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The nursing home today
the • nursing
home
today
by Roy J. McDonald
N
ursing home's across the length and breadth of this land are caught up in a socio-economic revolution that is having its effects on all engaged in the health care field. The revolution is particularly dynamic in the nursing home field. Although a relative newcomer to the health care field, nursing homes are playing a major role in the long-term care of the aged, the convalescent and the chronically ill. That role is going to be expanded. Not only are nursing homes themselves changing rapidly in character, there is also a tremendous building boom underway. The newer homes, as one would anticipate, are providing a much wider range of services and are decidedly larger than the older and smaller homes that, more often than not, are converted dwellings. As late as 1950, only five states had nursing home licensing laws. Today, of course, all states have such laws although some admittedly are inadequate. Between 1954 and 1961, the Public Health Service reported the number of skilled nursing home beds had nearly doubled to 362,000. A survey made in mid-1965 by the American Nursing Home Association disclosed that state licensing agencies reported nearly 600,000 licensed nursing home beds in the country. In California alone, the number increased some 134 percent be-
tween 1961 and 1964 and the boom there is still going strong. Much of the impetus for the construction boom came with the enactmen t of the Kerr-Mills (Medical Assistance for the Aged) program at the start of this decade. Expansion of this program under the Social Security Amendments of 1965 and the anticipated implementation of medicare nursing home benefits next January 1 are providing the incentive for continued construction. Admittedly nursing homes have grown like Topsy. And in the minds of many, the name nursing home still conjures up the image of the aged, dingy-looking converted dwelling. In defense of the early days of nursing homes and custodial homes-most of which provided a goodly amount of affectionate and personal concern for their guests-I would point out that they were a lot better than the publicly operated county poor farms, the alms houses and the insane asylums where many of the more unfortunate aged spent their declining years. To put matters in perspective, I might add that it has not been many years since hospitals were considered "butcher shops," a "point of no return," a "port of last call." And to many patients in nursing homes today, a proposed trip to the hospital is considered a last journey. Erasing the old image of the nursing
pharmaceutical services in nursing homes-APhA slide-talk 3.
The typical nursing home patient is about 80 years old with several chronic illnesses and receives at least three different medications. Some receive as many as 12. Two out of three patients have cardiovascular disease and one in four is senile to some degree.
4.
The pharmacist must share his special knowledge with other health professionals on the nursing home staff. There is a critical need for the professional service that only he can provide, such as personalized services, convalescent aids and appliances for the patient.
Vo l. NS6, No.5, May 1966
239
home is a difficult task for today's modern nursing home. The modern nursing home-be it a contemporary building or a converted structure-is light and airy, cheerful in decor. It places an emphasis not only upon good nursing care and good dietary care but also upon programs of recreation, rehabilitation and occupational therapy that will restore to the patient his own maximum functions of body and mind. Today's modern nursing home is not a place for the dying-nor is it a place for the well. Statistically we have learned that half of the patients in nursing homes are 80 (not 65) years of age or older. Seventy-seven percent of those 65 and over in nursing homes and 83 percent of those 75 and over are suffering from one or more chronic illnesses. Two out of three suffer from cardiovascular diseases, one in four have some degree of senility. About half in a recent California study had periods of incontinence and more than half suffered from periods of disorien ta tion. That same California survey disproved the thesis that a nursing home is the end of the line. A third were returned to their own homes and another third were either discharged to hospitals or other facilities. The new emphasis on restoration, rehabilitation and remotivation has brought about drastic changes in the
design and staffing of nursing homes. Today's nursing home patient-unlike the patient in a hospital who is there for treatment of a particular illness or injury-requires all-around treatment. The nursing home not only must provide for the patient's nursing care and physical, recreational and occupational therapy, but it must tend also to his religious needs. It must work with his family and, most importantly, it must be aware of the individual patient's capacity for rehabilitation. ANHA survey
In 1965, the American Nursing Home Association conducted a survey of its then 4,600 members (now in excess of 5,100) with the financial and professional assistance of the Smith Kline and French Laboratories. Despite its fourpage length, the survey drew a 35 percent return from ANHA members. Eighty-eight percent were proprietary homes, 10 percent were nonprofit and the remainder were governmental. Sixty-two percent were staffed aroundthe-dock by registered nurses or licensed practical nurses while the remainder provided a lower level of nursing care. The occupancy level was about 90 percent. While about one-third reported they were affiliated with one or more hospitals, only about one-fourth of these affiliations were formalized in writing. Only four percent of the homes re-
