Nursing and the Aging Family Chapter 7 – Economic and Legal Issues.Chapter Chapter 8 – Assessment and Documentation for Optimal Care. Questions: The

Nursing and the Aging Family
Chapter 7 – Economic and Legal Issues.Chapter
Chapter 8 – Assessment and Documentation for Optimal Care.
Questions:
The gerontological nurse is responsible to conduct a complete head-to-toe physical assessment. There are several considerations of common changes in late life during physical assessment discussed in your textbook.
1.Mention at least 3 common changes in late life that the gerontological nurse needs to have in consideration during a physical assessment.
2.Explain each one of them.
Guidelines: The answer should be based on the knowledge obtained from reading the book, no just your opinion.
Grading Criteria: Student mentioned 3 common changes in late life that the gerontological nurse needs to have in consideration during a physical assessment (30%). Student explained each one of them (70%).

Chapter 7

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Economic and Legal Issues
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Copyright 2018, Elsevier Inc. All rights reserved.

Social Security
Designed as a pay-as-you-go system
An age entitlement program
Age of eligibility has increased over time
Supplemental security income
Provides stipends to low income people who are aged 65 years or older, blind, or disabled
Social Security income is not adequate
Private investments
Pensions

Late Life Income
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*

Copyright 2018, Elsevier Inc. All rights reserved.

To be eligible for Medicare, one must be eligible for Social Security
Only covers select services and requires that they are medically necessary
Costs are covered by a employer and employee tax of 2.9% and by the beneficiary in the form of premiums, deductibles, and co-pays

Medicare
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Offers acute care or short-term rehabilitative care
Free to those who receive Social Security
Provides insurance regardless of financial status
A person is automatically enrolled on the first of the month of his or her 65th birthday
Deductible and co-payments under Part A vary by setting and can be quite high

Medicare Part A
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*

Copyright 2018, Elsevier Inc. All rights reserved.

A person eligible for Part A must apply for Part B in the 6 months surrounding his or her 65th birthday or wait until the next open enrollment
Choose either (the Original) Medicare Part B or an alternative plan available in his or her area
Original is a traditional fee-for-service arrangement
Patient is responsible for a monthly premium (usually deducted directly from the monthly Social Security check), an annual deductible, and co-pays

Medicare Part B
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Offers Medicare Advantage Plans similar to an HMO or PPO
Replaces both Medicare Part A and Medicare Part B
Co-pays and deductibles, if any, vary considerably, and extra premiums may be required for added services
Several new programs alternatives to Medicare Part C, such as Private Fee-For-Service Medical Savings Accounts

Medicare Part C
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Person pays a monthly premium and in exchange all of the co-pays and deductibles not covered by the primary insurance (e.g., Medicare) are paid
Some are part of a persons retirement benefit or available to members of organizations such as AARP

Supplemental Insurance
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Program funded jointly by federal government and state government
State determines eligibility, types, and extent of services to be covered; sets the payment rates to providers; and administers its own programs
States pay about 40% of the costs with the federal government paying the rest
Provides care for those with low incomes
Covers more services than Medicare

Medicaid
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Veterans Administration (VA) system is a model for the continuity of care in various care provider systems
Active duty and retired military members and their dependents are eligible
VA hospitals have restrictions; the problem has to be service related
Financial support, Aid and Attendance Pension, is provided

Care for Veterans
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*

Copyright 2018, Elsevier Inc. All rights reserved.

TRICARE health care program
Health care insurance program provided by the Department of Defense for eligible beneficiaries
Requires the person to enroll in both Medicare Part A and Part B and pay the premiums for Part B
As a Medigap policy, Tricare for Life covers expenses not covered by Medicare
Long-term care insurance

Other Veterans
Administration Services
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Which part of Medicare helps cover some skilled nursing facility care, hospice care, and home health care under certain conditions?
Part A
Part B
Part C
Part D

Question
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Copyright 2018, Elsevier Inc. All rights reserved.

AMedicare Part A covers acute hospital care, short-term acute rehabilitative care, and costs associated with hospice and home health care under certain circumstances.

Answer
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Financial issues
Health care decisions
Consent to treatments
Capacity

Legal Issues in Gerontological Nursing
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Ability to understand a problem, the risks and benefits of a decision, the alternative options, and the consequences of the decision
Range of tasks, from handling finances and daily business, to taking care of self and making medical decisions
Only the courts can declare the person incapacitated

Capacity
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*

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Powers of attorney
Conservatorship
Guardianship

Advanced Care Planning
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Legal document that gives a designated person the power to act on the behalf of a person
Two types of power of attorney (POA) documents
General POA

Usually has the right to make financial decisions, pay bills, and so on in defined circumstances but not necessarily to make decisions related to health care
Durable POA

Can make health-related decisions for persons when they are unable to do so themselves
Power of Attorney
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Individuals, agencies, or corporations that have been appointed by the court to have care, custody, and control of a disabled person to manage his or her financial responsibilities
Guardian is a person appointed to be responsible for another person
Conservator is a person specifically appointed to control the finances of the person

Guardians and Conservators
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Nursing roles include
Helping older patients deal with financial issues
Using their expert advocacy and negotiation skills
The nurse may be the first to notice the subtle changes indicating a potential change in capacity
Obligation to work with the applicable statutes of his or her state, province, or country

Implications for Gerontological Nursing and Healthy
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*

Copyright 2018, Elsevier Inc. All rights reserved.

Who can be the POA for an older adult?
Anyone
Attorney
Blood relative
Anyone except a blood relative
Question
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*

Copyright 2018, Elsevier Inc. All rights reserved.

AAlthough it usually is a friend or family member, a person can designate any another person to act on his or her behalf.

Answer
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*

Copyright 2018, Elsevier Inc. All rights reserved. Chapter 7

Economic and Legal Issues
Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.

Social Security
Designed as a pay-as-you-go system
An age entitlement program
Age of eligibility has increased over time
Supplemental security income
Provides stipends to low income people who are aged 65 years or older, blind, or disabled
Social Security income is not adequate
Private investments
Pensions

Late Life Income
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

To be eligible for Medicare, one must be eligible for Social Security
Only covers select services and requires that they are medically necessary
Costs are covered by a employer and employee tax of 2.9% and by the beneficiary in the form of premiums, deductibles, and co-pays

Medicare
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Offers acute care or short-term rehabilitative care
Free to those who receive Social Security
Provides insurance regardless of financial status
A person is automatically enrolled on the first of the month of his or her 65th birthday
Deductible and co-payments under Part A vary by setting and can be quite high

Medicare Part A
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

A person eligible for Part A must apply for Part B in the 6 months surrounding his or her 65th birthday or wait until the next open enrollment
Choose either (the Original) Medicare Part B or an alternative plan available in his or her area
Original is a traditional fee-for-service arrangement
Patient is responsible for a monthly premium (usually deducted directly from the monthly Social Security check), an annual deductible, and co-pays

Medicare Part B
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Offers Medicare Advantage Plans similar to an HMO or PPO
Replaces both Medicare Part A and Medicare Part B
Co-pays and deductibles, if any, vary considerably, and extra premiums may be required for added services
Several new programs alternatives to Medicare Part C, such as Private Fee-For-Service Medical Savings Accounts

Medicare Part C
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Person pays a monthly premium and in exchange all of the co-pays and deductibles not covered by the primary insurance (e.g., Medicare) are paid
Some are part of a persons retirement benefit or available to members of organizations such as AARP

Supplemental Insurance
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Program funded jointly by federal government and state government
State determines eligibility, types, and extent of services to be covered; sets the payment rates to providers; and administers its own programs
States pay about 40% of the costs with the federal government paying the rest
Provides care for those with low incomes
Covers more services than Medicare

Medicaid
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Veterans Administration (VA) system is a model for the continuity of care in various care provider systems
Active duty and retired military members and their dependents are eligible
VA hospitals have restrictions; the problem has to be service related
Financial support, Aid and Attendance Pension, is provided

