medicaid and Medicare in Long-Term Care: Medicaid: Medicaid is the primary payer for long-term care services in the U.S., especially for low-income individuals who meet specific eligibility criteria. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide It covers a broad range of services, including nursing home care, home and community-based services (HCBS), and personal care services. However, individuals often have to spend down their assets to qualify for Medicaid, which can impact their financial security. Medicare: Medicare provides limited LTC coverage. It primarily covers short-term nursing home stays for rehabilitation after a hospital stay and some home health care services, but it does not cover custodial care, which constitutes the majority of LTC needs. Medicare Advantage plans (Part C) may offer some additional benefits related to LTC, but these are also limited. The Future Role of Medicaid and Medicare: Expansion of HCBS: There's a growing recognition of the preference among seniors to age in place. Future policies may emphasize expanding Medicaid's coverage of home and communitybased services. Medicare Reforms: Discussions about reforming Medicare to include more comprehensive LTC benefits may gain traction, though this would require significant policy and financial adjustments. Sustainability Challenges: Both programs face sustainability challenges due to the increasing demand for LTC services and the rising costs associated with an aging population. Ensuring these programs can continue to support the elderly will likely require both innovation and reform. Why is LONG – TERM CARE insurance so important. Financial Protection LTC insurance provides financial protection against the high costs of long-term care services, whether they are received in a nursing home, an assisted living facility, or at home. Without insurance, these expenses can quickly deplete savings and retirement funds, placing a significant financial burden on individuals and their families. Preserve Savings and Assets By covering the costs of long-term care, LTC insurance helps preserve the individual's savings and assets. This can ensure that life savings are used as intended, such as for retirement or inheritance, rather than being consumed by healthcare costs. Access to Quality Care NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Having LTC insurance can provide individuals with more choices and greater access to quality care facilities and services. Policyholders might have the flexibility to choose between different types of care settings and providers, leading to better and more personalized care. Independence LTC insurance can help individuals maintain their independence longer by providing the financial means for home modifications, in-home care, and other services that can help them live independently at home for as long as possible. Relief for Family Members Reliance on family members for long-term care can place a physical, emotional, and financial strain on loved ones. LTC insurance alleviates this burden by providing the resources needed for professional care, allowing family relationships to remain more personal and less centered on caregiving responsibilities. Flexibility and Control LTC insurance policies often offer flexibility in terms of the types of services covered, ranging from in-home care to adult day care, assisted living, and nursing home care. This gives policyholders control over their care choices, enabling them to plan according to their preferences and needs. Protection Against Uncertainty The future is unpredictable, and the need for long-term care can arise unexpectedly due to illness, injury, or aging. LTC insurance provides a safeguard against this uncertainty, ensuring that individuals are prepared for whatever long-term care needs may arise. Cost-Effectiveness Purchasing LTC insurance at a younger age can be more cost-effective than attempting to cover long-term care costs out of pocket later in life. Premiums are generally lower for younger, healthier individuals, and locking in coverage early can provide peace of mind and financial security. 3. How might the care needs of older adults in residential care/assisted living, subacute care, and a nursing home differ? Residential Care/Assisted Living Residential care facilities or assisted living are designed for older adults who are relatively independent but require some assistance with daily activities. These facilities typically provide: Personal Care: Help with activities of daily living (ADLs), such as bathing, dressing, and eating. Medication Management: Assistance with managing and taking medications. Social and Recreational Activities: Organized activities to promote social interaction and engagement. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Housekeeping and Maintenance: Basic cleaning and maintenance services. Meal Services: Provision of meals, often tailored to dietary needs. The focus here is on maintaining a high quality of life, promoting independence, and providing support for daily activities. Subacute Care Subacute care is a level of care needed after hospitalization but not requiring the intense level of medical care provided in acute care hospitals. It is often provided in specialized facilities or designated units within a hospital or a nursing home. Care in this setting includes: Medical Monitoring and Treatment: For patients recovering from surgeries, injuries, or illnesses that do not require acute care hospitalization. Rehabilitation Services: Such as physical, occupational, and speech therapy to help patients regain strength and functionality. Nursing Care: More intensive nursing care than in residential care settings, including wound care, IV therapy, and monitoring of vital signs. Transition Planning: Preparing patients for a return home or transfer to a long-term care facility if needed. The goal is to bridge the gap between hospital care and home or long-term care, focusing on rehabilitation and recovery. Nursing Home Nursing homes provide the highest level of care for older adults outside of a hospital. Residents typically have complex medical conditions requiring 24-hour supervision and medical care, including: Extensive Medical Care: For residents with chronic conditions, severe physical or cognitive impairments, requiring constant nursing oversight. Personal Care and Assistance: High level of support with ADLs, similar to assisted living but tailored to those with greater needs. Rehabilitation Services: For those who require ongoing physical, occupational, or speech therapy. Specialized Care Units: Some facilities have specialized units for dementia care or other specific health conditions. What is the role of the professional nurse in each of these settings? Assisted Living In Assisted Living facilities, nurses play a key role in: NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Assessment and Monitoring: Conducting initial and ongoing assessments of residents' health status to determine the appropriate level of care needed. Care Planning: Developing and updating personalized care plans in collaboration with the resident, their family, and other healthcare providers. Health Education: Educating residents and families about health management and medication adherence, promoting independence and wellness. Medication Management: Supervising or directly managing the administration of medications, ensuring compliance with treatment regimens. Coordination of Care: Serving as a liaison between residents, families, and external healthcare providers to ensure continuity of care. Subacute Care In Subacute Care settings, the nurse’s role is more intensive and specialized, focusing on: Complex Clinical Care: Providing care for patients recovering from surgery, serious illnesses, or injuries, which includes wound care, intravenous therapy, and monitoring of vital signs. Rehabilitation Support: Working closely with physical, occupational, and speech therapists to implement comprehensive rehabilitation plans. Patient and Family Education: Educating patients and their families on post-discharge care and preparations for a safe transition to home or another facility. Care Coordination: Collaborating with a multidisciplinary team to plan for ongoing care needs, including arranging for home care services or transfer to a long-term care facility if needed. Nursing Home In Nursing Homes, nurses are tasked with providing comprehensive care: Comprehensive Clinical Care: Offering around-the-clock nursing care for residents with chronic conditions, severe cognitive impairments, and those needing palliative care. Management of ADLs: Assisting with or supervising the assistance of activities of daily living, especially for residents with significant physical or cognitive limitations. Medication Management and Treatments: Administering medications and treatments, managing complex medical regimens, and monitoring for side effects. End-of-Life Care: Providing compassionate palliative care, supporting not only the resident but also their families through the end-of-life process. Quality of Life Enhancement: Implementing strategies to enhance the quality of life for residents, including social engagement, personal choice, and maintaining dignity. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 4. Differentiate the types of long -term care assistance. 1. In-Home Care Personal Care Services: Assistance with everyday activities, such as bathing, dressing, and eating, provided in the individual's home by hired caregivers. Home Health Care: Medical care provided at home by licensed professionals, such as nurses, therapists, or home health aides. It often includes wound care, medication management, and physical therapy. Homemaker and Chore Services: Help with household chores that the individual can no longer manage alone, such as cleaning, yard work, and meal preparation. 2. Community-Based Services Adult Day Care: A program outside the home that provides health, social, and other support services in a supervised setting for adults who need some level of help during the day. Senior Centers: Local community centers offering a variety of activities, classes, and events tailored to the interests and needs of older adults, promoting social interaction and active lifestyles. Respite Care: Temporary relief services for family caregivers, ranging from a few hours to weeks. Care can be provided at home, in a healthcare facility, or at an adult day care center. Transportation Services: Assistance for individuals who are unable to drive themselves to appointments, shopping, or social events due to age, disability, or medical conditions. 