ported pharmacies within the facility, although about eight percent of the intensive care homes provided such a service on the premises. drug storage policies
Abou t two-thirds of all homes reported they had written policies covering the storage and administration of drugs. Forty-one percent reported they kept drugs in a locked medicine cabinet; 20 percent kept them in a locked cabinet with individual patient trays; 16 percent in a locked cabinet with a separate locked narcotic cabinet; 10 percent in a locked cabinet on the nursing station and four percent in a locked cabinet in the medicine room. Two percent reported no drugs were stored. The survey indicated that only 29 percent of the homes maintained an inventory of drugs that might be required for future use (other than individual patients' drugs). Nine percent of the intensive care homes said they employed a pharmacist on either a full- or part-time basis. Most of the homes obtain their drugs from a community pharmacy-61 percent mentioned only a pharmacy; 17 percent said a pharmacy designated by the nursing home; nine percent reported from a pharmacy named by the patient's family and six percent claimed from a pharmacy designated by physicians. In most cases- 56 percent- nursing
pharmaceutical services in nursing homes- APhA slide-talk
5.
In some homes patients are allowed to administer their own medication. This can be a serious hazard, especially for an older person with poor vision who may be confused. In one recent study a single patient was taking 22 different drug products. The extended care facility standards prohibit self-medication except for emergency drugs ordered by the physician.
240
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
6.
Adequate medication control can eliminate the hazards of overdosage or improper use. 1111edications prescribed for one patient must not be administered to any other. Nursing stations should maintain the items needed for proper administration. jll[edication cards should be used and checked against physician's orders. Pharmacists can help set up systems of control of medications.
homes said the pharmacy billed the patient directly. Sixteen percent said the pharmacy billed the home and the home billed the patient while 11 percent said the home billed the patientfamily. Thirty-eight percent of all patients in all levels of homes were reported completely ambulatory; 40 percent were either confined to bed and chair or were completely bedridden. Of all homes, 55 percent had organized recreation programs, but only about one-fourth had physical therapy and occupational therapy programs. The percentages, of course, were decidedly higher for intensive care homes. patient's costs According to this survey, only 37 percen t of the pa tien ts depended in whole, or in part, on personal or family funds for their care. Forty-four percent received some form of public assistance other than VA or Social Security checks. About one-half paid $150 to $250 a month for their care and 20 percent paid in excess of $300 a month. Of patients in intensive care facilities 29 percent paid $300 or more a month and 45 percent paid from $200 to $299 a month. Of full-time employees in the homes, two out of three were actually engaged in providing nursing services to patients. These statistics give a better picture of just what a nursing home is and does.
classification problem One of the major problems for many years has been classifying nursing homes and their patients for the name nursing home has come to cover a broad gamut of levels of care from custodial homes to intensive care homes that are almost "junior hospitals" in character. One of the salutary effects of the medicare law probably will be a more definitive breakdown of nursing homes. Because of the high standards being required for participating homes under the program we probably are going to see cost of care rise considerably. A recent observation of the American Hospital Association's council on longterm care points this up rather indirectly as it predicted acceleration of the development of hospital-based long-term care units because of "the assurance of adequate financing for post acute care" under the medicare program. For years, the American Nursing Home Association and many others knowledgeable in the field of long-term care have pointed out that the existence of substandard nursing homes has been encouraged by the failure of the states to provide payments to nursing homes to assure adequate care. The fact is that, in many cases, states have actually placed welfare patients in substandard homes to keep the cost of their care at a low level. There is no question in our minds that provision
Serving his second term as president of the 5,142-member American Nursing Home Association, Roy J. McDonald has been extremely active on the national scene during the passage of medicare legislation and the promulgation of regulations covering nursing homes. Prior to becoming president, he served two years as vice president of the national organization which represents some 225,000 nursing home beds in both proprietary and nonprofit facilities. A resident of Colfax, Washington, he has been active in the nursing home profession for more than a decade and is a former president of the Washington State Nursing Home Association. He is a graduate of Wash· ington State University where he majored in bacteriology and public health.
pharmaceutical services in nursing homes-APhA slide-talk 7.
