The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 22: Facilitating the TransitionSkilled Nursing CareSometimes a patient with advancing HIV wishes comfort care only, but is referred to a skillednursing26facilitypicasrather than a long-term care facility because of the reimbursement incentivesrelated to restorative care versus long-term care. Medicare skilled nursing facilities cover thecosts of skilled nursing and therapies, and many facilities attempt to maximize the number ofresident days with this coverage because it is the most lucrative for the skilled care facility. 23This may offer patients more care therapies such as hydrating IVs, parenteral nutritional andphysical therapy.The skilled nursing facility, the subacute long-term care option, was designed primarily for geriatricpopulations, to serve patients who required skilled nursing care before going home from anacute hospitalization. 24 Skilled nursing care may be more accessible for HIV-infected clients inneed of physically supportive care. The increasing chronicity of HIV disease with newer therapeuticagents and neuropsychiatric co-morbidities will most probably increase the need for longtermcare. This level of care may be increasingly important not only in reducing acute hospitallength of stays but in creating a bridge to community-based residential options in the emergingchronic disease phase of the AIDS epidemic. 24Child and Adolescent CareChildren and/or adolescents who require a transitional phase of stabilization before going homefrom the hospital have intensive medical, familial, and social needs. (See Chapter 12: The Careof Children and Adolescents.) Chronic care for pediatric AIDS patients requires flexible goalorientation within each treatment phase of care including long-term care and skilled nursingfacilities. An overarching problem is that the U.S. lacks a national care policy to insure childrenand adolescents needing such care. 24Helpful Placement StrategiesInterdisciplinary team social workers will generally be the best resource for placement advice.A well-informed social worker will know about admission criteria and policies of each facility. Athorough assessment of the patient’s social history should reveal any information that may influencehousing placement, such as how well the patient handles conflict, anger, frustration andgrief. Equally important, providers should be knowledgeable about the patient’s dietary restrictions,mental health, substance use, and anti-social behaviors such as confused wandering, sexualrelations, public masturbation, stealing, or personality disorders causing team and social splittingand chaos. 25Regular providers of HIV care would greatly benefit from visits to their local facilities to learnabout the physical settings and support services. Recent consumers of residential housing servicescan also be reliable informants.Encourage the family to visit potential settings and determine which facility feels most suitablein terms of location, attitude of care providers and culture sensitivity.PLANNING FOR DYING■ Planning for death and dying is an important part of caring for the HIV/AIDS patient and hisor her family. Conversations on this topic can be particularly challenging because of the substanceof the issues that must be addressed as well as the difficulties inherent in communica-464U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau