The care landscape is changing rapidly. For years, policymakers have been pointing out that we don’t have nearly adequate resources to care for our growing number of elderly. There aren’t enough geriatricians. There aren’t enough geriatric psychiatrists. There aren’t enough physical therapists and social workers with expertise in geriatrics. There aren’t enough skilled nursing facilities and assisted living facilities. Don’t take my word for it, you can find all the alarming numbers here, in a recent Eldercare Workforce Alliance report.
So what does this mean for my patients and their families? Increasingly, it means that families need to be aware that sometimes patients may be assigned to certain kinds of facilities simply because that’s all that’s available. Many hospitals are now treating “assisted living” venues as if they were “skilled nursing facilities.” These are not the same at all. Assisted living assumes that elders can take responsibility for part of their care, and it’s not set up for complicated medical issues. Skilled nursing means just that: skilled nurses and medical professionals who are qualified to provide medical care. Families need to be vigilant, to fight to make sure that their elder is in an appropriate facility.
Here’s a recent horror story that may make the point: I had a patient with complicated medical issues who had a hip replacement operation. To my dismay, the hospital discharged this man to “assisted living.”
Without the proper care necessary after such a major operation, the surgery wound opened up within a week. I sent the patient to the ER, and the hospital sent him back to assisted living with instructions that each day, he have “wet to dry” dressings changed. This is a delicate procedure in which a wet gauze bandage is placed on a wound, and allowed to dry. When it dries, the bandage can be removed, along with wound drainage and dead tissue. Trained medical staff should do these changes.
Alas, my patient’s bandages don’t appear to have been done properly in assisted living. He became septic, infected, within a few days. He had to go back to the hospital, where they had to remove his new hip. Then, finally, the hospital discharged him to a skilled nursing facility—where I think he should have been sent in the first place. There, the poor gentleman had to endure a much more difficult and expensive recovery.
In many cases, it may be possible for an assisted living facility to provide follow-up after a hospital stay. But it’s not appropriate after a complicated, major operation like a hip replacement.
If your elder is about to discharged from the hospital, make sure to ask questions:
• What sort of care will my loved one require after being discharged? Exactly what kind of wound care or rehabilitative therapy or tests will be required?
• Is this kind of care normally provided by a nurse or a doctor?
If the answer to this last question is “yes,” make sure your elder goes to a skilled nursing facility!
What do you think?
Elizabeth A. Landsverk, MD Specialist in Geriatric Medicine
Hi Dr. Landsverk,
Your article is very well taken. In addition to the "critical care" type of situation you describe, your readers should also begin to learn (or emphasize remembering) that Residential Care Facilities for the Elderly (RCFE’s) (which contain Assisted Living as well as Memory Care sections) have regulatory limits as well as their own internal no-no’s of what they cannot (or will not) do as hired help for an elderly resident. Many people think that placing their elder family member in these facilities is a substitute for care that’s borderline "nursing home". For example, some consider giving teeth-brushing assistance to an elder who has poor brushing abilities to be something a skilled nursing facility does, not an RCFE, and while they will accept such a resident, they have no concern for such as aspect of oral hygiene and will not provide assistance regardless of promises made to the family to entice the resident to move in. RCFE’s are also restricted in that they can prepare meds, but cannot give or feed the meds to the resident, even if the resident has an unsteady hand or other decreased ability. Oddly, however, RCFE’s are allowed to accept new residents who have Stage 1 & 2 pressure ulcers (or even create them as in the case of my loved one), but then argue the resident should be removed to a skilled nursing facility even though the RCFE created the ulcer with substandard hygienic care (which is very typical in RCFE’s, and in particular, memory care sections). I have learned over the last 5 years and 3 separate RCFE’s (2 of which were memory care sections) that these facilities are happier accepting elderly wealthy persons who can carry out most of their daily tasks and just need superficial assistance, and that it is the more disabled persons (who are short of skilled nursing need but require more attention than touch-and-go assistance) who suffer poor, inadequate, uneducated (where little to no elder conditions education is required or given), and unmotivated "care" because they are "in the middle" stages of their disabilities. But families are willing to pay the $8,000-$9,000 to place their elder in these facilities because of the weight of in-home caregiving. It would be nice to see more rigid standards in RCFE’s, but this is liberal California and the growing elder population is not getting the advance planning attention they should be getting from the legislature. After 5 years and 3 terrible facilities, I moved my elder into my family home, rearranged our family schedules, and we now provide the top quality individualized care and companionship that these facilities "promise". It is truly disappointing that the quantity of such facilities is increasing while the standards for caring for an increasing elder population with increasing clinical needs has not changed and persons are hired who have never handled an elderly person’s delicate needs and have no experience or training (and are not required to have either) in order to handle elders with Alzheimer’s, dementia, pacing, or other disorders of decline.