Nursing Care in Residential Board & Care Facilities

Nursing Care in Residential Board & Care Facilities

National Fire Protection Association

Dave Kyllo [email protected]

mailto:[email protected]

• Assessments

• Service/care planning

• Medication Management

• Oversee health promotion and disease prevention programs

• Care that optimizes resident function

• Determine cognitive abilities and end of life preferences

• Staff development/training

Source: Assisted Living Nursing -- Resnick/Mitty

Role of Assisted Living Nurses

U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities

• 31,100 facilities

• 971,900 licensed beds

• 733,200 residents

• 19% of residents covered by Medicaid

• 43% of facilities with at least one resident receiving Medicaid LTC services

http://www.cdc.gov/nchs/data/databriefs/db78.htm

Federal Assisted Living Study – Key Findings


While about half of facilities are small, most residents live in larger communities.


Federal Assisted Living Study – Facility Size

Facility Size Percentage of Residents

Extra Large (100+ beds) 29%

Large (26-100 beds) 52%

Medium (11-25 beds) 9%

Small (4-10 beds) 10%


Residential care facility beds per 1,000 persons aged 85 and over, by region


Regional Variation

Region Beds/1,000 persons 85+

West 245

South 164

Midwest 177

Northeast 131

Total: United States 177

2010 National Survey of Residential Care Facilities

Percent of facilities offering selected services, and residents using them

Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living

• Average Age = 86.9

• Average Age at Move-in = 84.6

• 73.6% Female; 26.4% Male

• Average Income = $27,260

• Average Assets (including home) = $431,020

• Median Income = $18,972

• Median Assets (including home) = $205,000

Assisted Living Residents

2010 National Survey of Residential Care Facilities Data National Center for Health Statistics

Hypertension 56.7% Alzheimer’s/Dementia 41.8% Diabetes 17.2% Coronary Heart Disease 13.2% Congestive Heart Failure 13.2% Heart Attack 4.2% Other Heart Condition 14.4% Stroke 10.9% Cancer 10.7%

Health Conditions


Osteoporosis 20.4% Arthritis 25.1% Depression 27.4% Serious Mental Problems 7.6% Intellectual Disability 3.3% Asthma 4.2% Chronic Bronchitis 2.0% COPD 10.8%

Health Conditions


MS/Parkinson’s 7.7% Anemia 9.6% Macular Degeneration 5.9% Glaucoma 6.3% Gastro Intestinal 7.5% Kidney Disease 5.7% Traumatic Brain Injury 1.5% Blind/both eyes 3.4%

Health Conditions


Dentures 39.4% Glasses/Contacts 9.6% Hearing Aids 18.6% Cane 12.9% Walker 45.9% Kidney Disease 5.7% Wheel Chair 22.9% Scooter/Electric Wheel Chair 5.3% Oxygen 7.6%

Assistive Devices

ADL ALF NF

• Bathing 72% 96%

• Dressing 52% 90%

• Toileting 35% 86%

• Transfer 13% 83%

• Eating 22% 54%

(NCHS 2010 Res. Care Survey & 2011 CMS NF Data)

ADL Dependence

• 48.7% experience confusion

• 46% experienced difficulty with short term memory in the last 7 days

• 28% experienced difficulty with long term memory in the last 7 days

• 18% could not find apartment

• 21% could not recognize staff names & faces

• 15% don’t know they are in a facility

• 22% don’t know what season it is Source: NSRC 2010 Survey

Residents’ Cognitive Abilities

• 19.9 % bowel incontinent in last 7 days

• 36.6% urinary incontinent in last 7 days

• 77.1% need help with medications

• 37% receive help with 3+ADLs

• 24% admitted to a hospital in last 12 months

• 35% treated in hospital ED in last 12 months

• 14% fell in last 12 months resulting in injuries other than hip fractures

Other Health Related Characteristics

Length of Stay

0-3 Months

3-6 Months

6 months to 1 year

1 to 3 years

3 to 5 years

5+ years Source: NCRC 2010 Survey

Assisted Living Length of Stay

% of Residents

9.2%

9.2%

14.2%

36.2%

16.0%

15.2%

Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living

Nursing home 59%

Home 9%

Another ALF 11%

Relative’s home 5%

Hospital (other than short term) 7%

Independent living 4%

Hospice 2%

Other 4%

One-third (33%) of residents die in the assisted living setting.

