Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions.

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.

Advance directives: older adults with dementia.

The benefits and risks for older adults with dementia executing advance directives are discussed. Salient issues related to decision-specific capacity and models for advance planning and end-of-life decisions by cognitively impaired older adults are presented.

Role of nursing in long-term care.

Nursing services are an essential component of long-term care, whether it is based in the community and home or traditional nursing facilities. The author reviews the various demands of each type of care in terms of nursing education and specific skills as well as resident characteristics, survey findings, and staffing recommendations. Innovative nursing models in long-term care and areas for future research are also addressed.

The nurse as advocate. Issues in LTC.

Patients and residents of nursing homes need advocates; otherwise they tend to fall through the cracks, says Mitty. What are the issues and the barricades to good and equitable care?

Resource utilization groups. DRGs move to long-term care.

The costs associated with a growing population of elderly persons in the United States combined with a need to restrain escalating acute care costs led to the development of a prospective payment system (PPS) for institutional long-term care in New York State. Although similar types of PPS exist in several other states, it is expected that RUGs will become the model for the nation. The price paid is based on a formula that combines the direct care components of care with allocated medical and ancillary costs per patient. Based on a patient classification case-mix system, the Resource Utilization Group (RUG) relies on specific nursing documentation of patient care delivered, that is, resource used. Implemented at the same time as diagnostic-related groups (DRGs), the RUGs system is not based on length of stay, diagnosis, or age. Activities of daily living (ADL) drive the system and, in that sense, RUGs has some similarities to severity of illness models. There are 16 RUGs (that is, 16 case-mix indexes and 16 prices), ranging from skilled rehabilitation and intensive skilled nursing care to light custodial care. Patients assessed at the low end of the spectrum--light care, lowest price--may be denied admission to nursing homes as well as prepared for discharge to the community or a lighter level of care. Discharge planning and patient teaching for less dependent living are recent phenomena in nursing homes. Nurses have to learn how to manage the complex, technologically dependent patient as well as learn aspects of preparing the patient--and family--for discharge. The challenge to nursing is to protect the patient from negative incentives inherent in the RUGs system; analyze the nursing process and productivity; and contribute to research that should be observing the effect of the reimbursement system on the quality of care.