3. Assisted Living Facilities Assisted living provides residential accommodations for individuals who may need help with daily activities but do not require the intensive medical and nursing care provided in a nursing home. Services typically include meals, personal care, medication management, housekeeping, and social activities. 4. Nursing Homes Nursing homes offer the highest level of care outside of a hospital, including 24-hour medical supervision, as well as assistance with daily activities. They cater to individuals with severe or debilitating physical or mental illnesses who are unable to care for themselves. 5. Continuing Care Retirement Communities (CCRCs) CCRCs provide a continuum of care from independent living to nursing home care, all within one community. Residents can move between levels of care based on their needs over time, allowing them to stay within the same community as their care needs change. 6. Memory Care Units NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Specialized care units designed for individuals with Alzheimer's disease, dementia, and other types of memory problems. These units often feature secure environments and staff trained to care for people with memory impairments. CARE COST Service Provided Criteria for Admission Covered by Medicaid or Medicare? Adult Day Service $75 - 100 per day Social/ Transportation/ Medical Services/ 65 or older/Independen ce/Health Assessment/Cogni tive function Medicaid Yes. Assistance with ADL’s/Access to Health Care/Dining Services/Social Level of care needs/Cognitive function/Behavior assessment/Medi cal evaluation Medicaid Yes. Medicare No. Residential Care/ Assisted Living $4500 per month CCRC’s $2000 – 6000 per month. Transportation/ Housing maintencance/Sec urity/ 55 or older/ability to live independently/Co gnitive function Medicare No. Subacute care/ Skilled Nursing Facility $7000 – 9000 per month. 24 hour nursing care/Rehabilitatio n services/Specializ ed Dementia Care/ Physician’s Order/Acute medical condition/Cogniti ve function Medicaid Yes. Nursing Home $7000 – 9000 per month. 24 hour nursing care/Rehabilitatio n services/Specializ ed Dementia Care/ Significant Functional Limitations/Physic ian’s Assessment/ Medicare limited. 5. What are the goals of long-term care? 1. Maintaining Independence Medicare No. Medicaid varies by state. Medicare Yes. Medicaid NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Long-term care seeks to support individuals in performing activities of daily living (ADLs) such as bathing, dressing, eating, and moving around, to the greatest extent possible. The aim is to preserve the individual's independence and autonomy for as long as feasible. 2. Improving Quality of Life Quality of life is a central focus, with care tailored to the individual’s needs, preferences, and interests. This includes not only physical care but also providing opportunities for social interaction, recreation, and engagement in community life. 3. Promoting Safety and Comfort Ensuring the safety and comfort of individuals is a priority. This can involve adapting living environments to prevent falls, managing medications to avoid adverse effects or interactions, and providing timely medical care to prevent complications. 4. Supporting Health and Medical Needs Long-term care provides for the medical and health needs of individuals, including managing chronic conditions, providing therapy and rehabilitation services, and ensuring that acute health issues are addressed promptly. 5. Enhancing Emotional and Psychological Well-being Recognizing the emotional and psychological impacts of chronic conditions and dependency, long-term care aims to provide emotional support, mental health services, and interventions that promote psychological well-being. 6. Assisting Caregivers Supporting family members and other caregivers is an essential aspect of long-term care. This includes providing education, respite services, and resources to help caregivers maintain their well-being while effectively supporting their loved ones. 7. Facilitating Social and Civic Engagement Long-term care encourages and facilitates engagement with the broader community, fostering social connections and enabling individuals to participate in civic, cultural, or religious activities according to their interests. 8. Adapting to Changing Needs As individuals’ conditions evolve, long-term care goals include regularly reassessing and adjusting care plans to meet changing needs, ensuring that the level and type of care provided continue to be appropriate. 9. Ensuring Dignity Throughout all aspects of care, maintaining the dignity of the individual is paramount. This involves respecting their choices, privacy, and individuality, and treating them with compassion and respect. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 10. Coordinating Comprehensive Care Long-term care often involves coordinating various types of care and services, from medical treatment to personal care and social services. Effective coordination ensures that care is holistic, continuous, and tailored to the individual’s unique needs. 