27 Maggio 2011 Se dovessi ideare ex novo l`Assistenza
10 LUGLIO 2015 Tra vent’anni: Il Futuro delle Residenze Sanitarie Assistenziali per anziani. Corrado Carabellese Regione Lombardia: DGR 1765 del 8.5.2014 IL SISTEMA DEI CONTROLLI IN AMBITO SOCIOSANITARIO: DEFINIZIONE DEGLI INDICATORI DI APPROPRIATEZZA IN ATTUAZIONE DELLA DGR X/1185 DEL 20/12/2013. La presente DGR definisce un set minimo di indicatori “generali” e “specifici” finalizzati a favorire nell’ambito del sistema sociosanitario lombardo l’uniformità metodologica per l’attuazione del processo assistenziale e del relativo sistema di controllo. DGR 1765 del 8.5.2014 INDICATORI SPECIFICI PER LE RSA Cadute Contenzione fisica Dolore Lesione da pressione Nutrizione/idratazione Psicosociale Cognitiva Attività motoria DGR 2022 del 1.7.14 Allegato 1 Procedure e Protocolli: approvvigionamento, conservazione e smaltimento Farmaci, tracciabilità della somministrazione farmaci, modalità di prelievo, conservazione e trasporto materiali organici, modalità di pulizia, lavaggio, disinfezione e sterilizzazione degli strumenti ed accessori, pulizia ambientale, modalità di conservazione FASAS Procedure e Protocolli di nuova emanazione: La sorveglianza e la prevenzione delle infezioni correlate all’assistenza, ivi compresa l’adozione di adeguate strategie vaccinali ove clinicamente ritenute opportune. L’Identificazione, la segnalazione e la gestione degli eventi avversi e degli eventi sentinella. Polizza assicurativa DGR 2989 DEL 23/12/2014 Costi Standard per le RSA: I costi standard sono un importante elemento per la revisione, nel rispetto dei LEA, della remunerazione oggi vigente. Il “pacchetto base” viene assunto a partire dal 2015 per la definizione del costo standard. I servizi da garantire agli ospiti delle RSA lombarde sono: - Dotazione infrastrutturali minimi e servizi generali. - Lo standard gestionale di 901 minuti settimanali per ospite. - Servizi essenziali: a) Consulenza dietologica, rendicontata nei 901 minuti, b) Assistenza infermieristica 24 ore per 7 gg, ricorso al servizio di reperibilità di personale infermieristico, c) Assistenza medica 24 ore per 7 gg, ricordo al servizio di reperibilità medica, DGR 2989 DEL 23/12/2014 - Servizi essenziali: d) Fornitura di presidi e materiale sanitario (non inclusi nel nomenclatore tariffario) e per incontinenza, e) Fornitura di farmaci e gas medicali ad esclusione dei farmaci del File F., f) Servizio di ristorazione (colazione, pranzo, merenda, cena, vino, acqua filtrata), g) Servizio di pulizia della struttura, igienizzazione del comodino, armadietti e letti a carico del personale assistenziale e ricompreso nei 901 minuti settimanali. h) Servizio lavanderia per biancheria piana e intima ospiti. Escluso gli indumenti ospiti. i) Tre gite in giornata durante il corso del’anno DGR 2989 DEL 23/12/2014 • 5.2.6 Applicazione sistema vendor rating RSA • Nel 2015 viene avviato un importante percorso di revisione delle modalità di acquisto di prestazioni dalle RSA, coerentemente con quanto definito nella DGR n. 1185/2013, introducendo il concetto di vendor rating e di indicatori di fabbisogno. • Nel 2016 sarà messo a regime il modello di vendor rating, andando a superare la logica del budget storico, per andare verso un meccanismo di acquisto del posto letto presso gli operatori maggiormente qualificati. • Ogni indicatore assegna alla struttura una classificazione parziale su 5 livelli che, partendo dal livello più basso al più alto, è così strutturata: C, B, A, AA, AAA. Il rating complessivo della struttura sarà dato dalla somma dei rating parziali sui singoli indicatori, che avranno così uguale peso nella determinazione del rating finale. DGR 2989 DEL 23/12/2014 • Le ASL provvederanno, sulla base degli indicatori descritti, alla valorizzazione del sistema di vendor rating per le RSA presenti sul proprio territorio. • Sulla base degli esiti degli indicatori, le strutture con rating B e C nella rideterminazione del budget annuale subiranno una riduzione rispettivamente del 2% e del 4% del budget storico. • Il valore economico complessivo derivante dalle riduzioni di cui sopra, a livello di ASL, verrà ridistribuito dalla stessa ASL secondo le seguenti priorità: - RSA con rating AAA o AA ubicate su territori che presentano un numero di posti letto inferiore alla media regionale - RSA maggiormente virtuose nei territori che presentano un indice di fabbisogno già in linea con la media regionale. COMUNICAZIONE DELL'ASSESSORE CANTU' ALLA GIUNTA NELLA