Care for Veterans
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

TRICARE health care program
Health care insurance program provided by the Department of Defense for eligible beneficiaries
Requires the person to enroll in both Medicare Part A and Part B and pay the premiums for Part B
As a Medigap policy, Tricare for Life covers expenses not covered by Medicare
Long-term care insurance

Other Veterans
Administration Services
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Which part of Medicare helps cover some skilled nursing facility care, hospice care, and home health care under certain conditions?
Part A
Part B
Part C
Part D

Question
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

AMedicare Part A covers acute hospital care, short-term acute rehabilitative care, and costs associated with hospice and home health care under certain circumstances.

Answer
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Financial issues
Health care decisions
Consent to treatments
Capacity

Legal Issues in Gerontological Nursing
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Ability to understand a problem, the risks and benefits of a decision, the alternative options, and the consequences of the decision
Range of tasks, from handling finances and daily business, to taking care of self and making medical decisions
Only the courts can declare the person incapacitated

Capacity
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Powers of attorney
Conservatorship
Guardianship

Advanced Care Planning
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Legal document that gives a designated person the power to act on the behalf of a person
Two types of power of attorney (POA) documents
General POA

Usually has the right to make financial decisions, pay bills, and so on in defined circumstances but not necessarily to make decisions related to health care
Durable POA

Can make health-related decisions for persons when they are unable to do so themselves
Power of Attorney
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Individuals, agencies, or corporations that have been appointed by the court to have care, custody, and control of a disabled person to manage his or her financial responsibilities
Guardian is a person appointed to be responsible for another person
Conservator is a person specifically appointed to control the finances of the person

Guardians and Conservators
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Nursing roles include
Helping older patients deal with financial issues
Using their expert advocacy and negotiation skills
The nurse may be the first to notice the subtle changes indicating a potential change in capacity
Obligation to work with the applicable statutes of his or her state, province, or country

Implications for Gerontological Nursing and Healthy
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

Who can be the POA for an older adult?
Anyone
Attorney
Blood relative
Anyone except a blood relative
Question
Copyright 2018, Elsevier Inc. All rights reserved.
*

Copyright 2018, Elsevier Inc. All rights reserved.

AAlthough it usually is a friend or family member, a person can designate any another person to act on his or her behalf.

Answer
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*

Copyright 2018, Elsevier Inc. All rights reserved. Chapter 8

Assessment and Documentation for Optimal Care
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Copyright 2018, Elsevier Inc. All rights reserved.

Is more complex
Is more detailed
Takes longer to perform
Requires special abilities
Done in every setting

Assessment of Older Adults
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Collection of data
Biological, psychosocial, and functional information
Cultural and spiritual assessments
Cognitive abilities
Psychological well-being
Caregiver stress or burden
Patterns of health and health care
Review of preferences for advanced care
Presence of any geriatric syndromes

Assessment Components
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Sexual function
Depression
Alcoholism
Hearing loss
Oral health
Environmental safety

Problems to Address in an Assessment
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Listen patiently
Allow for pauses
Ask questions that are not often asked
Obtain data from all available sources
Know that not all positive findings need interventions
Know normal changes
Pace the assessment according to the patients stamina

Special Assessment Abilities
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Establish rapport
Data collection approaches include
Self-report
Report by proxy
Observation
Ideally should be done to gather baseline data before the older adult has a health crisis

Collecting Assessment Data
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Conduct the assessment at a time when the patient is at his or her best
Avoid biasing the response
Explore for more information only if needed
Approach sensitive information in a matter-of-fact manner
Record the patients words for accuracy

Guidelines for an Assessment of the Older Adult
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What is the best approach to take when obtaining a health history from an older adult?
Choose a private, quiet area in a comfortable room
Ask a family member to respond to some of the questions
Raise your voice if the patient does not appear to hear you
Take thorough notes during the interview, asking detailed questions as needed

Question
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AWhen collecting a verbal health history, the nurse should use techniques that optimize communication. This includes choosing a private, quiet area in a comfortable room.

