What is the best approach for managing patients requiring long-term care?

Managing Patients Requiring Long-Term Care

The best approach for managing patients requiring long-term care centers on comprehensive multidisciplinary team-based care coordination, with care managers having geriatric expertise conducting regular assessments of functional, cognitive, and psychosocial status, combined with individualized care planning that prioritizes patient preferences and quality of life over disease-specific targets. 1

Core Components of Long-Term Care Management

Care Management Team Structure

• Care managers must be nurses or social workers with specific geriatric expertise, clinical experience in geriatric syndromes, geriatric assessment, evidence-based chronic disease management, rehabilitation basics, and cultural sensitivity training. 1
• Other professionals including primary care providers, pharmacists, and physical therapists should provide complementary care management services with multidisciplinary insight into medical, functional, and social issues. 1
• The team-based approach has been shown to decrease hospitalizations, improve quality of life, and enhance functional status compared to fragmented care delivery. 1

Initial and Ongoing Assessment Protocol

Conduct comprehensive assessment immediately upon admission to long-term care, covering:

• Physical status: Chronic pain, incontinence, nutritional and hydration requirements, physiological status including frailty assessment. 1
• Functional status: Activities of daily living, mobility, self-care capacity using standardized tools like RAI-MDS 2.0 or Multi-clientele Autonomy Assessment. 1
• Cognitive and communication status: Cognitive deficits, communication barriers, language problems, health literacy. 1
• Psychosocial assessment: Depression, anxiety, emotional well-being, social isolation, caregiver burden, cultural and spiritual needs. 1
• Medication review: Evaluate risk-benefit of each drug, interactions, adverse effects, adherence, prescribing cascades, including over-the-counter medications and supplements. 1

Reassess functional, physical, and cognitive status regularly—at minimum annually, but more frequently when health status changes or decline is identified. 1

Patient-Centered Care Planning

Elicit and document patient values, goals, and preferences as the foundation of all care decisions:

• Explore what matters most to the patient regarding quality of life versus length of life, treatment burden tolerance, and desired level of independence. 1
• Address medical, psychological, emotional, social, sexual, spiritual, and cultural needs explicitly. 1
• Determine the patient's preferred level of involvement in decision-making without making assumptions. 1
• Use structured patient decision aids for preference-sensitive decisions involving trade-offs between benefits and harms. 1

Advance Care Planning

• Review and update advance care plans periodically with patients, families, and caregivers, especially when health status changes. 1
• Document advance care planning discussions in the patient chart and discharge summaries, including designation of substitute decision-makers per provincial/state legislation. 1
• Initiate these discussions early in serious illness, not when death is imminent, as delayed planning negatively impacts outcomes. 2

Care Coordination and Communication

Discharge Planning and Transitions

Effective discharge planning with caregiver and family involvement is essential for smooth transitions:

• Ensure discharge summaries with complete care plans accompany patients to long-term care settings. 1
• Coordinate referrals to community care, hospice services, peer support groups, and disability support services based on patient goals and condition. 1
• Provide information relevant to changing needs at each phase, delivered interactively and adapted to cognitive and communication challenges. 1

Interprofessional Communication

• Explore patient contacts with other healthcare professionals and related management changes to maintain informational continuity. 1
• Use electronic health records to document all diagnoses, conditions, laboratory results, and medication-related problems. 1
• Coordinate between primary physicians and specialists with nurse case management to improve quality of life and reduce readmissions. 1, 2

Rehabilitation and Functional Optimization

• Stroke survivors and patients with ongoing rehabilitation goals must continue accessing specialized services (physiotherapy, occupational therapy) even after long-term care admission. 1
• When reassessments identify functional decline, update care plans to incorporate changes in care requirements, address safety issues, and refer to appropriate healthcare professionals. 1
• Long-term care staff should receive education in stroke care, maintenance and recovery goals, and best practice recommendations. 1

Caregiver Support

Screen adult caregivers routinely and periodically for practical and emotional needs:

• Establish disease and treatment burden effects on caregivers' day-to-day life, mental health, and quality of life. 1
• Assess additional burden from caring responsibilities and incorporate this when considering supports needed for self-management. 1
• Provide supportive care including listening to concerns, attention to grief, and regular information updates about the patient's condition. 2
• Evidence shows individualized multicomponent interventions are more beneficial than limited caregiver interventions. 1

Medication Management in Long-Term Care

Conduct structured medication reviews at least annually, more frequently during hospitalizations (admission, transfers, discharge):

• Evaluate each medication's risk-benefit ratio, potential interactions, adverse effects, and adherence issues. 1
• Be vigilant for prescribing cascades where new medications are prescribed to treat side effects of existing medications. 1
• Use multiple assessment methods: health record reviews, patient surveys during consultations or home visits, direct observation of medication administration. 1
• When goals shift to comfort measures only, reassess all medications and discontinue those no longer necessary (antiplatelets, anticoagulants, statins, hypoglycemics). 2

Quality of Life Prioritization

The primary goal of long-term care is maximizing well-being and quality of life, not disease-specific targets:

• Physical health and safety, independence, emotional well-being, and social engagement are the four key domains stakeholders prioritize for maximizing well-being in long-term care. 3
• Assess and address the quality of resident-carer relationships, as research shows carer behavior and well-being directly impact resident well-being. 4
• Create comforting environments that foster sharing of felt needs and instill hope and encouragement. 5

Common Pitfalls to Avoid

• Avoid fragmented care delivery without coordination: This leads to duplicated services, poor outcomes, and increased hospitalizations. 1
• Avoid conducting assessments without involving patients and family members: Their input is critical for clarifying misconceptions and understanding true needs. 1
• Avoid focusing solely on physical health: The COVID pandemic revealed this narrow focus in long-term care; psychological, social, and emotional domains are equally important. 4
• Avoid delaying palliative care consultation until end-of-life: Palliative care should begin at diagnosis of serious illness and be provided concurrently with other treatments. 2
• Avoid making assumptions about patients' desired level of involvement in decision-making: Always ask explicitly. 1

Reimbursement Considerations

• Care management should be considered a reimbursable benefit by Medicare and other insurance programs to improve patient and family access to these essential services. 1
• Funding for care management is often fragmented, with comprehensive programs available only for Medicaid-eligible or high-resource patients, creating gaps for those of average means. 1