TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

INTERNATIONAL NURSING SCHOOL

 

Health Services for Older Adult Populations

OBJECTIVES:

● Living Arrangements and Care Options.

● Day Care and Home Care Services.

● Living Arrangements Based on Levels of Care.

● Hospice and Respite Care Services.

 

 

Maintaining functional independence should be the primary goal of services for the older population. Assessment of needs and the ability to function and use of techniques such as OARS, the Instrumental Activities of Daily Living Scale, or other previously mentioned tools form the basis for determining appropriate services. Although many of the well elderly can assess their own health status, some are reluctant to seek needed help. Therefore, outreach programs serve an important function in many communities. They locate elderly people in need of health or social assistance and refer them to appropriate resources.

 

Health screening is another important program for early detection and treatment of health problems among older adults. Conditions to screen for include hypertension, glaucoma, earing disorders, cancers, diabetes, anemias, depression, and nutritional deficiencies (Eliopoulos, 2001). At the same time, assessment of elderly clients’ socialization, housing, and economic needs, along with proper referrals, can prevent further problems from developing that would compromise their health status.

 

Health maintenance programs may be offered through a single agency, such as an HMO, or they may be coordinated by a case management agency with referrals to other providers. These programs should cover a wide range of services needed by the elderly, such as those listed in Display 30–6.

 

Living Arrangements and Care Options

 

Three types of living arrangements and care options are available for elders. Some living arrangements are based on levels of care—from independent to skilled nursing care, and all levels of assistance in between. At times, seniors who remain in their own homes or apartments need home care services brought to them. Other seniors live with family members and go to an adult day care center during the day. The third category of living arrangements is those that are short term. It may be for respite care, which gives the usual caregiver a much-needed rest from 24-hour-a-day caregiving and helps prevent “burnout.” Families of terminally ill clients cared for at home often use respite services. Finally, hospices provide comfort-focused care in a homelike atmosphere for people who have less than 6 months to live.

 

To meet the multiple housing and caregiving needs of today’s elders and in anticipation of the larger numbers to come, many options are becoming available. A range of housing types, from luxurious retirement communities with all amenities for the active and healthier senior to secure and more modestly priced or low-income apartments for independent senior living, are being built in most communities.

 

Day Care and Home Care Services

 

Most older adults want to remain in their own homes for the remainder of their lives and be as independent and in control of their lives as possible. Some struggle to appear to be doing well in maintaining their independence. Often, they fear that their children or others will make decisions for them that include leaving their homes. Home, whatever form it takes, is where these people believe they are the happiest. There is increased emphasis on providing needed services for elders at home. This trend started several years ago when it became evident that people improved more quickly and at lower cost when they were cared for as outpatients in their own homes. Today’s heightened emphasis on health care cost control gives added support for providing services at home. Given the increase in longevity, the potential for cost savings appears great if dependent older people can be maintained at home. Doing so encourages functional independence as well as emotional well-being.

 

Home care provides services such as skilled nursing care, psychiatric nursing, physical and speech therapies, homemaker services, social work services, and dietetic counseling (see Chapter 37). Day care services offer a place where older adults can go during the day for social activities, nutrition, nursing care, and physical and speech therapies. Both services are useful for families who are caring for an elderly person if the caregivers work and no one is at home or available during the day. One disadvantage to those remaining at home is that services for the dependent elderly in the community are often fragmented, inadequate, and inaccessible, and at times they operate with little or no maintenance of standards or quality control.

 

The dependent elderly need someone in the community to assess their particular needs; assemble, coordinate, and monitor the appropriate resources and services; and serve as their advocate. Such case management roles are most appropriately filled by the community health nurse. This case management approach tailors services to the long-term needs of clients and enables them to function longer outside of institutions (Fast & Chapin, 2000).

 

  

Picture 1. The farm “Erve Knippert” is a good example of elderly daycare center.

 

Living Arrangements Based on Levels of Care

 

Although only 6% of the elderly population live in skilled nursing facilities, such organizations remain the most visible type of health service for older adults. These facilities provide skilled nursing care along with personal care that is considered nonskilled or custodial care, such as bathing, dressing, feeding, and assisting with mobility and recreation. Currently, approximately 2 million elderly people are receiving nursing home care.

 

Long-term care services “include all those services designed to provide care for people at different stages of dependence for an extended period of time” (Miller, 1999, p. 662). New choices are now available and provide housing for larger numbers of elders than nursing homes.