Answer
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Increase the likelihood of obtaining reliable, useful data
Can be used to monitor changes over time
Existing instruments can categorize physical health, mood, motor capacity, manual ability, self-care ability, instrumental abilities, and cognitive and social function

Assessment Instruments
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Is collected in a face-to-face approach with the patient or a review of the patients written history
Includes medical history, review of systems, medication history, nutritional history, and factors that influence the persons quality of life, including
Living arrangements
Financial resources
Support

Health History
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Begins the moment the nurse sees the person
Perform a problem assessment first because of the length of time it takes to conduct an assessment
When the focus is a well-check assessment, the emphasis is placed on health problems in later life

Physical Assessment
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FANCAPES
Fluids: State of hydration
Aeration: Respiratory function
Nutrition: Type and amount of food consumed
Communication: Adequate ability to communicate his or her needs
Activity: Ability to meet basic needs of toileting, grooming, and meal preparation
Pain: Physical, psychological, or spiritual pain
Elimination: Difficulty with bladder or bowel elimination
Socialization: Ability to give and receive love and friendship

Assessing Frail and Medically Complex Patients
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Need to conduct an assessment of mental status, especially cognitive abilities and mood whenever there is a change in an elders condition or safety
Assess whether an increase in chronological age has resulted in an increased rate of dementing illness
Assess cognition and mood

Mental Status Assessment
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Tools for cognition assessment
Mini-Mental State Examination
Clock Drawing Test
The Mini-Cog
Global Deterioration Scale
Tools for mood assessment
Geriatric Depression Scale

Cognition and Mood Assessment
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Thorough functional status of the patient includes
Identifying areas where help is needed
Determining whether a change in abilities from one period to another has occurred
Assisting in the determination of a need
Determining the safety of the patients living situation
If the patient is healthy and active, record a simple statement such as, The patient is active and independent and denies functional difficulties.

Functional Assessment
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Include
Eating
Toileting
Ambulation
Bathing
Dressing
Grooming
Tools to assess ADLs
Katz Index
Barthel Index
Functional Index Measure

Activities of Daily Living (ADLs)
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Considered to be more complex activities necessitating higher physical and cognitive functioning than ADLs
Include
House cleaning
Shopping
Managing money
Tools to assess IADLs

Instrumental Activities of Daily Living (IADLs)

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OARS Multidimensional Functional Assessment Questionnaire (OMFAQ)
Fulmer SPICES (sleep disturbance, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown)
Minimum Data Set used in skilled nursing facilities
OASIS used in certified home care agencies

Comprehensive Assessments
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A nurse who needs to assess a patients ability to perform ADLs will choose which tool for this assessment?
OASIS
Katz Index
Fulmer SPICES
Global Deterioration Scale

Question
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BThe Katz Index measures the ability to perform ADLs and has served as a basic framework for most of the subsequent measures.

Answer
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Chronicles, supports, and communicates the patients condition
Provides the data needed for the development of the individualized plan of care
Helps the nurse identify, monitor, and evaluate treatment or interventions
Provides the communication needed to ensure continuity of care
Determines reimbursement
Demonstrates the quality of care provided

Documentation
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Level of documentation required varies by setting and determined by state and local laws
Documents and communicates day to day care
When care is not considered skilled and covered by Medicare, narrative notes are reduced to problem-oriented only or as needed depending on the facility and licensing body

Skilled Nursing Facility Documentation
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When care is covered by Medicare, Medicaid, or another insurer, reimbursement in all settings is based on the assessment and the documentation
Documentation used varies by setting
Skilled nursing facilitiesMDS and RUG
Skilled home careOASIS
Initial reimbursement in acute care settingsDRGs

Documentation and Reimbursement
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Nursing responsibilities
Make sure that communication and documentation are of the highest quality
Communicate important information regarding safe patient care
Collect accurate data in the most efficient yet caring manner possible
Use tools as a way to organize assessment data and compare the data from time to time

Implications for Gerontological Nursing and Healthy Aging
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