Nursing homes: The new frontier

Back in the day, nursing homes were primarily for those too ill to be at home or who had no family. This was also before such a thing as same-day surgery and when hospital stays were measured in weeks, not hours. A patient undergoing surgery checked into the hospital the night before and expected to stay until completely well. After discharge, it was not unusual for the physician to stop by the house to check on the patient (think Marcus Welby).

All this has changed in the last 30 years. Today, same-day surgery is the norm; in-hospital patients are often cared for by a hospitalist, and patients are discharged sicker and quicker.

This has created a new role for nursing homes, longterm care facilities, skilled nursing facilities, and assisted living. So when the media trumpeted the news that the Census Bureau Report showed the U.S. nursing home population over age 65 decreased 20% from 2000 to 2010,¹ there was justifiable skepticism.¹ This fact which made headlines demonstrated the old adage about statistics: "There are lies, damn lies, and statistics."

The reported decrease in numbers of traditional nursing home patients failed to take into account the sharp increase in residents living in assisted living, along with an increase in home-based residents using paid and unpaid caregivers. While this was included in the report, it was often omitted in the attention-grabbing headlines.

The baby boom generation, those born between 1946-1964, began turning 65 in 2011. This generation represents close to 30% of the US population. This was the generation who flooded the elementary schools and is being blamed for depleting Medicare funds and is now on the precipice of flooding long term care.

Declining kidney function part of the picture

The population is aging and kidney function declines with age. There is a concurrent rise in diabetes and hypertension, the evil twins of chronic kidney disease risk factors. It does not take a crystal ball to see the incidence of CKD will rise; data from the U.S. Renal Data System have been telling us that for years.

Just as CKD is often undiagnosed in the general population, it is often unrecognized in nursing home residents. Furthermore, there are a significant number of people living in assisted living facilities and senior housing who are not part of the national statistics when estimating CKD incidence in the > 65 age group.²

McClellan et al. surveyed 82 nursing homes across the U.S. in geographical distribution. Of 794 residents, 50% were identified as having CKD (GFR < 60 ml/min/m2). The majority (86%) were stage 3a or 3b with the remaining 14% as stages 4-5 (not on dialysis).

Some of the findings were not unsuspected: as kidney function declined, the number of comorbidities increased. For those who did not have CKD, the incidence of five co morbidities in each patient was 57%. In the CKD population, the number of patients with >5 co-morbidities was 87%, or a 30% jump.³ CKD is often undiagnosed and under appreciated in the general population both in the community and in facilities.

This provides an area where advanced practitioners (APs) can make a positive contribution. While there are many opportunities for the AP to intervene, education of the patients and staff is first and foremost. Data from the Medicare Kidney Disease Education (KDE) Classes (2010-2011) show an increase in the incidence of classes taught in skilled nursing facilities, nursing facilities, and home classes (see Figure 1). As the CMS codes allow identification of the provider teaching the classes, one can note that APs are teaching a number of the home classes (see Figure 2). As noted in the data, classes in nursing homes (both skilled and long-term) increased from 0 in 2010 to 14 in 2011. That said, there are obviously ample opportunities to increase the number of KDE classes in both the skilled nursing home and the long-term nursing home sites. The number of classes taught at home (not those about home care but instead those taught in the home) had increased 100-fold from 48 classes in 2010 to 483 classes in 2011, with 31% of those classes taught by APs. ⁴

Medicare allows for six hours of KDE in a lifetime for Medicare beneficiaries with Stage 4 CKD. The requirement is that the session be 31 minutes in length, including topics like the normal aging of the kidney and options for renal replacement, including medical management. A post test is also required which can be as simple as asking the patient a question to determine understanding and making this part of the note or as elaborate as a written post-class quiz. As many nursing home and/or homebound patients have significant functional issues, many practitioners are using the teach back method Q&A as the basis to test comprehension.

The KDE visit is billed at G0420 and 12 can be billed in addition to the E/M visit on the same day. CMS has determined that after two hours of KDE, comprehension decreases. Thus the number of KDE classes that can be billed per day is two.

Managing dialysis patients in a nursing home

Caring for dialysis patients living in nursing homes is particularly challenging. Transportation is often an issue. It is usually the responsibility of the nursing home social worker to arrange transportation.

One frequent issue is when the patient needs more than a round trip in a day. Some insurance carriers will only pay for one round trip for, example, if an access intervention is required and the appointment is on a dialysis day. The Office of the Inspector General (OIG) has identified dialysis ambulance transport as one the cost centers they are targeting in 2015.⁵

The OIG noted that there had been a 269% increase in the use of ambulance transport for dialysis patients from 2002-2013.⁶ This was one of the largest increases in utilization and thus brought to the front and center of the OIG.

Medications and medication schedules are another challenge for the nursing home patient, especially coordination of binders with meals. Breakfast is served, then medications are distributed and the time may not coincide with the meal. Individualized meal plans are nearly non-existent.

In addition to salt being on the table, vending machines are often readily available. The nursing home dietitian usually covers multiple sites and it may be difficult to track down the AP on the day of his/her visit or call. Often the dietitian from the dialysis centers (for those patients on dialysis and not being medically managed) can assist in coordinating diet in long term care centers.

Many facilities pass out morning medications at 8:00 am or 9:00 am when the first shift patient is in dialysis. The AP often has to work with the management of the facility to tailor medication times to patient schedules. It is a good practice to review medication administration records (MARs) monthly and after every hospital discharge. Often dialysis patients are discharged from the hospital with an order for an ESA or another inappropriate medication. In addition, poly-pharmacy seems to be the rule and not the exception. APs who are accustomed to seeing hospital patients often have to make adjustments to a new normal. Even the lag time seen in the outpatient dialysis centers can seem speedy by comparison to those from nursing homes. Lab orders are not done STAT. It may take several days before results can be reviewed. Routine lab orders vary by institution. A phlebotomist may have issues with drawing blood on the typical dialysis patients with few useable veins. Change is often slow and when placing an order, it is a good idea to follow up to make sure it is being done. Weights and vitals are not always reliable.

The long-term care facilities don't generally try to use dialysis catheters, which is a plus. However, some facilities have to be reminded to remove the access dressing. Some practitioners have developed standing orders which are sent to the facility when the patient begins dialysis treatment.

Summary

As the population continues to age, we will see a larger percentage of end stage CKD patients in nursing homes, both skilled and long-term facilities. This is a fragile population and will take buy-in from all practitioners to care for them. Even with the dietitian to manage a complicated and detailed menu, the social worker to manage the transportation and multiple issues with equipment, the therapy staff to protect against loss of ADLs, the recreational therapist to protect against loss of cognitive function and the medical staff (APs, nursing, physicians), this population will continue to present both challenges and opportunities. -by Jane davis, DNP, CRNP; Kim Zuber, PA-C

References

Kim, SH. U.S. nursing home population decreased 20%. Census Bureau Reports. McKnights. July 1. 2014.

Hall RK, OHare AM, Anderson RA. ESRD in nursing homes. JAmMed Oir Assoc. 2013; 14: 241-241)

McClellan WM, Resnick B, Lei L, et al. Prevalence and severity of chronic kidney disease and anemia in the nursing home population . J Am Med Oir Assoc. 2010;11: 33-41.

Zuber K, Davis J. Kidney disease education: A niche for PAs and NPs JAAPA. 2013; 26: 42-47.

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