6. What quality measures are in place for evaluating nursing homes in the United States? 1. Five-Star Quality Rating System CMS uses the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. This system rates nursing homes from 1 to 5 stars, based on their performance in three areas: Health Inspections: Based on the outcomes of the state's health inspections of the nursing home. Staffing: Evaluation of the number of hours of care provided on average to each resident each day by nursing staff. Quality Measures (QMs): Based on performance on specific measures of care quality, such as pressure ulcers, physical restraints, and pain management. 2. Health Inspections State survey agencies conduct health inspections on behalf of CMS, evaluating compliance with federal standards on care quality, environment, resident rights, and many other aspects. These inspections include both standard surveys and complaint-driven investigations. 3. Quality Measures CMS collects data on more than a dozen physical and clinical measures for nursing home residents, covering areas like mobility, pain management, infection rates, and the use of antipsychotic medications. This information is used to evaluate outcomes and processes of care, contributing to the overall quality rating of the facility. 4. Staffing Levels Research has shown a strong relationship between nursing home staffing levels and resident outcomes. CMS assesses staffing levels based on payroll data, looking at the ratio of staff to residents and the consistency of staffing, among other factors. 5. Complaints and Incidents The handling of complaints and incidents is another critical measure of a nursing home's quality. Facilities are required to have processes in place for reporting, investigating, and resolving complaints and incidents, which are reviewed during inspections. 6. Resident and Family Satisfaction Surveys NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide While not formally part of the CMS rating system, many states and facilities conduct satisfaction surveys to gather feedback from residents and their families about their experiences. This feedback can provide valuable insights into the quality of life and care in the facility. 7. Certification and Licensure Nursing homes must be licensed by the state in which they operate and certified by CMS to receive payment from Medicare and Medicaid. Compliance with licensure and certification requirements is a fundamental measure of quality. What agency is in charge of Skilled Nursing Facility regulations? CMS sets and enforces standards through the following mechanisms: Certification: SNFs must be certified by CMS to receive payment from the Medicare and Medicaid programs. Certification is based on compliance with specific health care standards and quality measures. Inspections and Surveys: CMS, often through state health departments acting on its behalf, conducts regular health inspections and surveys of SNFs to assess compliance with federal standards. These inspections include unannounced visits and reviews of resident care, staffresident interactions, and the physical environment. Quality Measures: CMS uses a set of quality measures to evaluate the care provided in SNFs. These measures cover areas such as resident health, safety, and satisfaction. The results are made public to help consumers choose facilities and to encourage facilities to improve care. Enforcement Actions: When SNFs do not meet federal standards, CMS can impose enforcement actions, which may include fines, appointment of new management, or termination of the facility’s participation in Medicare and Medicaid. While CMS sets the federal standards and oversees the overall regulatory framework, state health departments play a critical role in the on-the-ground inspection and enforcement process. States may also have their own additional requirements for SNFs beyond the federal standards. Audio/Video Focus Areas Please watch the following video and answer the questions provided. 1. 1 An Age for Justice Confronting Elder Abuse in America (16:03) Where is elder abuse occurring in America? It is a national problem. Which individuals are most likely to be the abusers of the elderly? 1. Family members. 2. Care Givers. 3. Friends and acquaintences. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Abused elders are most likely to live a shorter life. Financial exploitation causes a loss of dignity in the elderly. Kamala Harris helped to establish the Elder Abuse Prevention and Prosecution Act to help protect the senior population. 2. What is a Long-Term Care Ombudsman (3:10)? An Ombudsman is an advocate for nursing home residents. An Ombudsman allows nursing home resident to express their wants and needs. What issue was mentioned in the short video above that was corrected for the resident? 3. Resident’s Rights” Your life, Your Care , Your Choice (12:31) Do nursing home residents have more rights than you or I? Yes. Congress created the bill of Residents Rights in recognition of: 1. The power imbalance between residents and staff; and 2. The tendency of nursing homes to operate as an impersonal system which required residents to fit-in. View the list of Residents Rights What choices do you have as a nursing home resident? 