Residents Moving Out

• National Center for Health Statistics also reconfiguring how Feds will collect data on paid, regulated LTC providers:

Nursing Homes Home Health Care Residential Care (including assisted living) Adult Day Care Hospice

• Biennial collection of ALF data will include:

Provider Services Provider Staffing Provider Practices (e.g. ,transitioning or PCC) User Characteristics (e.g., % needing ADL assistance)

Major Changes in Federal LTC Data Collection

• In 2011, at least 16 states made AL legislative/regulatory changes.

• GA, SD, NV, & NC made extensive changes.

• Focal points of change include: Staff education/training, Disclosure, Fire safety, Infection control/TB testing, Discharge/transfer between care sites.

• Other areas of change: Move-in/move-out requirements, Medication management, Physical plant.

Source: NCAL 2012 State Regulatory Review

State Regulatory Trends

In 2011, GA joined states adding second level of licensure (e.g., PA did so in 2010)

• GA facilities with 25+ beds now can opt for licensure as either Personal Care Home or Assisted Living Community.

• While the two categories share many common requirements, Assisted Living Community standards are more stringent or vary in a number of areas including disclosure, required services, admission thresholds, resident assessment, medication management, physical plant, staffing, staff training, and fire safety.

2012 NCAL State Regulatory Review - available at: www.ncal.org


SD overhauled its rules for Assisted Living Centers

• Skilled care must be delivered by a Medicare-certified home health agency or facility nursing staff for a limited time with a planned end date.

• Defines conditions for provision of hospice care.

• Updates fire safety standards for 2009 edition of NFPA Life Safety Code.

• Other areas of change: food service, occupant protection, infection control and prevention, TB screening, resident assessment, drug disposal, and architectural features.

2012 NCAL State Regulatory Review


Six states added to education/training requirements.

• WA: most new direct care workers (now called “long-term care workers”) must now take 75 hours of training within 120 days of hire and become certified home care aides.

North Carolina law allows reduced frequency of facility inspections based on quality ratings.

• Those with highest rating (4 stars) can be inspected every two years instead of annually.

Many state agencies dealing with limited resources, personnel changes.



Increased focus on transition between care sites

• NJ, e.g., mandated use of Universal Transfer Form to make sure accurate clinical care information is conveyed during transfer.

AL Medicaid changes:

• New CO rules aim to ensure that HCBS settings are home-like and integrated into the community.

• Mandatory use of managed care in NJ.

• RI substantially cut in state supplements to SSI (and many states made Medicaid rate cuts).


State Regulatory/Medicaid Trends

States shifting from cuts to restructuring:

• 11 states plan to implement Medicaid managed care, joining 12 with existing Medicaid managed care programs.

• Many shifting away from institutional settings -- 27 report HCB census up from FY 2010 to FY 2011, and 31 expect increases from FY 2011 to FY 2012.

• At least 28 states are focusing on improved integration of care for dual eligibles.

AARP : “On the Verge: The Transformation of Long-Term Services and Supports”: http://www.aarp.org/health/health-care-reform/info-02-2012/On-the-Verge-The-Transformation-of-Long-Term-Services-and-Supports-AARP-ppi-ltc.html.

State LTSS Strategies

http://www.aarp.org/health/health-care-reform/info-02-2012/On-the-Verge-The-Transformation-of-Long-Term-Services-and-Supports-AARP-ppi-ltc.html




































Source: CMS Percentage of LTSS Spending for HCBS Usinig FFY 2009 Data)“

Home & Community-based Services (HCBS) as a % of Medicaid LTC Spending

Percent HCBS

New Mex. 83.2%

Oregon 72.3%

Nebraska 38.4%

Iowa 38.4%

Miss. 14.4%

• Higher acuity in every setting

• More tele-health & remote monitoring

• More meals on demand & fast food

• More nursing involvement – reducing re-hospitalizations is critical to the future

• A completely different outlook on aging by residents both physically and emotionally

• Many unknown changes yet to come as Boomers increasingly shape senior care

The Future…

Nursing Care in Residential Board & Care Facilities

Documents