Monday, March 22, 2010

What's Wrong With Nursing Homes

Let’s face it. No one wants to spend their last days in a dreaded nursing home. Institutional care is just that. Institutional! We associate institutional care with places like prisons and hospitals. These facilities are often dehumanizing. They use assembly line techniques to achieve certain efficiencies that benefit the facility; not the patient. Our older patients dread home placement because of loss of independence and loss of dignity. Unfortunately some health care facilities are good at disguising the “institution” with superficial amenities.

It doesn’t have to be this way. The focal point should be the patient. Nursing home costs approach $12,000 per month. You can live in an upscale downtown apartment and enjoy fine dining every day for that amount. Instead patients "spend down" their life savings in facilities to be told what to do and when to do it. If you need to use the bathroom outside your toileting schedule, you are out of luck and you will probably soil yourself. Hope you’re not hungry after dinner is served. Weight loss is a common problem in nursing homes. I remember being called to evaluate a patient for weight loss. I learned the patient was frequently up all night and slept most of the day. Just by offering meals at night (against the staff's objection) the patient gained weight. A medication schedule change fixed the sleep problem. This illustrates the problem. There is no common sense. Care is schedule-based not patient-based. If a baby is crying, most caretakers would check to make sure the baby is not hungry, wet, or sick. In the elderly this common sense approach is bypassed in favor of asking the doctor to prescribe a sedative.

Many facilities subscribe to the patient-centered concept of "cultural transformation" but very few invest the required resources. Why? Because most spending decisions are short-sighted and not clinically based. Facilities are in survival mode and unwilling to venture into a highly regulated environment that discourages innovation. You see, regulators are in survival mode also and they have to justify their existence.

Here’s an example of a change that can be accomplished in one day. It’s called “bathing without a battle”. Many nursing home patients are placed in a plastic chair and rushed into a shower with the same level of compassion as a car driven through a car wash. Patient and their caretakers are quite literally battle weary after this unpleasant experience. “Bathing without a battle” is an effective cleansing technique that employs the use of warm moist towels and massage while the patient is in bed. So why is this not the standard? Short sighted bean counters are concerned about the cost of supplies. In the long run, this expense will effectively increase quality of life for both the patient and the caretaker. Processes like this will make the facility more desirable, increase census, and generate revenue.

There are many more examples that focus on quality indicators such as pressure sores, medication reduction, toileting and effective behavior management. These require an investment in nursing staff and education.

In the same way car manufactures had to re-tool their factories, health care facilities must re-think the status quo. Perhaps if administrators spent a day or two as their patients do, they would develop an enlightened perspective.

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