1. The right to make your own schedule. 2. The right to see your own visitors. 3. The right to make your own medical decisions. If you file a complaint with your Ombudsman program representative, he/she will: 1. 2. 3. 4. 5. Acknowledge your complaint. Review and Assessment of complaint. Investigate the complaint. Facilitation and Mediation for resolution. Report on the complaints they work. The following video was taken at the Harding Place Retirement Home in Searcy Arkansas Please make sure you are logged into your HU google account. Student Link: Harding Place Tour (44:09) As you watch this video, look for the following concepts to be discussed: 1) benefits of living at Harding Place (what is included in rent, social benefits, social calendar) Utilities, Television, Internet, Three Hot Meals a day, Weekly House Cleaning w/Linen and Towel Service, Transportation, Emergency Call System. Hands on healthcare is not included, the facility does not have a license to do so. 2) aging in place (medication reminders) NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide The longer they live at they may need medicine reminders, dressing, undressing assistance, bill delivery, home health care and hospice care. 3) impact of covid-19 Closing doors early, placing residents in quarantine if they test positive while away from the facility. New creative activities that includes spacing and increased planning. Salon has a limited number of people allowed at one time due to COVID restrictions. 4) role of nurse in independent living although working as marketing director Creative way to implement medication reminders (Employed a robot, called EZ dose at no charge to the resident), that dispenses medication monthly. The medications are controlled and “released” by a pharmacist on a blister pack sheet. The care giver is not responsible for medication administration. The caregiver is only gives a verbal queue or reminder to take medications. 5) interview of a resident and their thoughts on living at Harding Place. Loves: Fantastic Food, Lots of Activities (New Year’s Eve (Day) Bubble Wrap Stomp, Socially distance card games, Clean building, Fantastic employees, “Free” Washers/Dryers, House Cleaning, Haiti Mission Project (Plastic Sleeping Mats) to protect from parasites, World Bible School, Wonderful Library, Loves being involved on the Library Committee, Bingo over TV. Application Questions or Case Studies The following case studies were retrieved from the textbook: Touhy, T.A., & Jett, K.F. (2020). Ebersole & Hess' toward healthy aging: Human needs & nursing response (10th ed.). Elsevier. Michael is a 68-year-old male who has been hospitalized for a planned surgical procedure. He had a total knee replacement due to degenerative joint disease. He is about to be discharged home with home health physical therapy. The discharge planner approaches him to discuss his options. He is very concerned about how the services will be paid for because he is living on a fixed income with only his Social Security benefits. His primary insurance is Medicare. 1. Which portion of Medicare covers home health care services? Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) can cover eligible home health care services. Generally, these services are covered under Part B, but if your home health care is part of the care you need after a hospitalization or a stay in a skilled nursing facility, some of the costs might be covered under Part A. 2. What are the criteria for Social Security eligibility in the United States? Age: You can start receiving benefits as early as age 62, but they will be reduced unless you wait until your full retirement age (FRA), which ranges from 66 to 67, depending on your birth year. Work Credits: Similar to retirement benefits, eligibility for disability benefits is based on the number of work credits you have, but the number needed depends on your age when you become disabled. Deceased's Work Credits: The amount of work needed for family members to receive survivors benefits depends on the worker's age at death. The younger a person is, the fewer credits they need for family members to qualify for survivors benefits. However, no one needs more than 40 credits (10 years of work) for their relatives to be eligible. NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide Age/Disability: SSI is a program for people with limited income and resources who are disabled, blind, or age 65 or older. Children with disabilities can also qualify. 