Inservice training for the professional staff of nursing homes is an important responsibility for the consultant pharmacist. Nursing supervisors want him to offer pharmacology and metrology instructions to the staff. Before any inservice training program begins the pharmacist should observe procedures used to administer drugs in the home.
8.
Complete pharmaceutical service includes proper physical facilities, medication control, storage procedures, record keeping, inservice training and drug information. Nursing home administrators need these services, recognize their value and are willing to pay for them. Pharmacists should not be hesitant to charge appropriate fees for them.
Vol. NS6, No.5, May 1966
241
of adequate funds will lead to improved patient care all along the line. The American Nursing Home Association long has been in the forefront of the fight to improve patient care. It was for this reason that we established and co-sponsored with the American Medical Association the first accreditation program for nursing homes. That program, early this year, was merged in to a new accredi ta tion program administered by the Joint Commission on Accreditation of Hospitals. medicare program
We in the nursing home field are working closely with our members and with federal and state agencies involved to make the medicare program operate successfully. We have certain misgivings about the law as it now stands. We fear it contains a built-in inflationary factor that will lead to costly overutilization of hospitals. For example, the law provides 60 days of free hospital care and only 20 days of free nursing home care before a patient, or his family, or the state has to pick up a portion of the daily cost. What incentive does this provide for the family physician to move his patients from costly hospital beds into nursing home beds where the cost to the government may be only onethird or one-fourth the cost of hospital care?
Because Congress failed to provide for nursing home benefits until January 1, 1967, six months after hospital benefits become available July 1, we fear that many private pay patients and even state-supported patients will be tranferred from good nursing homes into more costly hospital beds during the early months of the program. Finally we have a very deep concern for the future of nursing homes because of the failure of Congress to provide for equal treatment of hospitals and nursing homes under the Title XIX program (extension of KerrMills). Both facilities will get "reasonable cost" reimbursement under the medicare program, but this was allowed only for hospitals under the Title XIX program. This could mean that some nursing homes will gear up for the medicare program, traveling a "high road" while others go a "low road" of providing care for welfare and medically indigent patients.
been becoming increasingly costly over the years since World W ar II-spells a brigh t future for the nursing home field. Because of the ability of this type of facility to provide adequate rehabilitation and remotivation programs for the convalescent at much lower rates than hospitals are forced to charge, we anticipate increased use of nursing home facilities not only for the care of the aged, but for all age groups. Average nursing home stays-now about a year-will become shorter, admissions and discharges will rise sharply and the median age of the nursing home pa tien t will drop substantially . •
nursing home economics Nursing homes, in effect, are caught in an economic pincer. Federal authorities are pushing the states to force medicare standards on all facilities receiving state funds, but they have failed to provide the assurance that reimbursement will be provided to meet these relatively high standards. Despite these problems, the simple economics of health care- which has
Two recent publications are "basic books" for the pharmacist interested in serving nursing homes. The 1966 revision of "Pharmaceutical Services in the Nursing Home" may be obtained from the American Pharmaceutical Association, 2215 Constitution Avenue N.W., Washington, D.C. 20037, without charge. The Ohio State University college of pharmacy publication, "Pharmaceutical Services for Nursing Homes," summarizing the December 1965 conference can be obtained from the college of pharmacy, 1958 Neil Avenue, Columbus, Ohio 43210 at $2 per copy.
pharmaceutical services in nursing homes-APhA slide-talk 9.
Agreements between nursing homes and pharmacists should be clearly stated in writing. All of the services that the consultant pharmacist will provide should be indicated and procedures for dispensing and administering drugs should be stressed. Surveys indicate that at present nursing homes do not have written agreements with pharmacists but they also show a definite need for them.
242
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
10.
