High Risk Admissions in Nursing Homes: Spotting the Red Flags and Taking Steps Toward Prevention

Skilled nursing facilities are frequently faced with admissions that, although initially are very appropriate, eventually turn into headaches for the administration. What characterizes the high-risk admission and what are some of the red flags that trigger us to the possibility that there could be difficulty down the road? First, families who present with conflicted decision making. In other words, they disagree with one another on the course of the care, and what is the most effective or the most appropriate care necessary. Or, there may be family members residing in different cities yet there has been no single person to assume a primary role or more care than the others, and suddenly the mother has to be placed in a nursing home. Here, we have what is called a diffusion of responsibility – no one and everyone wants to decide what’s best for the mother. Another red flag is when a family member who has been out of the picture and surfaces, taking control of all affairs, or attempting to take control, and now wants to make all health care decisions.

Another category of high risk admissions includes those families with very unrealistic positions on resident care. For example, when there are demands for very special schedules or personalized care. This is reflected in the case where the family member adamantly says that “my mother never bathed in the morning, she always took a shower at night – you’ll just have to accommodate her. This must be included in her schedule.” Another example is where there are very unrealistic expectations about the treatment that is required for a given condition, or the diagnosis that precipitated the admission. Families may disagree on how aggressive or non-aggressive the treatment should be. Is palliative care desired, or is aggressive treatment desired for the patient with a terminal condition. There may be very real differences of opinion in a given family context. Anytime we have these unrealistic expectations or mixed opinions we have the potential for caregiving conflicts. Conflicts among family members about "do not resuscitate orders" are frought with risk.

Families may disagree on how much care and how much cost they want to put into the long-term treatment of a loved one. When we have these disagreements, there is, again, a potential red flag. Similarly, another red flags comes up when the resident has clear desires about what type of care he or she wants, and the family refuses or vice versa, especially when the resident is alert and capable of his or her own health care decisions.

The third category of high-risk admissions includes those where there is a strong emotional component, or emotional overlay to placement. An example of this is when the family member, requiring placement, creates the guilt and overwhelming feelings of helplessness on the part of the family member, in turn creating more stress surrounding the admission. How often have we heard the phrase, “How could you do this to me after all I’ve done for you. You promised you’d never put me in a nursing home.” Such families may become very conflicted about what the best course of action should be. Again it just doesn’t necessarily mean there will be problems, but it is a potential cause for concern, especially if the resident makes hurtful comments to the family or makes them feel worse throughout the placement. The common refrain “After all I’ve done for you – how could you let me down like this” can be quite an emotional burden for some family members, and can cause families to be hyper-vigilant about the patient’s care.

Another common problem is when the placement is rushed and there has not been proper time to look for the most appropriate level of care that is needed. For example, a hip fracture or other acute development requiring placement in a facility when the family is unprepared, often leads to strong emotional reactions. Or, when the necessary admission actually accelerates the decision and confirms for the family that placement is needed can create conflict between patient and family. In other cases, there may be regrets about the costs of long term care, and fears about depleting the parent’s savings. Questions like “How can we spend all this money, doesn’t she qualify for Medicaid, doesn’t she qualify for Medicare. What do you mean we have to pay privately?” can easily generate dissention and conflicts about the placement, and may lead to serious caregiving complaints among the family members.

The last category of the high risk admission would include “hot buttons,” like the family that brings up their influential friends or a neighbor who happens to work for the District Attorney’s Office. Or, in another example, the family who stresses that they really want to be involved and want to be part of all the decision making, but they are unavailable by phone and they instruct that you only call between 7:00 and 8:00 p.m. on Monday nights. This mixed message – the expressed desire to be involved coupled with limited access – is a sign of potential difficulty, and the possibility that any untoward events will be perceived as lapses in good caregiving. Of course, the family member who complains on admission about the other facilities that Mom or Dad has been in, and recounts multiple placements over the past year, or certainly any resident with an outstanding law suit elsewhere definitely raise a red flag.

Here are some recommended steps to manage these high risk admissions:

o educate the patient and the family on the progression of their particular disease, and what level of care will be offered? What are the industry standards? Help to understand what the family’s expectations and how these fit with the facility’s routine care practices. Offer a detailed explanation about the progression of that particular disease or diagnosis precipitating the admission.

o clarify what expectations families have about nursing homes and placement, and try to uncover any misunderstandings about day-to-day issues they may have. What do they think is standard care regarding scheduling and what happens to laundry and personal items, how are the meals selected? When happens when there is a change of condition, what’s routine, what’s not routine.

o Help families to understand there is always a decision between balancing dependence and independence. How much care do we want to offer? How much ADL assistance, how much help with getting dressed? Is it better for the person to do it himself. Is it better for him to comb his own hair, to do his own grooming and hygiene? Or, is it better for the caregivers? What’s the trade-off? Yes the caregivers do it, the CNA’s do it, and yes, the job may get done quicker, it may be even better, but at what cost? If the patient does it and maintains some level of independent self-care it may not be the best, but it gives that person some level of dignity and purpose, rather than being so dependent on others.

o assign someone on the staff who will take on the role of being the designated risk manager, to do the trouble shooting, to handle the high-risk cases and to provide the role model for other staff so that they can develop these skills, especially those requiring good communication and problem solving.

The family that is part of these decisions and participate in care plans are really much more involved and are less likely to have an angry reaction or become dissatisfied, and less likely to threaten a lawsuit when something does go wrong. Primary prevention means keeping families involved in decision making, and not on the periphery as mere spectators of care.

If you are interested in this topic (the angry resident and avoiding litigation) or related subjects, visit the cohealth website (http://www.cohealth.org/) for a full array of programs on behavioral approaches to caring for older adults. CoHealth programs on end of life decision making, improving communication and safety in health facilities, ethical dilemmas, and motivational interviewing can enhance the work that we do as caregivers, and ultimately improve the welfare of our patients.