SEDUTA DEL 5 GIUGNO 2015 OGGETTO: DETERMINAZIONI CONSEGUENTI ALLA DGR. N. 2989/2014 SULLA COMPOSIZIONE DEI COSTI A RILEVANZA SOCIALE E SOCIOSANITARIA DELLE RSA Con dgr n. 2989/2014 Regione Lombardia, in continuità con quanto anticipato nella dgr n.1185/2013, ha dato ulteriori indicazioni riguardanti il percorso finalizzato dalla determinazione dei costi standard per le RSA. Attraverso l'analisi delle componenti di spesa riferita ai diversi fattori produttivi effettuata processando le schede struttura delle 649 RSA operanti nel contesto regionale, con posti a contratto, è stato possibile quantificare un costo a standard comprensivo dei costi derivanti dai servizi sanitari e socio-sanitari, ma anche alberghieri, le dotazioni infrastrutturali e i servizi generali. La metodologia di calcolo così organizzata ha consentito di quantificare in 83,48 euro il costo medio a standard delle RSA lombarde in termini di Euro per giornata erogata. Il percorso attuato non rappresenta, di fatto, un dato statico e determinato in termini assoluti ma un valore che è sottoposto ad un monitoraggio e ad un aggiornamento con cadenza annuale, funzionale anche ai fini della valutazione delle performance delle RSA secondo gli indicatori di rating prospettati nella già richiamata delibera n. 2989/2014 e in via di perfezionamento. Tra vent’anni: Futuro delle Residenze Sanitarie Assistenziali per anziani. Spunti ed indirizzi della letteratura per Nursing Home anno 2015: Le nuove specificità della Rsa nella rete dei servizi sanitari. Nutrizione: Curr Opin Clin Nutr Metab Care. 2015 Jan;18(1):17-23 Malnutrition in the nursing home. Bell CL1, Lee AS, Tamura BK. Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. RECENT FINDINGS: Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. J Nutr Gerontol Geriatr. 2015;34(1):1-21.. Malnutrition and Dysphagia in long-term care: a systematic review. Namasivayam AM1, Steele CM. Determining the co-occurrence of malnutrition and dysphagia is important to understand the extent to which swallowing impairment contributes to poor food intake in long-term care (LTC). The reported frequency of participants in LTC with dysphagia ranges from 7% to 40%, while the percentage of those who were malnourished ranges from 12% to 54%. Due to discrepancies used to describe and measure these conditions, it is difficult to determine the exact prevalence of either condition separately, or in combination. Consequently, the impact of dysphagia on malnutrition must be considered and studied using valid definitions and measures. J Am Med Dir Assoc. 2015 Jun 1;16(6):527 Both intravenous and subcutanous infusion can be done in nursing homes. Zorowitz RA1. J Am Med Dir Assoc. 2015 Mar;16(3):175-6 Dehydration is difficult to detect and prevent in nursing homes. Lima Ribeiro SM1, Morley JE2. Int J Prosthodont. 2015 Mar-Apr;28(2):198-200. doi: 10.11607/ijp.4016. Prosthetic rehabilitation of edentulism prevents malnutrition in nursing home residents. Andreas Zenthöfer A, Rammelsberg P, Cabrera T, Hassel A. To investigate the association between prosthetic rehabilitation and malnutrition in institutionalized elders, 255 nursing home residents were recruited for this study and underwent a comprehensive dental examination. Participants with BMI < 20 kg/mc were categorized as malnourished (n = 33), whereas all others were categorized as adequately nourished (n = 222). The number of teeth present and the prevalence of prosthetic rehabilitation were significantly lower in malnourished participants (P < .05). Malnutrition risk was 4.6 times higher for participants who were edentulous and did not wear dentures. Adequate replacement of teeth is important to prevent malnutrition in institutionalized older people. INFEZIONI Geriatr Nurs. 2015 Jun 9. pii: S0197-4572(15) Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study. Travers J1, Herzig CT2, Pogorzelska-Maziarz M3, Carter E4, Cohen CC5, Semeraro PK5, Bjarnadottir RI5, Stone PW5. Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for perdiem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals. Infect Control Hosp Epidemiol. 2015 Apr 29:1-6. [Epub ahead of print] Multidrug-Resistant Gram-Negative Bacteria: Inter- and Intradissemination Among Nursing Homes of Residents With Advanced Dementia. D'Agata EM1, Habtemariam D2, Mitchell S2. OBJECTIVE To quantify the extent of inter and intra nursing home transmission of multidrug-resistant gram-negative bacteria (MDRGN) among residents with advanced dementia and characterize MDRGN colonization among these residents. CONCLUSIONS MDRGN are spread both within and between nursing homes among residents with advanced dementia. Infection control interventions should begin to target this high-risk group of nursing home residents. DOLORE J Am Geriatr Soc. 2015 Apr;63(4):642-3. Pain management in American nursing homes – a long way to go. Hallenbeck J1. Ned Tijdschr Geneeskd. 2015;159:A7833. [Treatment of spasticity in nursing homes: botulinum toxin type A as part of therapy]. [Article in Dutch] Wolswijk AH1, Dirkx AE. Complications of spasticity can severely limit daily activities and caregiving. For those who treat or provide care to patients with spasticity in nursing homes, it is important to recognise complaints in order to prevent serious complications such as carerelated pain, contractures and pressure sores. Both patients received botulinum toxin injections in the affected muscles, combined with an appropriate splint. These efforts substantially reduced care-related pain and improved social behaviour and care options. If spasticity prohibits treatment or care, consultation of a rehabilitation physician at an early stage is indicated. PROSPETTIVE PER IL FUTURO DELLE RSA Int J Nurs Stud. 2011 Jun;48(6):732-50 The relationship between nurse staffing and quality of care in nursing homes: a systematic review. Spilsbury K1, Hewitt C, Stirk L, Bowman C. OBJECTIVES: To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies. REVIEW METHODS: Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n=3). RESULTS: A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified). CONCLUSIONS: A focus on numbers of nurses fails to address the influence of other staffing factors (e.g., turnover, agency staff use), training and experience of staff, and care organisation and management. 'Quality' is a difficult concept to capture directly and the measures used focus mainly on 'clinical' outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings. R I Med J (2013). 2015 Mar 3;98(3):20-2. The Roles and Functions of Medical Directors in Nursing Homes. Nanda A1. The medical director is an important member of the healthcare team in a nursing home, and is responsible for overall coordination of care and for implementation of policies related to care of the residents in a nursing home. The residents in . The medical director has an important leadership role in assisting nursing home administration in providing quality care that is consistent with current standards of care. nursing homes are frail, medically complex, and have multiple disabilities This article provides an overview of roles and functions of the medical director, and suggests ways the medical director can be instrumental in achieving excellent care in today's nursing facilities. J Am Med Dir Assoc. 2015 Apr 7. Physicians in Nursing Homes: Effectiveness of Physician Accountability and Communication. Lima JC1, Intrator O2, Wetle T3. OBJECTIVES: The objective of this study was to develop a measure of the perceptions of nursing home (NH) directors of nursing (DONs) on the adequacy of physician care and to examine its variation as well as its construct validity. RESULTS: The established EPAC score is the first measure to capture specific components of the adequacy of physician care in NHs. EPAC exhibited good construct validity: more effective practices were correlated with greater physician involvement in discussions of do-not-resuscitate orders, the frequency with which the medical director checked on the medical care delivered by the attending physician, the tightness of the NH's control of its physician resources, and the DON's perception of whether or not avoidable hospitalizations and emergency room visits could be reduced with greater physician attention to resident needs. : As increased attention is given to the quality of care provided to vulnerable elders, effective measures of processes of care are essential. The EPAC measure provides an important new metric that can be used in these efforts. The goal is that CONCLUSION future studies could use EPAC and its individual domains to shed light on the manner through which physician presence is related to resident outcomes in the NH setting. PROSPETTIVE PER IL FUTURO DELLE RSA J Am Med Dir Assoc. 2015 May 23. pii: S1525-8610(15)00253-4. Effect of a Novel Interdisciplinary Teaching Program in the Care-continuum on Medical Student Knowledge and Self-Efficacy. 1 2 Lathia A , Rothberg M , Heflin M3, Nottingham K2, Messinger-Rapport B4. OBJECTIVES: Medical students report that they receive inadequate training in different levels of care, including care transitions to and from post-acute (PA) and long-term care (LTC). The authors implemented the Medical Students as Teachers in Extended Care (MedTEC) program as an educational innovation at the Cleveland Clinic to address training in the care-continuum, as well as the new medical student and physician competencies in PA/LTC. SETTING: The program occurs in a community facility that includes subacute/skilled nursing, assisted living, and nursing home care. RESULTS: Between October 2011 and December 2013, approximately 100 students participated in 20 sessions of MedTEC. All students reported improved self-efficacy and attitudes regarding care of older adults and care transition management. Mean percentage correct on the knowledge test increased significantly from 59.8% to 71.2% (P = .004) for the MedTEC participants but not for the comparison group students (63.1%-58.3%, P = 47). There was no significant difference in mean percentage correct on the post-program knowledge test between MedTEC medical students and hospitalists (71.0% versus 70.3%, P = .86). Students led 8 in-service sessions for facility staff on various topics relating to the care of older adults in PA/LTC. The MedTEC program appears to be a successful innovation in medical student education on levels of care. It could serve as a model for CONCLUSION: building competency of health professionals on managing care transitions and determining appropriate levels of care for older adults. PROSPETTIVE PER IL FUTURO DELLE RSA J Am Med Dir Assoc. 2015 Jul 1;16(7):603-6 Frailty Index and Mortality in Nursing Home Residents in France: Results From the INCUR Study. Tabue-Teguo M1, Kelaiditi E2, Demougeot L2, Dartigues JF3, Vellas B4, Cesari M4. OBJECTIVE: The objective of this study was to examine whether the capacity of an age-related deficit accumulation index (the so-called Frailty Index [FI] proposed by Rockwood) to predict mortality in a nursing home population. MEASUREMENTS: The FI was computed as the ratio between actual and 30 potential deficits the participant might have presented at the baseline visit (range between 0 [no deficit] and 1 [30 deficits]). Death events were monitored and detected over a 12-month follow-up. The risk of death was estimated using Cox proportional hazards models. RESULTS: Mean age of participants was 86.2 (SD 7.5) years, with a mean FI of 0.35 (SD 0.11). At the end of the follow-up, 135 (17.4%) death events were recorded. A positive association between the FI and mortality (per 0.01 FI increment: age- and gender-adjusted hazard ratio 1.018, 95% confidence interval 1.002-1.035, P = .03) was reported. The use of the traditional 0.25 cut-point for detecting the frailty status is inadequate in this population. CONCLUSION: The FI is able to predict mortality even in very old and complex elders, such as nursing home residents. J Am Med Dir Assoc. 2015 Feb;16(2):87-9 Frailty in nursing homes: the FRAIL-NH Scale. Kaehr E1, Visvanathan R2, Malmstrom TK3, Morley JE4. J Am Med Dir Assoc. 2015 Feb;16(2):87-9. Frailty in nursing homes: the FRAIL-NH Scale. Kaehr E1, Visvanathan R2, Malmstrom TK3, Morley JE4. PROSPETTIVE PER IL FUTURO DELLE RSA J Am Med Dir Assoc. 2015 Mar;16(3):181-4. An international definition for "nursing home". Sanford AM1, Orrell M2, Tolson D3, Abbatecola AM4, Arai H5, Bauer JM6, Cruz-Jentoft AJ7, Dong B8, Ga H9, Goel A10, Hajjar R11, Holmerova I12, Katz PR13, Koopmans RT14, Rolland Y15, Visvanathan R16, Woo J17, Morley JE18, Vellas B15. There is much ambiguity regarding the term "nursing home" in the international literature. The definition of a nursing home and the type of assistance provided in a nursing home is quite varied by country. The International Association of Gerontology and Geriatrics and AMDA foundation developed a survey to assist with an international consensus on the definition of "nursing home." BMC Res Notes. 2014 Dec 9;7:889. Intermediate care in nursing home after hospital admission: a randomized controlled trial with one year follow-up. Herfjord JK, Heggestad T, Ersland H, Ranhoff AH1. 1Department of Clinical Science, University of Bergen and Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Hospital, Ulriksdal 8, 5009 Bergen, Norway. [email protected] Intermediate care is intended to reduce hospital admissions and facilitate early discharge. In Norway, a model was developed with transfer to intermediate care shortly after hospital admission. Intervention group patients were transferred to a nursing home unit with increased staff and multidisciplinary assessment, for a maximum stay of three weeks. Patients in the control group received usual care in hospital. Blinding to group assignment was not possible. The primary outcome was number of days living at home in a follow-up period of 365 days. Secondary outcomes were mortality, hospital admissions, need for residential care and home care services. RESULTS: 376 patients were included, 74% female and mean age 84 years. There was no significant differences between intervention (n=190) and control group (n=186) for number of days living at home (253.7 vs 256.5, p=0.80) or days in hospital (10.4 vs 10.5, p=0.748). Intervention group patients spent less time in nursing home (40.6 days vs. 55.0, p=0.046), and more patients lived independently without home health care services (31.6% vs 19.9%, p=0.007). For orthopaedic patients (n=128), mortality was higher in the intervention group; 15 intervention patients and 7 controls died (25.1% vs 10.3%, p=0.049). There was no significant difference This model of rapid transfer to intermediate care did not significantly influence number of days living at home during one year follow-up, but reduced demand for nursing home care and need for home health care services. In post-hoc in one-year mortality for medical patients (n=150) or the total study population. CONCLUSIONS: analysis mortality was increased for orthopedic patients. JAMA Intern Med. 2015 Feb;175(2):296-7.. Post-acute care: who belongs where? Jenq GY1, Tinetti ME1. Ugeskr Laeger. 2015 Mar 16;177(12). [Teminal care in a nursing home]. Andersen JH1, Hansen J, Rosholm JU. This article focuses on patients with limited life expectancy who no longer benefit from preventive medication but not yet qualify for palliative care - a time frame often referred to as End-of-Life (EOL). The purpose of this article is to identify and assess international guidelines for prescribing in EOL. No relevant clinical trials were available, but we found advice mainly based on logic assumptions and thoughts. Optimal prescribing for EOL patients remains mostly unexplored. Our study revealed two pivotal questions: How do we identify EOL patients, and what specific drugs should be removed? J Am Med Dir Assoc. 2015 May 1;16(5):434-5. Hospice in the nursing homes: perspectives of a medical director. Raider M1. Nurs Clin North Am. 2015 Jun;50(2):269-281. Transforming Home Health Nursing with Telehealth Technology. Farrar FC1. Telehealth technology is an evidence-based delivery model tool that can be integrated into the plan of care for mental health patients. Telehealth technology empowers access to health care, can help decrease or prevent hospital readmissions, assist home health nurses provide shared decision making, and focuses on collaborative care. Telehealth and the recovery model have transformed the role of the home health nurse. Nurses need to be proactive and respond to rapidly emerging technologies that are transforming their role in home care. Gerontologist. 2015 Apr;55(2):296-301. doi: 10.1093/geront/gnv010. Epub 2015 Apr 9. A new long-term care manifesto. Kane RL1. This article argues for a fresh look at how we provide long-term care (LTC) for older persons. . LTC has three basic components: personal care, housing, and health care (primarily chronic disease management). Essentially, LTC offers a compensatory service that responds to frailty They can be delivered in a variety of settings. It is rare to find all three done well simultaneously. Personal care (PC) needs to be both competent and compassionate. Housing must provide at least minimal amenities and foster autonomy; when travel time for PC raises costs dramatically, Health care must be proactive, aimed at preventing exacerbations of chronic disease and resultant hospitalizations. Enhancing some form of clustered housing may be needed. preferences means allowing taking informed risks. Payment incentives should reward both quality of care and quality of life, but positive outcomes must be defined as slowing decline. Providing post-acute care should be separate from LTC. Using the tripartite LTC framework, we can create innovative flexible approaches to providing needed services for frail older persons in formats that are both desirable and affordable. Such care will be more socially desirable and hence worth paying for.