Groups that arrange showings of the film strip will receive a supply of the revised guidebook "Pharmaceutical Services in the Nursing Home ." The guidebook discusses each topic considered in the film strip and includes additional information and sample forms. Write to APhA Academy of General Practice of Pharmacy, 2215 Constitution Avenue N. W. -, Washington, D. C. 20037.
home
today
by Roy J. McDonald
N
ursing home's across the length and breadth of this land are caught up in a socio-economic revolution that is having its effects on all engaged in the health care field. The revolution is particularly dynamic in the nursing home field. Although a relative newcomer to the health care field, nursing homes are playing a major role in the long-term care of the aged, the convalescent and the chronically ill. That role is going to be expanded. Not only are nursing homes themselves changing rapidly in character, there is also a tremendous building boom underway. The newer homes, as one would anticipate, are providing a much wider range of services and are decidedly larger than the older and smaller homes that, more often than not, are converted dwellings. As late as 1950, only five states had nursing home licensing laws. Today, of course, all states have such laws although some admittedly are inadequate. Between 1954 and 1961, the Public Health Service reported the number of skilled nursing home beds had nearly doubled to 362,000. A survey made in mid-1965 by the American Nursing Home Association disclosed that state licensing agencies reported nearly 600,000 licensed nursing home beds in the country. In California alone, the number increased some 134 percent be-
tween 1961 and 1964 and the boom there is still going strong. Much of the impetus for the construction boom came with the enactmen t of the Kerr-Mills (Medical Assistance for the Aged) program at the start of this decade. Expansion of this program under the Social Security Amendments of 1965 and the anticipated implementation of medicare nursing home benefits next January 1 are providing the incentive for continued construction. Admittedly nursing homes have grown like Topsy. And in the minds of many, the name nursing home still conjures up the image of the aged, dingy-looking converted dwelling. In defense of the early days of nursing homes and custodial homes-most of which provided a goodly amount of affectionate and personal concern for their guests-I would point out that they were a lot better than the publicly operated county poor farms, the alms houses and the insane asylums where many of the more unfortunate aged spent their declining years. To put matters in perspective, I might add that it has not been many years since hospitals were considered "butcher shops," a "point of no return," a "port of last call." And to many patients in nursing homes today, a proposed trip to the hospital is considered a last journey. Erasing the old image of the nursing
pharmaceutical services in nursing homes-APhA slide-talk 3.
The typical nursing home patient is about 80 years old with several chronic illnesses and receives at least three different medications. Some receive as many as 12. Two out of three patients have cardiovascular disease and one in four is senile to some degree.
4.
The pharmacist must share his special knowledge with other health professionals on the nursing home staff. There is a critical need for the professional service that only he can provide, such as personalized services, convalescent aids and appliances for the patient.
Vo l. NS6, No.5, May 1966
239
home is a difficult task for today's modern nursing home. The modern nursing home-be it a contemporary building or a converted structure-is light and airy, cheerful in decor. It places an emphasis not only upon good nursing care and good dietary care but also upon programs of recreation, rehabilitation and occupational therapy that will restore to the patient his own maximum functions of body and mind. Today's modern nursing home is not a place for the dying-nor is it a place for the well. Statistically we have learned that half of the patients in nursing homes are 80 (not 65) years of age or older. Seventy-seven percent of those 65 and over in nursing homes and 83 percent of those 75 and over are suffering from one or more chronic illnesses. Two out of three suffer from cardiovascular diseases, one in four have some degree of senility. About half in a recent California study had periods of incontinence and more than half suffered from periods of disorien ta tion. That same California survey disproved the thesis that a nursing home is the end of the line. A third were returned to their own homes and another third were either discharged to hospitals or other facilities. The new emphasis on restoration, rehabilitation and remotivation has brought about drastic changes in the
design and staffing of nursing homes. Today's nursing home patient-unlike the patient in a hospital who is there for treatment of a particular illness or injury-requires all-around treatment. The nursing home not only must provide for the patient's nursing care and physical, recreational and occupational therapy, but it must tend also to his religious needs. It must work with his family and, most importantly, it must be aware of the individual patient's capacity for rehabilitation. ANHA survey
In 1965, the American Nursing Home Association conducted a survey of its then 4,600 members (now in excess of 5,100) with the financial and professional assistance of the Smith Kline and French Laboratories. Despite its fourpage length, the survey drew a 35 percent return from ANHA members. Eighty-eight percent were proprietary homes, 10 percent were nonprofit and the remainder were governmental. Sixty-two percent were staffed aroundthe-dock by registered nurses or licensed practical nurses while the remainder provided a lower level of nursing care. The occupancy level was about 90 percent. While about one-third reported they were affiliated with one or more hospitals, only about one-fourth of these affiliations were formalized in writing. Only four percent of the homes re-
