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4/28/2010 3:45 PM 

Recently the magazine “Smart Money” ran an excerpt from a book called “1,001 Things They Won’t Tell You: An Insider’s Guide to Spending, Saving and Living Wisely.” The excerpt was relegated to only 10 things, though—specifically, the “10 Things Nursing Homes Won’t Tell You.”

I’ve been at pains in this blog to give you the whole story about long-term care—not just the sour one-note bad news so customary in the popular media, but some sense of the context in which long-term care occurs and the dedication with which many facilities provide it, attempting to offer decent care despite obstacles both financial and social. I witnessed many examples of this in my 18 years of covering this field.

But when all is said and done, you really do have to be careful in selecting and dealing with a long-term care facility for your loved one. Nursing homes and, for that matter, assisted living facilities are basically institutional, no matter how hard they try to escape this, and present all the attendant risks to privacy and personalized care. Moreover, the residents of these facilities are highly vulnerable by definition. The setting and its inhabitants offer temptations toward abuse by less scrupulous individuals than I’ve been accustomed to.

And here’s where the “Smart Money” list comes in. For the sake of “blog-brevity” and direct relevance to readers, I’d like to quickly comment on six of their 10 “hush hush” statements:

“We’re careless about the drugs we give out.” The particular implication here is that “psychoactive” drugs are being over-used, with “psychoactive” in this case largely implying Alzheimer’s drugs, like Aricept and Namenda. Two quick comments about this: these drugs are indeed being used in this fast-growing resident population to modify or slow the progression of dementia, with controversial results. Second, the involvement of physicians in nursing homes prescribing is not as direct as it would be in physicians’ offices or hospitals; rather, physicians (and sometimes nurse practitioners) leave medication orders on occasional visits to these facilities. So, pay attention to the drugs ordered for your loved one, and ask about physician involvement in the facility. The ideal situation would be active involvement of a physician medical director serving the facility full-time or part-time—they make it their special purpose to closely monitor prescribing. For more information, log onto the American Medical Directors Association web site.

“We’re woefully understaffed.” As I indicated in a previous blog, staffing is the ultimate issue determining long-term care quality. I don’t deny that there are facilities that cut staff to boost profits, a very common accusation. I think a more typical situation, though, is facilities continually hunting for reliable, competent staff to perform very demanding duties for minimal pay, a minimalism that has more to do with our sick financing system than with profiteering greed. Aside from watching for the sheer ratio of staff to residents—the lower the ratio, the better—you should look for evidence of staff empathy and involvement with residents and their families, which is more a reflection of the human nature of the facility than of money.

“Mr. and Mrs. Smith, meet Sticky Fingers Louie.” This goes back to that situation of heightened vulnerability I mentioned. That theft exists in nursing homes should come as no surprise. Keep careful tabs on your loved one’s valuables, minimize their presence to the extent possible, and report missing items immediately. Facility management countenances such behavior no more than any other reputable business would. And more and more these days, they’re taking seriously the task of running background checks on prospective employees, a system that has been long in the works and is codified in the recent healthcare reform law. Ask about this.

“If it’s not in the care plan, we’re not gonna do it.” Every resident must have a formal care plan, no matter what his/her medical condition—it’s Federal law. Moreover, family members should be invited to participate in care planning with nursing home medical staff. Make sure that this process does indeed take place, and that you’re involved.

“We use physical restraints on your loved ones.” It’s the image that many have of nursing homes—helpless elderly people tied to beds or chairs to keep them from falling down and hurting themselves. In fact, restraint use has been frowned upon by mainstream facilities for several years now. It’s increasingly accepted that attentive nursing staff, imaginative activities and modern monitoring technology go a long way toward alleviating safety concerns. Many facilities have made it an overriding goal to become restraint-free. There may be exceptions—circumstances in which a resident might be in a particularly emergent but temporary need for restraint, but this should be neither frequent nor common. Keep an eye open for restraint use, and ask tough questions when you see it.

“Take our report cards with a grain of salt.” As noted in a previous blog, nursing homes are required to undergo a thoroughgoing inspection by state authorities every 12 to 15 months using detailed Federal guidelines. The state survey is a nice idea, and those well thought out guidelines can be helpful—but, unfortunately, the process can foster an emphasis on “paper compliance,” with facilities putting their best foot forward at survey time but otherwise doing business as usual. This is why the state survey reports facilities are required to display, as well as the Medicare “Nursing Home Compare” web site that relies on this documentation, cannot be taken as gospel. You must visit, you must scrutinize the facility and its staff in some detail, and you must form your own impression of its suitability for your loved one.

In short, be careful—both when you initially explore a facility and when conducting your dealings with it, through all the days, months and years to come.

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Location: Blogs Caregiving by Richard Peck

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