 

Nursing home reform was promoted in 1987 with passage of the Omnibus Budget Reconciliation Act (OBRA), which put increased demands on facilities to provide competent resident assessment, timely care plans, quality improvement, and protection of resident rights starting in 1990 (Miller, 1999). This increased complexity of services has resulted in increased costs in these facilities. Staffing needs increase as care becomes more complex and the resident population grows. Licensed personnel must be knowledgeable decision-makers, managers of unskilled staff, staff educators and role models, and efficient and effective administrators in an essentially autonomous practice setting.

 

In the past, nursing homes had stigmas attached to them. Many people saw them as places that enforced dehumanizing and impersonal regulations, such as segregation of sexes, strict social policies, and sometimes overuse of chemical and physical restraints. Media attention to such conditions, together with current licensing regulations, should make these types of practices the rare exception. Gradually, the fear and despair associated with such facilities will begin to dissipate. In addition, as competition comes from facilities offering lower levels of care (eg, assisted living centers), residents in nursing homes who are receiving more minimal care may be attracted to move to other types of housing.

 

Even in institutions in which the quality of care is outstanding, costs are so high that family resources are soon depleted if not planned for long in advance of the need. Although Medicaid pays for skilled nursing costs if the client meets low income and asset requirements, and Medicare pays for a limited period, clients and families pay more than half of the total costs (Eliopoulos, 2001). Life savings that older parents had hoped to leave to their children may be quickly consumed, forcing them into indigence. In 2004, it was not unusual for a skilled nursing facility to cost $4000 to $6000 per month based on level of caregiving needed and amenities offered.

 

Intermediate care facilities are less costly and still provide health care, but the amount and types of skilled care given are less than that provided in skilled nursing facilities. Frequently, older adults need assisted living. According to the mission statement of the Assisted Living Federation of America, “ALFA’s primary mission is to promote the interests of the assisted living and senior housing industry and to enhance the quality of life for the population it serves” (Assisted Living Federation of America, 2004). This is a less intense level of care than intermediate care units or facilities provide. Medicare generally pays only for care in skilled nursing facilities. Medicaid pays for care in intermediate care facilities, but only after the client meets income and asset tests that leave them essentially indigent. Costs in 2003 for assisted living choices averaged $4000 a month.

 

Personal care homes offer basic custodial care, such as bathing, grooming, and social support, but provide no skilled nursing services. Payment may also come from private funds, Title XIX or XX (Social Security Act) funds, or Supplemental Security Income (aid to the aged, disabled, and blind). Boarding homes, board and care homes, and residential care facilities house elderly people who need only meals and housekeeping and can manage most of their own personal care. Government funds are not available to support these institutions. Costs averaged $2400 a month for a shared room in 2004. Group homes are an alternative for specific elderly populations, such as the mentally ill, alcoholics, or developmentally disabled individuals. They are often subsidized by concerned community organizations. Homes focusing on the care of people with AD are physically designed with clients’ safety and individual needs considered and are staffed with paraprofessionals trained to meet each person’s needs.

The concept of continuing care centers (sometimes called total life centers), in which all levels of living are possible, from total independence to the most dependent, are designed to meet the continuous living needs of older aging adults (Display 30–8). This choice is usually expensive; however, it is a very attractive alternative for wealthier segments of the aging population. Others may choose to remain in their own home because they do not desire consolidated living arrangements in which only older adults reside or because they cannot afford such an arrangement. Nevertheless, demand is increasing for this type of housing option. Adults nearing retirement today are investigating this concept as a viable choice as they actively plan for a long old age. Many of these centers have a 5- to 10-year waiting list, so older adults need to seek them out long before they intend to live there.

 

Nursing Homes

Different Products:

-  Rehabilitation

-  Day care

-  Chronical mental illness

-  Chronical physical illness

 

Attitudes of staff

Affect both quality of treatment and regard given to maintaining autonomy and dignity

Negative Attitudes

-  Stereotypical attitudes are common amongst professionals

-  Considerable numbers of professional staff have pessimistic views of older people

-  A nurse’s pessimistic attitude can translate into a loss of dignity, identity and decision-making power for seniors

 

Positive Attitudes

-                                      Specialist education and training promotes a positive attitude

-                                      Positive attitude can enhance quality for life for older people

-                                      Positive attitudes enable patients to retain autonomy and dignity for longer

 

Nursing Home Care

-Symptom management on the basis of evidence based knowledge, guidelines and protocols

Ø     Communication skills and active listening

Ø     Skills to provide information [written and verbal]