ported pharmacies within the facility, although about eight percent of the intensive care homes provided such a service on the premises. drug storage policies
Abou t two-thirds of all homes reported they had written policies covering the storage and administration of drugs. Forty-one percent reported they kept drugs in a locked medicine cabinet; 20 percent kept them in a locked cabinet with individual patient trays; 16 percent in a locked cabinet with a separate locked narcotic cabinet; 10 percent in a locked cabinet on the nursing station and four percent in a locked cabinet in the medicine room. Two percent reported no drugs were stored. The survey indicated that only 29 percent of the homes maintained an inventory of drugs that might be required for future use (other than individual patients' drugs). Nine percent of the intensive care homes said they employed a pharmacist on either a full- or part-time basis. Most of the homes obtain their drugs from a community pharmacy-61 percent mentioned only a pharmacy; 17 percent said a pharmacy designated by the nursing home; nine percent reported from a pharmacy named by the patient's family and six percent claimed from a pharmacy designated by physicians. In most cases- 56 percent- nursing
pharmaceutical services in nursing homes- APhA slide-talk
5.
In some homes patients are allowed to administer their own medication. This can be a serious hazard, especially for an older person with poor vision who may be confused. In one recent study a single patient was taking 22 different drug products. The extended care facility standards prohibit self-medication except for emergency drugs ordered by the physician.
240
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
6.
Adequate medication control can eliminate the hazards of overdosage or improper use. 1111edications prescribed for one patient must not be administered to any other. Nursing stations should maintain the items needed for proper administration. jll[edication cards should be used and checked against physician's orders. Pharmacists can help set up systems of control of medications.
homes said the pharmacy billed the patient directly. Sixteen percent said the pharmacy billed the home and the home billed the patient while 11 percent said the home billed the patientfamily. Thirty-eight percent of all patients in all levels of homes were reported completely ambulatory; 40 percent were either confined to bed and chair or were completely bedridden. Of all homes, 55 percent had organized recreation programs, but only about one-fourth had physical therapy and occupational therapy programs. The percentages, of course, were decidedly higher for intensive care homes. patient's costs According to this survey, only 37 percen t of the pa tien ts depended in whole, or in part, on personal or family funds for their care. Forty-four percent received some form of public assistance other than VA or Social Security checks. About one-half paid $150 to $250 a month for their care and 20 percent paid in excess of $300 a month. Of patients in intensive care facilities 29 percent paid $300 or more a month and 45 percent paid from $200 to $299 a month. Of full-time employees in the homes, two out of three were actually engaged in providing nursing services to patients. These statistics give a better picture of just what a nursing home is and does.
classification problem One of the major problems for many years has been classifying nursing homes and their patients for the name nursing home has come to cover a broad gamut of levels of care from custodial homes to intensive care homes that are almost "junior hospitals" in character. One of the salutary effects of the medicare law probably will be a more definitive breakdown of nursing homes. Because of the high standards being required for participating homes under the program we probably are going to see cost of care rise considerably. A recent observation of the American Hospital Association's council on longterm care points this up rather indirectly as it predicted acceleration of the development of hospital-based long-term care units because of "the assurance of adequate financing for post acute care" under the medicare program. For years, the American Nursing Home Association and many others knowledgeable in the field of long-term care have pointed out that the existence of substandard nursing homes has been encouraged by the failure of the states to provide payments to nursing homes to assure adequate care. The fact is that, in many cases, states have actually placed welfare patients in substandard homes to keep the cost of their care at a low level. There is no question in our minds that provision
Serving his second term as president of the 5,142-member American Nursing Home Association, Roy J. McDonald has been extremely active on the national scene during the passage of medicare legislation and the promulgation of regulations covering nursing homes. Prior to becoming president, he served two years as vice president of the national organization which represents some 225,000 nursing home beds in both proprietary and nonprofit facilities. A resident of Colfax, Washington, he has been active in the nursing home profession for more than a decade and is a former president of the Washington State Nursing Home Association. He is a graduate of Wash· ington State University where he majored in bacteriology and public health.
pharmaceutical services in nursing homes-APhA slide-talk 7.
