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
Most important
is the level of care who is dependent of the wish of the ‘client’
Hospice “De Winde” in the Netherland city of
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.
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)
Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community:
Community-Oriented Practice (2nd Edition)
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.
Cicirelli,
V.G. (2002). Older adults’ views on death.
Ebersole, P., & Hess, P.
(2004). Toward healthy
aging (6th ed.).
WEB SITES on Aging
American
Diabetes Association, Facts and Figures: http://www.diabetes.org
Assisted Living
Federation of
National Institute on Aging. http://www.nia.nih.gov