Change in Sites of Care

Discussion: Changes in Sites of Care

Since the culture and practices of care settings are inherently different, changes in sites of care are often difficult for geriatric patients. Efforts should be made to limit changes to only those necessary; however, sometimes a patient’s situation might require multiple changes in sites of care.

When selecting sites of care, such as homes, assisted living, rehabilitation facilities, and hospitals, many factors must be considered by patients, their families, and their health care providers.

Health status, ability to perform self-care, financial limitations, and patient preferences are all factors that might influence a patient’s site placement. As an advanced practice nurse who recommends sites of care and facilitates changes, you must evaluate factors and consider sites that limit the impact of these changes on geriatric patients.

To prepare:
Review this week’s media presentation, as well as Chapters 3 and 8 of the Resnick text.
Reflect on your personal experiences, observations, and/or clinical practices from the last 5 years. Select a case from the last 5 years that involves an elderly patient who has been in two different sites of care such as a home, assisted living, hospital, etc.

Note: When referring to your patient, make sure to use a pseudonym or other false form of identification. This is to ensure the privacy and protection of the patient.
Reflect on issues that occurred because of the change in the patient’s sites of care. Think about the impact of differences in the settings themselves, inherent cultures of the settings, and ethical practices of these sites on the patient.

Consider whether the patient had an advanced directive in place at the time of the change in sites of care. Reflect on whether any difficult treatment decisions had to be made as a result.
Think about the impact of financial issues on on-site placement and treatment decisions.
By Day 3
Post a description of a case from your personal or clinical experiences in the last 5 years that involves an elderly patient who has been in at least two different sites of care. Explain the impact of differences in the settings themselves, an inherent culture of the settings, and ethical practices of these sites on the patient.

Then, explain whether the patient had an advanced directive in place at the time of the change in sites of care, and if so, whether any difficult treatment decisions had to be made as a result. Finally, explain the impact of financial issues on on-site placement and treatment decisions.

SOLUTION

Change in Sites of Care

Frail Elders

In the treatment process, patients often require a change of site, such as from the admission ward to the intensive care unit, depending n the change of the patient’s situation. Different sites have varying cultures regarding the level of care, available interventions, and cost.

The change in elderly patients should only happen when necessary due to factors such as poor financial status due to decreased productivity, availability of family support, ability to perform self-care, and general health status, which are likely to hinder the positive impact of the site change on geriatric patients.

Case Scenario

An 84-year-old African American male presented to the ER with severe shortness of breath, rapid breathing, low blood pressure, confusion, and fatigue. A chest x-ray showed the presence of fluid in both lungs. Based on these factors, the patient was diagnosed with acute respiratory distress syndrome (ARDS).due to the severity of is symptoms; he lost consciousness during diagnosis thus was admitted to the Intensive care unit(IC U).

The care provider performed a tracheostomy procedure that entailed the insertion of a tube into the windpipe to the lungs through a hole made on the neck to help with the breathing due to obstruction of airways by the lung fluid. The patient was then put in ICU for rehabilitation as he awaited full recovery of the lungs.

It entailed oxygen therapy through ventilation support, prone positioning in specialized beds to promote oxygen circulation and medication to promote healing of lung infection, and increase fluid excretion through urination.

Since respiratory rehabilitation is a long-term process, there was a need to transfer the patient from the ICU to a more specialized long-term acute care facility (LTAC) for ventilator management. This is a specialized facility for patients in need of extended hospitalization and specific acute care.

The identified LTAC facility sent a physician to assess the patient for qualifications for LTAC admission. These include; insurance coverage, need for critical care services, and a tracheotomy with respiratory insufficiency. After the physician established the patient had met the criteria, he was transferred to an LTAC facility.

The ICU setting is different from LTAC. ICU provides short term emergency invasive and advanced interventions  such as  respiratory support,  and organ systems support in case of a sudden organ failure; therefore, it is convenient for unstable patients likely to require emergency services, such as those whose specific diagnosis has not been determined  . On the other hand, LTAC provides long term intensive care to already stabilized patients, whose diagnosis has already been established.

Additionally, unlike the ICU that provides a wider variety of general intensive care services, LTAC provides a limited number of intensive services tailored to the individual patient. This is because the services are long-term, thus customizing them achieves better outcomes as they, meet the specific patient’s needs.

After the patient was admitted to the ICU, it was difficult to determine whether he had any legal document spelling his end of life decision because he was barely conscious. However, after consulting with his family members, it was established that he did not have an advanced directive thus was open to all interventions to save his life in case of an emergency. This facilitated a smooth transition from ICU to LTAC because there was no limit to medical interventions.

The transfer had some financial implications for the patient family. For uninsured patients, LTAC facilities are more economical compared to ICU because they receive already diagnosed patients with specific conditions, offer fewer services tailored according to patient needs, thus utilizing resources. However, for Medicare insured patients such as the one in the current scenario, LTAC is expensive than ICU.

Since the patient is beyond 65 years of age, his institutional care in nursing facilities is covered in Medicare part A. his ICU stay period was less than60 days thus he paid deductible 1316 dollars while Medicare paid the rest. Since the LTAC care was long-term, he paid the same value during the first 60days after which he was responsible for 329 dollars for another 60 days if the patient stayed longer than that he was responsible for full payment of costs.

The increased cost is likely to lead to exclusion of some crucial services or early discharge if the family cannot afford the cost anymore .These factors impacts on the healthcare outcomes.

References

Blumenthal, D., Chernof, B., Fulmer, T., Lumpkin, J., & Selberg, J. (2016). Caring for high-need, high-cost patients—an urgent priority. New England Journal of Medicine, 375(10), 909-911.

Bohmer, R. M. (2016). The hard work of health care transformation. New England Journal of Medicine, 375(8), 709-711.

Makam, A. N., Nguyen, O. K., Xuan, L., Miller, M. E., Goodwin, J. S., & Halm, E. A. (2018). Factors associated with variation in long-term acute care hospital vs skilled nursing facility use among hospitalized older adults. JAMA internal medicine, 178(3), 399-405.

Also check: Ways of Knowing in a Nursing Situation