Inservice training for the professional staff of nursing homes is an important responsibility for the consultant pharmacist. Nursing supervisors want him to offer pharmacology and metrology instructions to the staff. Before any inservice training program begins the pharmacist should observe procedures used to administer drugs in the home.
8.
Complete pharmaceutical service includes proper physical facilities, medication control, storage procedures, record keeping, inservice training and drug information. Nursing home administrators need these services, recognize their value and are willing to pay for them. Pharmacists should not be hesitant to charge appropriate fees for them.
Vol. NS6, No.5, May 1966
241
of adequate funds will lead to improved patient care all along the line. The American Nursing Home Association long has been in the forefront of the fight to improve patient care. It was for this reason that we established and co-sponsored with the American Medical Association the first accreditation program for nursing homes. That program, early this year, was merged in to a new accredi ta tion program administered by the Joint Commission on Accreditation of Hospitals. medicare program
We in the nursing home field are working closely with our members and with federal and state agencies involved to make the medicare program operate successfully. We have certain misgivings about the law as it now stands. We fear it contains a built-in inflationary factor that will lead to costly overutilization of hospitals. For example, the law provides 60 days of free hospital care and only 20 days of free nursing home care before a patient, or his family, or the state has to pick up a portion of the daily cost. What incentive does this provide for the family physician to move his patients from costly hospital beds into nursing home beds where the cost to the government may be only onethird or one-fourth the cost of hospital care?
Because Congress failed to provide for nursing home benefits until January 1, 1967, six months after hospital benefits become available July 1, we fear that many private pay patients and even state-supported patients will be tranferred from good nursing homes into more costly hospital beds during the early months of the program. Finally we have a very deep concern for the future of nursing homes because of the failure of Congress to provide for equal treatment of hospitals and nursing homes under the Title XIX program (extension of KerrMills). Both facilities will get "reasonable cost" reimbursement under the medicare program, but this was allowed only for hospitals under the Title XIX program. This could mean that some nursing homes will gear up for the medicare program, traveling a "high road" while others go a "low road" of providing care for welfare and medically indigent patients.
been becoming increasingly costly over the years since World W ar II-spells a brigh t future for the nursing home field. Because of the ability of this type of facility to provide adequate rehabilitation and remotivation programs for the convalescent at much lower rates than hospitals are forced to charge, we anticipate increased use of nursing home facilities not only for the care of the aged, but for all age groups. Average nursing home stays-now about a year-will become shorter, admissions and discharges will rise sharply and the median age of the nursing home pa tien t will drop substantially . •
nursing home economics Nursing homes, in effect, are caught in an economic pincer. Federal authorities are pushing the states to force medicare standards on all facilities receiving state funds, but they have failed to provide the assurance that reimbursement will be provided to meet these relatively high standards. Despite these problems, the simple economics of health care- which has
Two recent publications are "basic books" for the pharmacist interested in serving nursing homes. The 1966 revision of "Pharmaceutical Services in the Nursing Home" may be obtained from the American Pharmaceutical Association, 2215 Constitution Avenue N.W., Washington, D.C. 20037, without charge. The Ohio State University college of pharmacy publication, "Pharmaceutical Services for Nursing Homes," summarizing the December 1965 conference can be obtained from the college of pharmacy, 1958 Neil Avenue, Columbus, Ohio 43210 at $2 per copy.
pharmaceutical services in nursing homes-APhA slide-talk 9.
Agreements between nursing homes and pharmacists should be clearly stated in writing. All of the services that the consultant pharmacist will provide should be indicated and procedures for dispensing and administering drugs should be stressed. Surveys indicate that at present nursing homes do not have written agreements with pharmacists but they also show a definite need for them.
242
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
10.
Groups that arrange showings of the film strip will receive a supply of the revised guidebook "Pharmaceutical Services in the Nursing Home ." The guidebook discusses each topic considered in the film strip and includes additional information and sample forms. Write to APhA Academy of General Practice of Pharmacy, 2215 Constitution Avenue N. W. -, Washington, D. C. 20037.