Long term care

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Long term care

Long term care is the system of activities undertaken by informal caregivers (family, friends, and/or neighbours) and/or professionals (health, social, and others) to ensure that a person who is not capable of self care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest degree of independence, autonomy, participation, personal fulfilment and human dignity . Long term care is source of anxiety for many and a political ‘hot potato’. The number of older persons in long term care is growing 15-20% per year.

Residential Care

Residential care is the response of society to what could be considered a normative life process. Eventually, some older persons will need help with personal care and/or household activities, especially in the presence of multiple disabling diseases. Residential care could be considered as the means by which the needs of older persons are met to compensate for age related functional impairments. It covers a spectrum of care on a continuum from housing and social support to 24 hr medical care.

Level of residential or long term care will depend on health status and level of care required:
• retirement village (no care provided)
• with other family members
• ‘live in’ help or external help in own home (home health care)
• private hostels/assisted living facilities (no nursing care, but assistance with domiciliary activities) (sometimes called ‘residential assisted living’ – RAL)
• aged care facility – various levels of care (eg high, medium, low level)

Can also be:
• respite care (temporary residential care to give relief to caregiver)
• short term post acute residential care for rehabilitation

Thrust of community based care is to keep the elderly at home as long as possible – assumed to be better off psychologically and socially in own home – may be better off financially as well. About 5% of those >65yrs live in residential care - 20% of those over 85yrs. The incidence rate of institutional care doubles for each 5 year interval from the age of 60 years . Other than age, other risk factors for being admitted to a long term care facility are living alone, inability to self care, impaired mental status, lack of social supports, lower income and being female.

The decision to institutionalise an elderly parent or relative  potential for a number of conflicts. Health professionals need to respect the individuals wish to stay in their own home, even if it is believed not to be in their best interests. This can be a difficult time for the older person, their family and friends. Well meaning family members may also be insisting that they move into residential care – this at times can be more detrimental than helpful.

Some of the reasons for staying in their own home can be compelling and include :
older people may feel that by giving up their home, they are giving up their freedom and independence
they may feel emotionally attached to a home that holds years of cherished memories
they may like the neighbourhood and not want to leave friends
they may want to maintain a large house for when family and friends visit
many people either do not like or are even fearful of change

Reasons for needing residential care:
behaviour problems associated with dementia
incontinence
inability to self toilet or transfer
falls
pressure lesions
failure to rehabilitate to self care after stroke
inability of caregivers to cope

Services provided by long term care facilities:
medical and nursing care with access to other services (eg ophthalmologic, podiatric, psychiatric)
higher level facilities may provide IV therapy, enteral nutrition support, ventilator support etc; also there may be special units to accommodate those with, for example, HIV or Alzheimer’s disease
physical, occupational and speech therapy; social workers
recreational programs (eg leisure time activities, outings etc)
personal services (eg hairdressing, make up)

Eliopoulous (1998) developed a nursing model of residents needs based on a hierarchy from hygiene to holism to healing:
• Hygiene – restoration and/or stabilisation of physical and mental health; treatment of medical conditions; assurance of safety of human and physical environment; satisfaction of physiological needs
• Holism – exercise of individual rights; ownership of maximum possible responsibility for self care; prevention of avoidable decline and dysfunction; connection with community within and outside facility; attainment of mind, body, and spirit
• Healing – establishment of meaningful, purposeful life; self discovery through use of illness as an opportunity to seek growth and purpose; spiritual awareness and growth; achievement of peak potential of biopsychosocialspiritual functioning or peaceful dying

News media reports often paint pictures of neglect, unsafe facilities, cost cutting, understaffing etc. The response of governmental/regulatory agencies to quality of care in facilities is regulation, usually in the form of accreditation. The purpose of accreditation of facilities is to ensure a certain standard of care. Gaining accreditation will be dependant on the quality of personal care; the safety of the facilities; have staffing numbers and qualifications are appropriate to the level/status of the mix of residents; and documented care plans and procedures/policies.

A primary issue that is often highlighted is the need to and how to maintain a quality of life in residential care facilities/ Many facilities will have a bill of rights, or something similar, for residents. For example, Meshinsky (1991):
• Every resident shall be treated with respect and full recognition of her dignity and individuality
• Every resident, prior to or at the time of admission, shall receive a written statement of the provided services at the facility and those that require extra charges
• Every resident shall receive complete and current information concerning her health and medical condition, in terms she can understand, from her physician, unless the physician decides that informing the patient is medically contraindicated. She will participate in he planning of this treatment or may refuse medication and treatment
• Every resident shall be given privacy and respect during treatment and care of personal needs
• Every resident's medical record shall be treated in confidence and the written consent of the resident or family shall be obtained to release the records to any individual not otherwise authorised to receive it, except as needed in the case of the resident's transfer to another health facility or as required by law or third party payment contract.
• Every resident shall be free from mental and physical abuse and free from chemical and physical restraints except as authorised by a physician
• Every resident shall be encouraged to submit complaints and recommendations concerning the nursing home policies and services to the staff or outside representatives or the resident's choice, or both. Such complaints shall be submitted free from restraint, coercion, discrimination or reprisal.
• Every resident shall be informed of the relationship of this nursing home to any other health care facility insofar as the resident's care is concerned.
• Every resident shall be free to associate with persons and groups of her choice unless this infringes upon another resident's rights.
• Every resident shall be assured of sending and receiving unopened personal mail
• Every resident shall have the right to manage her financial affairs and may inspect her accounts an statements
• Every resident shall have the right to retain her personal possessions and clothing as space permits.
• Every resident shall have the right to remain in the facility and shall note be transferred or discharged, nor have her treatment altered radically, without prior consultation with the resident or, if the resident is incompetent, without prior notification of the next of kin or sponsor.
• Every married couple shall be afforded the right to privacy during their visits and, if both are residents of the facility, shall be offered the opportunity to share a room, unless medically contraindicated.
• Every resident shall the have the opportunity to perform services for her own benefit and not for the sole benefit of the facility.
• the administrator shall be responsible for the implementation of all the resident's rights
• The facility shall train the staff in the implementation of the residents' rights.

Aged Care Sector Code of Conduct and Ethical Practice for Commonwealth Residential and Community Care Services Provided under The Aged Care Act 1997 (Australia) Extracts:
“Human values and human rights which stem from respect for the inherent dignity of the human individual, and which are at stake in the provision of aged care services, include:
i) the rights of the individual to life, liberty, and security
ii) the right of individuals to have their religious and cultural identity respected
iii) the right to self determination of competent individuals
iv) the right to a reasonable standard of care appropriate to individual needs
v) the right to privacy and confidentiality
vi) the recognition that human beings are social beings with social needs, including the rights of married couples to live a married life
vii) the freedom to hold opinions and to express them having regard to the common good of all”

“4.5 Attending Professionals
The Code recognises the professional responsibility of each attending professional in aged care facilities to be cognisant of, and adhere to, his or her professional Codes of Ethics or Practice. The Code does not seek to replace those professional Codes but rather desires to enhance them within the relationships specific to aged care facilities.

Subject to the above, approved providers will ensure that each attending professional who provides temporary or sessional work in the facility adhere to The Code by:

4.5.1 Care Recipients – Personal
i. treating care recipients with courtesy and respect
ii. assuring care recipients that their independence will be encourage and respected
iii. providing the standard of medical consultation and level of attention and interaction, appropriate to the individual needs of care recipients
iv. using his or her skills and knowledge to administer care to current best practice, and within his or her levels of expertise and qualifications
v. maintaining a standard of care appropriate to the needs of care recipients, including being available for follow up, in order to optimise health and well being
4.5.2 Care recipients – Environment
i. respecting the rights of care recipients, their families or guardians, other staff, and the provider, to personal, religious, moral, cultural, and social opinions an beliefs; and
ii. undertaking all care, processes, and tasks in a manner that respects the privacy and confidentiality of clients, families, and other staff members
4.5.3 Approved Providers and Staff
i. ensuring adequate communication with salaried staff which will result in adequate documentation of care provided
ii. adhering to all the ethical and other protocols which the attending professional has negotiated with the approved provider
iii. working collaboratively and courteously with salaried staff, to achieve the best outcomes for recipients of aged care services.”

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