Case Scenario

My 85-year-old patient, E.P., with a history of Alzheimer disease, hypertension, hypothyroidism, and mild chronic obstructive pulmonary disease, has been receiving adult day center support and family care for their Alzheimer disease. E.P. is now wheelchair walking, experiencing delusions and hallucinations, has bowel and bladder incontinence, and is dependent in all activities of daily living. E.P. has not been able to direct their medical and executive affairs for a few years. The adult care center cannot continue to provide services for E.P., and the family is unable to provide further assistance. A family member (E.P.’s guardian) is asking for help with placing E.P. in a long-term care facility. E.P. currently receives Medicaid support. What critical steps do I need to understand and take to assist the patient and their family in transitioning E.P. into a long-term care facility? What information and documentation does the facility need from me to effectively manage this transition?

Commentary

Part 1 of this Curbside Consultation, published in the November 2022 issue of American Family Physician, discussed the importance of planning for long-term care support and services, including strategies for aging in place, alternatives to long-term care facilities, long-term care insurance, and Medicaid requirements.¹ In the case stated here, these alternatives have been exhausted, and the patient now requires care in a long-term facility.

This patient’s experience is a common one. In the United States, approximately 1.3 million people live in 15,600 long-term care facilities; 90% of these individuals are 65 years and older.² About 60% use Medicaid as a payer source.² Nearly 50% of patients in long-term care facilities have dementia, and the majority experience impairments in activities of daily living.²

Selection of a long-term care facility is influenced by many factors, including social and cultural norms, timing of placement (e.g., from hospital vs. from home), language, and family dynamics. Selection is most heavily influenced by location, with the usual goal of being close to family and friends. Secondary factors include facility resources and cost, staffing, racial and language concordance (e.g., Spanish-speaking staff), patient experiences, and the patient’s and family’s overall sense of comfort and confidence in the facility.^3,4 The Alzheimer’s Association (https://www.alz.org) and community Area Agencies on Aging can be valuable resources. The U.S. Centers for Medicare and Medicaid Services collects quality data on long-term care facilities and hosts a website for consumers to compare facilities within a community. The site provides information on facilities’ health inspection results, staffing ratios, and quality measures.⁵ Patients and families should be shown and encouraged to use available resources to guide facility selection.

Long-term care facility placement is likely to result in a transition of medical practice. Only 10% of primary care physicians provide long-term care, and numbers continue to decline.^6,7 Care of adults who are frail and who have medical complexities is increasingly provided by nurse practitioners and physician assistants dedicated to care in a long-term care environment.^6,7 Long-term care facility staff utilize an interdisciplinary team approach to attend to the physical, medical, nutritional, functional, recreational, emotional, social, and environmental needs of residents. Poor communication of the patient’s medical, functional, cognitive, emotional, and social function will result in concomitantly poor transitional care, which increases the risk of medical errors, inappropriate care, adverse outcomes, and patient and family dissatisfaction.⁸

The physician’s focus in transitioning the patient to a long-term care facility is captured in the 4Ms framework described by the Institute for Healthcare Improvement.⁹ Before the move to the facility, the physician should explore the 4Ms: what Matters to the patient and family for future care, Medication use, Mentation, and Mobility (Table 1^9–11). Multimorbidity is often considered a fifth M in this care paradigm because these patients commonly have dementia, depression, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, vascular disease, and/or gastroesophageal reflux disease.^12,13