Assisted living- what happens when patients need more care?

[lexilou]

Help- new to hospice and don't know how to approach this subject. I have a patient who is in assisted living and is falling much. We provided temporary continuous care til facility and family could provide back-up plan for safety. Family sits with patient for a few hours a day and then facility does hourly checks. Any other suggestions? Patient remains at a risk for falls and I don't know that this plan is enough.

[soapynurse@adel]

We had several ALF's who used our services. We did not provide continuous care unless symptoms were out of control. Luckily, over time, the staff became very well educated and appreciated our help. This was especially good because they followed our protocol and the patient was allowed to stay in familiar surroundings. Family members often chose to stay with the patient, often around the clock. Luckily, this worked out very well for all concerned.

Alice in VA

[Micheal shawn]

This is because the patient need proper care and proper attention...

There are some assisted living centers or the independent living centers where they admit the patients but the treatment that is being offered there is not satisfactory or u can say that they do provide certain treatment for a time but after that time they leave the patient or the old aged one at his own.......

[tewdles, RN]

Most hospices can only provide continuous care for exacerbation of symptoms although some are large enough to provide CC for those actively dying. The hospice my mother used in Florida offered CC to our family when she was imminent, we declined.

There are areas where there are no LTC/SNF beds and there are no inpatient hospice beds. I work in a territory where all LTC/SNF beds are full and there is a waiting list. ALL of our patients who are not in their private homes are in ALF. They remain there when they become unresponsive and require total care. Communication is the largest part of our plan. The ALF staff need to know when to call, when you will come, what you will do, what they can and can't do. We need to know if they have access to a nurse for prn meds...some do...or if the family will stay to provide meds.

In hospice, we assess for fall risk, help the family and facility create a plan to prevent falls, and then document the crap out of the success.

[curiousauntie]

I think it has been said already, but CC is for out of control symptoms. And should end once the symptoms are under control. My company will do CC, but we have to show symptoms that are not controlled and show changes in meds/interventions to get them under control. Falls are not a symptom. Falls are almost expected with weakness, worsening dementia and progression of disease. The ALF should have a policy about increasing falls/safety even if it is to say that the family must provide a 1:1 (either the family themselves or hire a companion) to provide the supervision the patient needs. In my state, the big thing for many years was "Aging in place", meaning if they were in an ALF, they should stay there til death, with increases in level of care toward total care as needed. We rarely will try to get a family to transfer a patient to LTC from and ALF unless absolutely necessary...makes for unhappy referral sources!:bowingpur

[GinaDecorRN]

The ALF I researched here in Missouri require that residents be alert/ oriented and sharp cognitively so that they can describe where the closest emergency exits are and ambulatory enough to get themselves to the exits during a fire drill. This was practiced to prepare for state inspections. Walkers were allowed but not wheelchairs. Occasional incontinence allowed but residents were expected to be able to toilet themselves. Indwelling foleys not allowed. Meals were taken in a common dining room, not in your room and residents fed themselves. The facility my mom was in had only med techs there in the evening / night shifts, with an LPN (the director) on call for emergencies. They did not have an RN on staff! This was strictly private pay and ran around $3500 / month. This was much less than the LTC faciluity which ran $5000 / month private pay but had Medicaid beds for when you had "spent down" and qualified.

[DSkelton711]

Yes when a patient gets worse they should be moved to a LTC. However, when I worked at assisted living they always allowed the "private pay" patients to stay at the assisted living even if they were violent or totally unable to care for themselves.

Ooh big no-no. Can't remain in ALF if combative or unable to care for themselves. Against state regs. Now in the case of needing help with ADLs or more skilled care--if the resident is expected to improve within 90 days and there is someone to provide the care--might get to stay. However if this is a decline or something needing care you cannot provide or expected to last longer than 90 days then they are to be discharged to a higher level of care. No way would I work in that ALF.

[DSkelton711]

I am an RN who heads a rather large ALF and SCALF. I follow the regs when unsure of something. Even if it means the resident decides to move somewhere else. If I have a resident who is constantly falling we put in interventions, but if it persists then they must move to LTC. They must be able to self-transfer. Long ago Hospice provided more CC services but now only for imminent death. By CC I mean round the clock care. We do allow sitters but if falls or weight loss or other problems become unmanageable the they are transferred to LTC. It is for safety and also to keep us safe against lawsuits and such. We are a little different in that we have LPNs on the unit with the CNAs. Most residents do not want to move which I can understand, but if they are not surviving well or are unsafe I have no hesitation to send them to LTC, where many end up doing much better. I do have to add that our LtC is a very good one.

[DSkelton711]

Also, in my state, ALF and SCALF do not require licensed or certification to staff. Praise the Lord my facility decides to operate above that.

[tothepointeLVN, LVN]

I find sometimes the ALF will promise things of hospice that hospice can't reasonable deliver like continious care for a non immnient patient for more than a few days because then it takes the onus off them. Most ALF's are great but some I have found when the CC nurses stop checking on the patient at all. I don't mind doing my job but the ALF is still being paid and should provide the same level of support. It's more comfortable for the patient when there is an assist with turned and ADL's and in the home the family usually helps.

[DSkelton711]

I will input but only what I know for my facility. We have 43 residents. 2 CNAs do the care and the LPN does the meds. In assisted living our resident must be able to transfer and ambulate without excessive falls. They must be able to go to meals in the dining room. They must be able to toilet themselves. If they have a low mini-mental or mental health issues that put them at risk for self-care or are agitated or combative--they cannot be admitted nor can they stay. We transfer to LTC or SCALF depending on situation. When this originally posted, CC was offered by many hospices. This is no longer the case. Only in immenent death is that allowed by Medicare now (at least where I am at). Also, ALF and SCALF in my state DO NOT require licensed or certified caregivers so if you have someone who needs a lot of care--well, those people may not can properly care for them as they may not know how. Each ALF is different, though. Oh, and if you have a resident on ALF who needs turning--they are in the wrong place. They need to be in LTC.

[DSkelton711]

"[ALL of our patients who are not in their private homes are in ALF. They remain there when they become unresponsive and require total care."

Unless death is imminent or there is a round the clock person and they are expected to die, this is completely wrong for ALF and may be against regulation. I feel bad when a resident must move from ALF but my license will not be in jeopardy by not following regs. If you don't know ALF regs then you should read them so there will be no problems when state comes to survey. Each state is different and usually you can go to a website to look at the regs.

[SuesquatchRN, BSN, RN]

Continuous care never met fulfulling the job of a sitter. It's for crisis/EOL.