BACHELOURATE
NURSING PROGRAM
Community
and Public Health Nursing
PRACTICUM
Criteria
for Effective Elderly Service
HEALTH SERVICES FOR
OLDER ADULT POPULATIONS
How well are the needs of older adults being met? To
answer this question, other questions must be raised. Do health programs for
the elderly encompass the full range of needed services? Are programs both
physically and financially accessible? Do they encourage elderly clients to
function independently? Do they treat senior citizens with respect and preserve
their dignity? Do they recognize older adults’ needs for companionship,
economic security, and social status? If appropriate, do they promote
meaningful activities instead of overworked games or activities such as bingo,
shuffleboard, and ceramics? Games can be useful diversions, but they must be
balanced with opportunities for creative outlets, continued learning, and
community service through volunteerism (see What Do You Think? II).
Services for
Healthy Older Adults
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.
Health Services
People over age 65 need regular primary health care
services to maintain health and prevent disabling chronic illness and
life-threatening conditions. Health promotion services that can form the basis
for a community nursing intervention include:
- Immunizations
(influenza, diphtheria, tetanus, pneumococcal vaccine)
- Screening
for chronic illnesses, such as cancers, cardiovascular disease, and
diabetes
- Management
and control of existing chronic illnesses (health education, case
management, and medication management)
- Knowledge
of coverage and reimbursement practices (including alternative medicine)
of Medicare/Medicare Managed Care, Medicare supplemental insurance, and
specific state health insurance programs
- Community
outreach and advocacy efforts to ensure linkage of elderly people to
needed resources, such as health advocates, health coaches, and community
gatekeepers. These individuals may be trained employees of businesses,
churches, and corporations who can refer elders to community resources
(Florio et al., 1996).
- Referral
to existing state pharmacy assistance programs and advocacy to establish
such programs where they are needed
- Education
and outreach related to the Medicare Prescription Drug, Improvement and
Modernization Act of 2003
- Education
on medication management (scheduling, adherence, calendars, and so forth)
- Continuous source of primary care
- One-stop
shopping for health care
- Connection
to chronic illness support groups.
Several criteria help to define the characteristics of
an effective community health service delivery system for the elderly. Four, in
particular, deserve attention.
For the delivery system of a community health service
to be effective, it should be comprehensive. Many communities provide some
programs, such as limited health screening or selected activities, but do not
offer a full range of services to more adequately meet the needs of their
senior citizens. Gaps and duplication in programs most often result from poor
or nonexistent community-wide planning. Furthermore, such planning should be
based on thorough assessment of elderly people’s needs in that community. A
comprehensive set of services should provide the following:
• Adequate financial support
• Adult day care programs
• Health care services (prevention, early diagnosis
and treatment, rehabilitation)
• Health education (including preparation for
retirement)
• In-home services
• Recreation and activity programs
• Specialized transportation services
A second criterion for a community service delivery
system is coordination. Often, older people go from one agency to the next.
After visiting one place for food stamps, they go to another for answers to
Medicaid questions, another for congregate dining, and still another for health
screening. Such a potpourri of services reflects a system organized for the
convenience of providers rather than consumers. It encourages misuse and
discourages use. Instead, there should be coordinated, community-wide
assessment and planning. Communities must consider alternatives, such as
multiservice agencies, that can meet many needs in one location.
A coordinated information and referral system provides
another link. Most communities need this type of information network, which
contains a directory of all resources and services for the elderly and includes
the name and telephone number of a contact person with each listing. Such a
network is available in some communities and should be developed in those
without one. A simplified information and referral system that includes one
number, such as an 800 number, to call to find out what resources and services
are available and how to get them is particularly helpful to older people.
In most communities, coordination is not present, or
it is not done with any regularity or thoroughness. Many agencies in a given
community do not coordinate services, but instead deliver their own services to
the elderly in a patchwork and uncoordinated fashion. Collaboration among those
who provide services to seniors can provide vital information for planning and
implementing needed programs. This was documented in a seven-county area in
central
A third criterion is accessibility. Too often,
services for the elderly are not conveniently located or are prohibitively
expensive. Some communities are considering multiservice community centers to
bring programs and services for the elderly closer to home. More convenient and
perhaps specialized transportation services and more in-home services, such as
home health aides, homemakers, and Meals on Wheels, may further solve
accessibility problems for many older adults. Federal, state, and private
funding sources can be tapped to ease the burden on the economically pressured
elderly population.
