Chapter 7 and 8 Notes - Summary Ebersole and Hess\' Gerontological Nursing & Healthy Aging PDF

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Late Life Income

Health Care Insurance Plans in Late Life

Chapter 7: Economic and Legal Issues  Social Security- was designed as a pay-as-you-go system; payroll taxes collected from employees and employers are immediately distributed to beneficiaries (retirees, the disabled, eligible spouses, or children)  the revenues are no reserved for any one individual, all funds that are not immediately paid to beneficiaries are “borrowed” by the federal government for regular operating expenses  Supplemental Security Income (SSI)- established in 1965 to provide a minimum level of economic support to older adults and select others  Late Life Income- may come from private retirement investments or employer pensions; monies are held for the beneficiary until such a time when he or she must begin to “withdraw” all or a portion of the money at the age determined by the fund  Medicare- only covers select services and requires that such services are medically necessary; to be eligible, one must be eligible for Social Security o Medicare Part A- an “age entitlement” program that provides insurance to eligible beneficiaries regardless of their personal financial status; a plan covering acute hospital care, short-term acute rehabilitative care, and costs associated with hospice and home health care under certain circumstances o Medicare Part B  Original Medicare Part B plan- the patient is responsible for a monthly premium (usually deducted directly from the monthly Social Security check), an annual deductible, and co-pays  Alternative Plans o Medicare Part C (Medicare Advantage Plans or

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MAP)- privately managed care plans similar to what we know as health maintenance organizations (HMOs) and preferred provider organizations (PPOs); replaces both Medicare Part A and Medicare part B  Alternatives to Medicare Part C- Private Fee-For-Service Medical Savings Account- the federal government makes monthly payments directly into the person’s own private savings account and when health services are obtained, the individual pays for them directly o Medicare Part D- an optional prescription coverage plan; must enroll within the same 6 months of initial Medicare eligibility to prevent paying penalties and waiting until next open enrollment Supplemental Insurance/Medigap Policies- a monthly premium is paid and in exchange all or part of the co-pays and deductibles not covered by the “primary insurance” are paid Medicaid- a form of insurance for the elderly, the disabled, and children with very low incomes Indian Health Services (HIS)- a federal health program for and with American Indians and Alaskan Natives Care for Veterans o TRICARE for Life (TFL)- the health care insurance program provided by the Department of Defense; it is available for active duty and retired military/uniformed service personnel and their dependents o Veterans Aid and Dependence- for those who served in a war zone and receive a military pension, there is additional monetary support available to them if they

need assistance with daily personal needs  Long-Term Care Insurance (LTCI)- these policies cover the expenses related to co-pays both for nursing home and home care and for what is called custodial care, which helps with activities of daily living (ADLs) Legal Issues in Gerontological Nursing  Decision-Making- the provider has a responsibility to inform the individual of the decision needed and the individual has the right and responsibility to make his or her decisions  Decisional Capacity- a person is able to understand a problem, the risks and benefits of a decision the alternative options, and the consequences of the decision  Capacity- presumed when the legal age of “adult” is reached  Advance Care Planning- wishes regarding potential incapacity  Power of Attorney (POA)- a legal document in which one person designates another person to act on his or her behalf  Health Care Proxy- a “hierarchy” of those who have the authority to act on a person’s behalf when capacity has been either temporarily or permanently lost and preferences have not been documented or expressed in advance  Guardians and Conservators- individuals, agencies, or corporations that have been appointed by the court to have care, custody, and control of a disabled person (ward) and manage his or her personal or financial (or both) when the person had been found (adjudicated) to lack capacity o Guardians- the person appointed to be responsible for the ward o Conservator- appointed specifically to control the finances of the ward Chapter 8: Assessment and Documentation for Optimal Care The Assessment Process Health assessment- the collection of physical data and the integration pf spiritual and psychosocial factors within an individual’s cultural context

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The Health History

Physical Assessment

It is never appropriate to address the patient by the first name unless invited to do so 3 approaches used for collecting assessment data: 1. Self-report 2. Report-by-proxy 3. Observation  Conduct the assessment at a time when the patient is at his or her best  If a standard tool is being used, be sure it is used correctly  To avoid biasing the response, do not direct the way the question will be answered  Attempt to obtain additional information only if it is needed to complete the assessment  Approach questions that are more personal (such as sexual functioning) in a matter-of-fact, but nonetheless sensitive, manner  Record the responses accurately, using the patient’s own words whenever possible; do not analyze at the same time data are being collected  Best collected either verbally in a face-to-face interview or using the interview to review a written history completed by the patient or by the patient’s trusted proxy beforehand  LEARN Model is highly recommended to complement the health history  The assessment is directed to that which is most likely associated with the presenting problem or major diagnoses and progresses from there  Comprehensive Physical Assessment of the Frail and Medically Complex Elder o FANCAPES  F- Fluids  Current state of hydration  Capacity to consume adequate

fluids  A- Aeration  Pulmonary function (aeration) and cardiovascular function are assessed simultaneously  Measurement of the oxygen saturation rate  N- Nutrition  Type and amount of food consumed  Ability to bite, chew, and swallow  Oral health status  Dentures fit properly?  Special diet recommended?  Can the person afford special foods needed?  Aspiration precautions  C- Communication  Ability to communicate needs  Do the persons who provide care understand the patient’s form of communication?  Person’s ability to hear in various environments  Is vision adequate for lip-reading?  Does the person have expressive or receptive aphasia?  A- Activity  Participation in enjoyable activities  Risk for falls  P- Pain  Physical, psychological, or

spiritual pain? Ability to express pain or relief of pain  Cultural barriers that make the assessment or expression of pain difficult  Cognitive limitations  E- Elimination  Difficulties with bowel and bladder functioning  Incontinence?  Lack of control?  Personal hygiene?  Are assistive devices accessible and functioning? (high-rise toilet seat, bedside commode)  S- Socialization and Social Skills  Ability to negotiate in society  Ability to give and receive love and friendship  Ability to feel self-worth Cognitive Measures o Mini-Mental State Examination (MMSE)- used to screen and monitor orientation, short-term memory and attention, calculation ability, and ability to correctly copy a figure o Clock Drawing Test- has been found to be useful across cultures and languages and is a sensitive instrument to differentiate among those with and without some level of dementia; second in frequency of use to the MMSE  Ask the person to:  Place the numbers 1-12 inside the 

Assessment of Mental Status

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circle as for a clock. Place the hands so that the clock reads 10 minutes after 4.  Scoring:  Draws a closed circle = 1 point  Places numbers in correct position= 1 point  Includes all 12 correct numbers= 1 point  Places hands in correct position= 1 point o The Mini-Cog- a screening tool for cognitive impairment that has replaced the MMSE  Tell the person you are going to name 3 objects and ask the person to repeat the objects after you and remember them (max 3 tries)  Administer the clock drawing test.  Ask the person to repeat the objects back to you.  Give 1 point for each recalled word. 2 points for a normal clock, and 0 points for an abnormal clock.  Scoring:  0 recall  indication of dementia  0-2 recall  indication of dementia  3-5 recall  no indication of dementia o The Global Deterioration Scale- a classic measure of the levels of cognitive changes as one passes through the process of dementia 

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Stage 1: no cognitive decline (no dementia) Stage 2: very mild cognitive decline (no dementia) Stage 3: mild cognitive decline (no dementia) Stage 4: moderate cognitive decline (early stage) Stage 5: moderately severe cognitive decline (midstage) Stage 6: severe cognitive decline (middle dementia) (midstage) Stage 7: very severe cognitive decline (late dementia) (late stage)

Mood Measures o Geriatric Depression Scale- used to determine depression because it deemphasizes physical complaints, sex drive, and appetite- those things most affected by medications  Are you basically satisfied with your life?  Have you dropped many of your activities and interests?*  Do you feel that your life is empty?*  Do you often get bored? *  Are you in good spirits most of the time?*  Are you afraid that something bad is going to happen to you?*  Do you feel happy most of the time?  Do you often feel helpless?*  Do you prefer to stay at home, rather than going out and doing new things?*  Do you feel you have more problems with memory than most?*

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Functional Assessment

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Do you think it is a wonderful time to be alive?  Do you feel pretty worthless about the way you are now?*  Do you feel full of energy?  Do you feel that your situation is hopeless?*  Do you think that most people are better off than you?*  Each answer indicated by * counts as 1 point; scores greater than 5 indicate need for further evaluation Activities of Daily Living (ADLs)- the Katz Index  the ability to complete the task independently (1 point) or the complete inability to do so (0 points); the tool is useful because it creates a common language about patient function for all caregivers involved in planning overall care o Barthel Index (BI)- a quick and reliable instrument for the assessment of both mobility and the ability to perform ADLs  Bathing  Dressing  Using the toilet  Transferring oneself  Feeding oneself  Controlling bowel and bladder function (continence) o Functional Independence Measure (FIM)- designed to asses a person’s need for assistance with ADLs during inpatient stays and for discharge planning (especially after stroke) o Instrumental Activities of Daily Living (IADLs)- use

Comprehensive Geriatric Assessments

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Documentation for Quality Care

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the self-report, report-by-proxy, and observed formats with three levels of functioning (independent, assisted, and unable to perform) The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ)- the areas evaluated include social and economic resources, mental and physical health, and ADLs; the person’s functional capacity in each area is rated on a scale of 1 (excellent functioning) to 6 (totally impaired functioning) Fulmer SPICES- assessment tool of older adults focusing on geriatric syndromes o Sleep disorders o Problems eating or feeding o Incontinence o Confusion o Evidence of falls o Skin breakdown Resident Assessment Instrument (RAI)/Minimum Data Set (MDS 3.0) o Resident Assessment Instrument (RAI)- was created and mandated for use in all skilled nursing facilities that receive compensation from either Medicare or Medicaid o Minimum Data Set (MDS 3.0)- the basis for the assessment within the RAI Outcome and Assessment Information Set (OASIS-C1)the assessment is very comprehensive and focuses on the development of interventions to prevent hospitalization and ensure safety in the home setting Documentation in Acute Care and Acute Rehabilitation Care Settings- electronic medical record (EMR) Documentation in Long-Term Care Facilities- usually written but slowly transitioning to electronic medical

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records (EMR) Documentation in Home Care- will often develop documentation systems of their own to track appointments, medication administration, and health care provider instructions Documentation and Reimbursement- when care is covered by Medicare, Medicaid, or another insurer the reimbursement in all settings is based on the assessment and the documentation of care...