3. Discuss the criteria for providing home health services to a Medicare recipient. To receive home health services under Medicare, a recipient must meet specific criteria. These criteria ensure that only those who need these services for their medical care, and who meet Medicare's conditions, can receive them. Doctor’s Certification The recipient must be under the care of a doctor who must certify that the patient needs one or more of the following: Intermittent skilled nursing care (other than just drawing blood) Physical therapy Speech-language pathology services Continued occupational therapy Homebound Status The recipient must be homebound, meaning it’s extremely difficult for them to leave their home because of illness or injury, and their outings are infrequent, of short duration, or to receive medical treatment. Being homebound also includes needing the help of another person or medical equipment (like crutches, walkers, wheelchairs, or canes) to leave home or having a condition such that leaving home is medically contraindicated. Receiving Services from a Medicare-certified Home Health Agency The home health services must be provided by a Medicare-certified home health agency (HHA). Specific Services Covered Medicare covers the following home health services when they meet the above conditions: Part-time or intermittent skilled nursing care. Physical therapy, speech-language pathology, and occupational therapy for as long as your doctor says you need it. Medical social services. Part-time or intermittent home health aide services (personal hands-on care). Injectable osteoporosis drugs for women. Medical supplies (like wound dressings) but not prescription drugs, with some exceptions. What’s Not Covered NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide 24-hour-a-day care at home. Meals delivered to your home. Custodial or personal care (like bathing, dressing, or using the bathroom) when this is the only care you need. 4. Perform a Google search to define Medicare’s “homebound” criteria and definition of “skilled need.” Discuss your findings. Homebound Criteria A patient is considered homebound under Medicare rules if: Leaving the Home Is a Major Effort: The individual has a condition due to an illness or injury that makes leaving the home medically contraindicated or requires the aid of supportive devices (such as crutches, canes, wheelchairs, or walkers), the use of special transportation, or the assistance of another person to leave their place of residence. Absences Are Infrequent or of Short Duration: The patient’s absences from the home are infrequent, of relatively short duration, or are attributable to the need to receive medical treatment. Being homebound means that leaving home is a considerable and taxing effort for the patient. It's important to note that being homebound does not mean the patient is bedridden. Patients can still be considered homebound if they leave the home for short periods for non-medical reasons, such as attending a religious service, without losing their eligibility for home health benefits. Definition of "Skilled Need" A "skilled need" refers to medical services that require the expertise and clinical judgment of licensed professionals, such as registered nurses, licensed practical nurses, physical therapists, speech-language pathologists, and occupational therapists, to be safe and effective. The criteria for a skilled need include: Services Are Medically Necessary: The skilled services must be necessary for the diagnosis or treatment of the patient’s condition. Services Require a Skilled Professional: The care must be such that it can only be safely and effectively performed by, or under the supervision of, professional or technical personnel. Part-Time or Intermittent Care: Skilled nursing care is covered when it is needed on a part-time or intermittent basis. "Part-time" means fewer than 8 hours each day, and "intermittent" refers to care needed or provided on fewer than 7 days per week. An 88-year-old widow with mild dementia lives with her daughter and five grandchildren (ages 2 to 11) in a three-bedroom apartment in a large city. Her daughter is recently widowed and moved in with her mother in order to be able to care for her mother. Her daughter works in two different jobs, and the children are cared for by a neighbor. The daughter brings her mother to the geriatric clinic because she is complaining of back pain and is becoming more confused. When the nurse assists the woman to NURS 3540 – Gerontological Nursing Module 13 Active Learning Guide undress, she notes bruises in various stages of healing on her back, right leg, left shoulder, and forehead. The woman cannot remember how she got the bruises and does not make eye contact when answering the nurse’s questions. The daughter states that her mother tripped and fell down the stairs. She is wearing a soiled dress and smells of urine. Her daughter states that her mother is “getting harder and harder to care for.” 1. Is the woman at risk for elder mistreatment? If so, why? What factors make her at risk? Yes. Bruises in various stages of healing. Woman does not remember how she gained the bruises. Woman is wearing soiled dress and smells of urine. 2. What steps should the nurse take when assessing an older adult for elder mistreatment? Establish Trust and Rapport Perform a Comprehensive Assessment Ask Direct but Sensitive Questions Observe Interactions Document Findings Thoroughly Understand and Follow Reporting Protocols Provide Support and Resources Follow-Up 3. What resources can the nurse offer the woman and her family? Adult Protective Services (APS) National Center on Elder Abuse (NCEA) Eldercare Locator Local Law Enforcement Legal Assistance for the Elderly Support Groups and Counseling Services National Domestic Violence Hotline State Ombudsman Programs