Finally, an effective community service system for
older people should promote quality programs. This means services that truly
address the needs and concerns of a community’s senior citizens. Evaluation of
the quality of a community’s services for the elderly is closely tied to their
assessed needs. What are the needs of this specific population group in terms
of nutrition, exercise, economic security, independence, social interaction,
meaningful activities, and preparation for death? Planning for quality
community services depends on having adequate, accurate, and current data.
Periodic needs assessment is a necessity to ensure updated information and to
initiate and promote quality services.
Health Promotion
and Health Protection Strategies for Community Elders
Health promotion and health protection are two
elements of primary prevention. Health promotion denotes emphasis on helping
people change their lifestyles and move toward a state of optimal health,
whereas health protection focuses on protecting people from disease and injury
by providing immunizations and reducing exposure to carcinogens, toxins, and
environmental health hazards. The concept of health for the elderly must be
revisited in planning health promotion interventions. Filner and Williams
(1979) define health for the elderly as the ability to live
and function effectively in society and to exercise self-reliance and autonomy
to the maximum extent feasible, but not necessarily as freedom from disease.
Messecar (2002) found that older people themselves define health as going and
doing something meaningful, which consists of four components: 1) something worthwhile
and desirable to do; 2) balance between abilities and challenges; 3)
appropriate external resources; and 4) personal attitudinal characteristics.
More than any other age group, older Americans are actively seeking health
information and are willing to make changes to maintain their health and
independence. Health promotion efforts should focus on modifiable risk
behaviors, matched to the leading health problems by age (USDHHS, 2002). Hahn
(2003) interviewed older ethnic women attending a senior center and found that
they defined healthy as being able to perform meaningful activities, which in
turn keep them healthy. It is evident from these views of health that health
care goals for elderly persons must focus on improving functional ability, maintaining
independence, and helping them find meaningful activities in life. To maximize
health promotion for community elders, a multifaceted approach is needed.
Interventions should target individuals and families as well as groups and
communities.
Individual- or
Family-Focused Interventions
Individual- or family-focused health promotion/health
protection interventions are designed to increase the individual's or family's
knowledge, skills, and competence to make health decisions that maximize
health-promoting and health-protecting behaviors. The goal is empowerment of
the elderly and their families to make rational health decisions. Some
categories of health promotion and health protection intervention that target
the individual and/or family are:
- Health screenings
- Lifestyle modification
- Health
education (one-to-one or group)
- Counseling
- Support groups
- Primary health care
- Immunizations
- Home safety
- In-home
care (home health, personal care, or household assistance)
- Home-delivered meals
- Social
support (telephone reassurance and home visiting)
- Case management
- Home maintenance help
Community-Focused
Interventions
Community-focused interventions are activities and
programs that are directed toward community elders as a whole or various
elderly subgroups in a community. The goal of community-focused
interventions is to improve community capacity and availability of the appropriate
mix of health and social services required to prolong independence and
functional status of community elders. Interventions at the community level
primarily involve advocacy, political action, and participation in policy
making that affects community elders. Examples of community-focused
interventions are:
- Community-wide
health educational campaigns that emphasize older people
- Holding
campaigns in May, which is designated as "Older American Month"
- Community
coalitions to address specific elderly issues, such as development of
local information centers, telephone hotlines, or Internet sites
- Political
involvement to advocate for needs of the elderly, such as preserving or
expanding Medicare coverage for in-home services
- Collaboration
with universities, churches, senior centers, senior housing projects, and
other established community organizations to provide comprehensive
services to subgroups of elders
- Crime prevention activities
- Participation
in community-based health fairs.
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
Picture 1. The farm “Erve
Knippert” is a good example of elderly daycare center.
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).
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.
Picture 2. Lunch in the nursing
home.
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.
Picture
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.
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)
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