Ø     Able to provide holistic care

Ø     Spiritual support

Ø     Psychological support

Ø     Complementary therapy

Ø     Skills to support families and caregivers

Ø     Bereavement support

Ø     Skills to coordinate care across different settings

Ø     Coordination, continuity and seamless care

 

Levels in Nursing Home Care

       Depending on complexity of the product:

Ø     Low care [care workers, volunteers, nurse as a consultant, level 2 and 3]

Ø     Medium care [nurses, care workers, volunteers, level 3 and 4]

Ø     High care [nurses, volunteers, level 5]

 

 

Hospice and Respite Care Services

 

Respite care is a service that is receiving increasing attention. It is aimed primarily at caregivers’ needs. Many older people at home are cared for by a spouse or other family member. The demands of such care can be exhausting unless the caregiver gets some relief, or respite—thus the name of this service (see Chapter 37). Respite care may be available through an agency that provides volunteers to relieve caregivers, giving them time off regularly or permitting a periodic vacation. Some skilled nursing facilities or board and care homes provide an extra room to give temporary institutional housing for the elderly while caregivers take a break.

Elderly clients may also need a change from the constant interaction with their caregivers.

 

Hospice care may be offered through an institution, such as a hospital or home health agency, or it may be a freestanding facility existing solely as an inpatient hospice. Hospices and other agencies providing hospice care offer services that enable dying people to stay at home with the support and services they need. The purpose of hospice care is to make the dying process as dignified, free from discomfort, and emotionally, spiritually, and socially supportive as possible. Some community health nursing agencies offer hospice programs staffed by their nurses. It is a service that has been well received by elders, meets important needs, and is growing in use. Hospice and respite care are two services most needed and used by the families of clients with AD.

 

Organization of palliative care

In any setting

Based on guidelines and [nursing] standards

Continuity of care

Team approach

Multidisciplinary

Coordination of care

 

Specialized care

Level of care needed [low, medium, high care]

 

Levels in palliative care

Depending on complexity:

Low care [care workers, volunteers, nurse as a consultant]

Medium care [nurses, care workers, volunteers]

High care [nurses, volunteers]

 

In our understanding finding a new balance of Cure and Care in a nursing home means promoting independence in dependence.

 

Factors:

Autonomy and dignity

Attitudes of healthcare professionals

Exposure of staff to healthy older people

Education and training

 

Information provision

 

Cultural expectations

 

Summary
 
Levels of care are dependent of the product

*      Levels of care are dependent of the organization

*      Levels of care are dependent of de concept / vision of the organization

*      Levels of care are dependent of Bologna

*      Most important is the level of care who is dependent of the wish of the ‘client’

 

 

 Hospice “De Winde” in the Netherland city of Enshede.

 The dining room in the “De Winde” Hospice gives the possibility for socialization of its clients: having coffee or some parties together, inviting friends and relatives inside.

  Relaxation room is a part of holistic care: a place for meditation, prayer.

 There is a peaceful environment in the yard of the hospice.

 

 Boards with photos of all the staff members of the hospice give clients and their relatives possibility to be familiar with them.

   The rooms in the hospice don’t look like hospital rooms: it’s a house. Clients are encouraged to bring their own staff from their home.

 

 

READINGS

Allender, J. A., Spradley, B.W. (2001). Community Health Nursing: Concepts and Practice (5th edition). Lippincott Williams & Wilkins; 5th edition (January 15, 2001). 799 pages. ISBN-13: 978-0781721226. Chapter 30, Pp. 719-726.

Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.

Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.

Allender, J. A., Spradley, B.W. (2004). Community Health Nursing: Promoting and Protecting the Public's Health (6th Edition) Lippincott Williams & Wilkins, 2004. – 992 p.

 

Additional readings:

Age-friendly Primary Health Care Centres TOOLKIT // World Health Organization, 2008.

Bell, V., & Troxel, D. (2001). The Best Friends staff: Building a culture of care in Alzheimer’s programs. Baltimore: Health Professions Press.

Burbank, P.M. & Riebe, D. (2002). Promoting exercise and behavior change in older adults: Interventions with the transtheoretical model. New York: Springer.

Cicirelli, V.G. (2002). Older adults’ views on death. New York: Springer.

Ebersole, P., & Hess, P. (2004). Toward healthy aging (6th ed.). St. Louis: Mosby.

 

WEB SITES on Aging

American Diabetes Association, Facts and Figures: http://www.diabetes.org

Assisted Living Federation of America http://www.alfa.org

National Institute on Aging. http://www.nia.nih.gov