NURSING HOMES

One of the most dentally underserved populations in the USA is the nursing home (NH) population. Some have suggested that NH residents are invisible to the dental profession. Often among the most physically and cognitively impaired individuals in the healthcare system, dental needs are not met or are overlooked for a number of reasons. This area is addressed in greater detail in Chapter 19. Our chapter will describe the different types of long-term care facilities and how to work with many aspects of providing oral health services in long-term care facilities, including contracts and affiliation agreements, medical records, dental records, billing systems, advanced directives, and treatment delivery options, among other important topics.

Although the number of Americans over the age of 65 has increased dramatically over the past decade by 5.4 million or 15.3% (US Department of Health and Human Services, 2014), a relatively small percentage of those persons (4.1%) reside in an institutional setting such as a NH at any given time. However, recent projections indicate that the number of Americans needing long-term care will double between 2000 and 2050 (CDC, 2009). As a result, consumers along with their families, legislators, healthcare providers, and other interested parties will require current and accurate information in order to plan a continuum of health care that gives consideration to the best possible oral healthcare delivery system for each person.

Definitions

The healthcare needs of the aging population vary considerably, as does the location that these needs are provided. Described below are the different types of facilities that are available to provide care to the elderly or debilitated.

Assisted living facility

A residence that provides services but emphasizes the residents’ privacy and choice. Housing may consist of an apartment or a room with locking doors and bathrooms. Resident units often contain a full kitchen. Most assisted living facilities (ALFs) provide breakfast and dinner to all residents; some provide all three meals. Personal care services are available on a 24-hours-a-day basis. Care services include some assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) such as shopping, house cleaning, or laundry. However, it does not include nursing services such as the administration of medication. ALFs emphasize independence and generally provide less intensive care than that delivered in a NH. Some residents may elect to hire aides to assist them. The cost structure for ALFs varies widely; some require a large buy-in fee (several hundred thousand dollars and above) as well as ongoing monthly fees (several thousand dollars). Typically, this option is a choice for older adults who sell their homes and have financial resources available. Other ALF models require a substantial monthly fee but no buy-in. ALFs may be independent or part of a continuing care community (CCC or “triple-C”), where residents may “age in place” – staying at the same community, but transitioning from independent living to assisted living to skilled nursing care facilities as their health needs change.

Intermediate care facility

An intermediate care facility (ICF) is a NH that provides health-related care and services to individuals who do not require acute or skilled nursing care and is recognized under the Medicaid program for reimbursement. Specific requirements vary by state and are subject to different regulations and coverage requirements than for institutions that do not provide health-related care and services.

Long-term care

Long-term care (LTC) is defined as a range of medical and/or social services designed to help people who have disabilities or chronic care needs. Services may be short- or long-term and may be provided in a person’s home, in the community, or in residential facilities (e.g., NHs or ALFs).

Nursing home

A nursing home (NH) is a facility licensed by the state to offer residents personal care as well as skilled nursing care on a 24-hours-a-day basis. In addition to nursing care and personal care, the NH provides room and board, supervision, medication, therapies, and rehabilitation. Rooms are often shared, and communal dining is common.

Skilled nursing facility

A skilled nursing facility (SNF) is a NH that is certified by Medicare to provide 24-hour nursing care and rehabilitation services in addition to other medical services.

Contracts and affiliation agreements

In 1987. President Ronald Reagan signed into law the first major revision of the federal standards for NH care since the creation of both Medicare and Medicaid in 1965 (known as OBRA ‘87). This revision is known as Federal Regulation 42 CFR 483. This legislation changed the public’s expectations of NHs and the care provided. Since 1987, any NH or SNF that establishes eligibility for Medicare or Medicaid funding must provide services so that each resident can “attain and maintain her highest practical physical, mental, and psychosocial well-being” (Turnham, 1987). The dental service specifications of 42 CFR 483 are outlined as follows:

• Both skilled nursing facilities (SNF) and nursing facilities (NF) must provide the following dental services (US National Archives and Records Administration, 2012):
  1. Provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident.
  2. The Medicare resident may be charged an additional fee for routine and emergency dental services.
  3. The facility must if necessary, assist the resident:
     1. in making appointments; and
     2. arranging for transportation to and from the dentist’s office; and
  4. Promptly refer residents with lost or damaged dentures to a dentist.

Nursing homes that receive Medicare or Medicaid reimbursement are required by law to perform and record an oral examination as part of a comprehensive physical exam done for each new resident admission. This examination is part of a Minimum Data Set that must be completed within 14 days of a resident being admitted to a facility, and then must be done on an annual basis (Schwartz, 2002).

To comply with the above regulations, LTC facilities will seek to have an affiliation agreement, or contract, with a dental group or single providers to provide the dental services for their residents. According to the CDC’s The National Nursing Home Survey: 2004, many services provided to NH residents are delivered through formal contracts with outside providers (CDC, 2009). Of all facilities who provide oral and dental services for their residents, 62.5% are provided by outside groups (CDC, 2009). When creating such an agreement or contract, the dental group or provider should meet with the facility’s chief executive officer (CEO), director of nursing (DON), director of social work (DSW), chief financial officer (CFO), and legal counsel. In most instances the provider will need to apply for and receive medical staff privileges by completing a packet of required documentation.

All of the important issues should be addressed prior to signing the affiliation agreement such as expectations of both parties, compensation, billing, space, equipment, supplies, schedule, and access to charting systems.

Record keeping

Medical charts

All NH facilities must maintain a comprehensive medical chart on every patient that is admitted into the facility. The medical chart may be an electronic health record (EHR) or a paper chart. The paper chart is usually maintained in a binder and kept in the nurses’ station of each floor or ward. If the chart is electronic, computer terminals are usually accessible in the nurses’ stations or in an area specifically for providers. The purpose of the chart is to provide the nursing staff with a medical and daily care plan for each resident and to record every event that occurs over the course of the day for each resident. Although different facilities may utilize different versions of the chart, the basic information is the same. In each chart you will find the following information.

Patient information or ‘face” sheet (Fig. 17.1)

Occasionally a photograph of the resident may be included on the inside front cover of the hard chart or in front of the “face” sheet.

The “face” sheet is usually the first page of the chart and multiple copies of it may also be present. This “face” sheet is very important as it provides all of the billing information needed including home address, social security number, Medicare or Medicaid number, and type of insurance coverage for the patient, if any. It may also include a snapshot of the patient’s medical diagnoses and whether or not they have advanced directives. It is duplicated so that the consultant may take a copy for their records.

Advanced directives section

Advanced directives are legal documents that provide a way for people to communicate to family, friends, and healthcare providers their wishes should they not be able to make healthcare choices for themselves. Advanced directives typically involve the election of a healthcare proxy via a document called a durable power of attorney for health care. This proxy (the person elected to hold this responsibility) will make healthcare decisions for the patient. It is expected that the healthcare proxy will have had conversations with the person for whom they have been appointed to determine that person’s wishes in the event critical health issues occur and the person is not able to direct care decisions themselves.

Also included in advanced directives is a living will. A living will expresses the person’s view about efforts to sustain their life. The person can accept or refuse medical care and specify certain conditions including:

• The use of dialysis and breathing machines.
• A desire to not be resuscitated if breathing or heartbeat stops. This is known as a DNR (Do Not Resuscitate) order. (The person can also direct that they do want to be resuscitated.)
• Whether the person wants tube-feeding to sustain life.
• Whether the person wants to be an organ or tissue donor.

Before a healthcare practitioner may provide any form of treatment, it is necessary to determine whether the patient is their own guardian and is capable of making their own healthcare decisions (i.e., whether they have been determined to be competent). If they have selected a healthcare proxy, then that individual must give their consent in order for the patient to be seen. On occasion, a NH resident may be capable of making their own healthcare choices but may have a family member or friend handling their finances. It is important to discuss the fees for dental care with that individual as well in order to prevent future misunderstandings.

History and physical section

As stated earlier, upon each and every admission to a NH the admitting physician is required to perform and document a comprehensive medical history and physical. In this section, the providing oral healthcare practitioner can review the patient’s medical history, review of systems, medications, and treatment plan for care. This information is critical to know before any oral health care is provided.

Progress notes

In this section of the chart every practitioner who has an encounter with the patient or resident must enter what has been done in that visit. It is important to include the date, time, and treating service at the top of the note. The note should follow the SOAP (Subjective, Objective, Assessment and Plan) format. Clearly defining and recording the next step in the dental treatment plan is very helpful to the facility in assisting the provider with the next visit. It may be useful to include a statement of general disposition of the patient at the end of treatment such as “the patient left the dental area in stable condition.”

Doctors’ orders section

Upon admission to a NH, the facility assumes responsibility for the total care of the NH resident. Similar to a hospital admission medication lists, nursing requirements, diet, vital signs, activities, and bathing must be planned and ordered by the appropriate healthcare provider for the resident. The doctor’s order section is where all of the orders for each patient are recorded. This is also where the oral healthcare provider will write orders for medication needed in the treatment of dental disease.

In most charts, a medication list compiled and printed by the pharmacy will follow the doctors’ order section. Typically each month a new medication list will be generated.

Consult section (Fig. 17.2)

The dental team will often be asked to consult on a resident for a specific reason such as pain, swelling, or malodor. When this occurs, the oral health practitioner should complete a consultation form. These forms are either in the chart or available at the nurses’ station and may be in duplicate or triplicate form. The top section of the form should provide the reason for consult and the medical history. The portion for the consultant to complete should include the findings upon examination of the resident expressed in the SOAP format. The original usually remains in the chart and the consultant takes one copy for their records.

Laboratory result section

In this section all recent laboratory results may be found. This section should be c/>