Service and Housing Trends Return to the Beginning
A. Nursing Home Versus Community-Based Care
Fact #19. Your patients are less likely to be in nursing homes now than ten or twenty years ago.
An elder has 25% lower chance of living in a nursing home now than 30 years ago (Redfoot & Pandya, 2002). This change is most likely due to a number of reasons, including:
a drop in the disability rate (Korczyk, 2002) more husbands are living longer and are therefore available to take care of their wives (Korczyk, 2002) Medicare and Medicaid reimbursement policies (Redfoot & Pandya, 2002; Redfoot & Pandya, 2002) elders prefer to receive care at home rather than in a nursing home (Gibson, et al. 2003; Bayer & Harper, 2000)
What does this mean?
Those in community-based practices may be caring for patients who are frailer than ever before. This means that you will need to be familiar with the special care very frail elders need, including incontinence diagnosis and treatment, fall prevention, and medication management.
You will also need to be more vigilant about self-neglect, since functioning can deteriorate dangerously when a frail elder lives alone. If you are concerned, use a screening tool and track your concerns in charts over time so that other nurses know to watch for signs of self-neglect like dehydration and malnutrition.
Fact #20. Some of your patients will be living in new forms of elder housing such as assisted living.
Your patients who can no longer live at home but who are not yet ready for a nursing home now have other options. Usually called "assisted living," these facilities offer an apartment and fewer services than nursing homes. Some facilities also offer "independent living" in seniors-only complexes that generally do not have services included. Some facilities offer a continuum of options from independent living to nursing home care. This can be especially valuable when one member of a couple needs nursing care and the other only assisted or independent living. The number of people in these facilities increased by 50% between 1991 and 1999 (Redfoot & Pandya, 2002) to about 800,000 (National Institutes of Health, 2001).
What does this mean?
Some of your patients may be continue to come to see you even after they enter one of these facilities. Find out what medical and nursing care they receive there and who you may need to speak with to coordinate care.
Elders and their families contemplating these facilities may need your advice about how much in-home care they really need now and are likely to need in the foreseeable future. On one hand, elders who could live independently may be frustrated and depressed in an environment with people who do not function as well as they do. However, being in an assisted living facility when an emergency happens can significantly reduce stress and ensure a frail elder's safety.
Fact #21. Many of your patients will be living at home with in-home services.
Currently, 20,000 home health providers provide care for 5.2 million elders (National Association for Home Care, 2001). This is about one of every seven elders nationally.
What does this mean?
You need to be familiar with what kinds of services are offered for elders in your community. Besides traditional home health care, special services such as adult day health may help keep your older patients safely at home. However, many elders and family caregivers don't know that these services exist so try to keep resource guides and brochures handy.
Communicate with elder service providers within the bounds of confidentiality and time. Home health and adult day staff frequently help elders with care plans and can do a better job if they have better information about what you would like the elder to do.
Fact #22. Patients who depend on Medicare may receive less in-home care than before.
Your patients may not be getting the services they need. Between 1998 and 2000, Medicare spending on home health fell $2 billion due to the Balanced Budget Act. Fewer patients receive Medicare-covered care and those that do generally have fewer visits. Home health agencies also seem to be reducing the number of very ill patients they serve (Smith, Maloy, & Hawkins, 2000). This is especially distressing since there is a statistically significant relationship between use of in-home care and reduced in-hospital care (National Association for Home Care, 2001).
What does this mean?
If you notice that an older patient doesn't seem as well cared-for or isn't following your instructions, they may be struggling with fewer hours of care per week than they need. Also, those who now must private pay for home health care may be scrimping on food or heat. So, if you are worried, ask whether their Medicare home health benefits have been cut. Have a guide to other sources of in-home care, such as state-sponsored programs or Medicaid, in your office to hand out.
B. Health Care Utilization
Fact #23. You will probably see most of your Medicare patients within the next year.
In 1998, 74% of Medicare beneficiaries saw a physician, 18% had an inpatient hospital stay, 8% had Medicare home health services, and 4% were in a skilled nursing facility (Gluck & Hanson, 2001).
What does this mean?
Medicare patients have many contacts with the health care system over a year. These are good opportunities for you to screen for elder abuse or self-neglect, incontinence, and other conditions that may affect an elder's health but which your patients may not bring up themselves.
Fact # 24. More older patients than you know use complementary and alternative medicine (CAM)
Probably about one in three of your older patients used CAM last year. Seniors most commonly use chiropractic, herbal remedies, relaxation, vitamins, religious or spiritual healing. About half aren't telling you about it (Foster, Phillips, Hamel, & Eisenberg, 2000).
What does this mean?
You need to ask about CAM use. This is especially true with patients whose CAM use could be potentially harmful. One example would be those who are taking medications that could interact with herbal remedies or those with pacemakers who use magnets.
Some CAM has also been proven to have benefits. Find out what seems to work so that you can suggest massage to a patient with chronic pain or meditation for someone with hypertension.
C. Out-of-pocket Health Care Costs
Fact #25. Your patients may not be able to pay for your services.
Medicare patients are paying for more and more for their care out-of-pocket. Last year, Medicare HMO patients had a 20% to 34% increase in their out-of-pocket costs. Those in the poorest health paid an average of $4,783 (Gold & Achman, 2002). This problem is made worse by the growing numbers of employers who are dropping their retiree health benefits (Gregory & Pandya, 2002).
What does this mean?
If a patient suddenly stops filling prescriptions or does not get needed care, think about whether they may not be able to pay. Elders will probably not tell you they are scrimping on health care, but they may pick up information about state-sponsored prescription drug programs, Medicaid, and other sources of coverage that you leave in the waiting room. Also, many senior centers or other elder service agencies offer help in finding the cheapest health coverage.
D. Family Caregivers, the Hidden Health Care System
Fact # 26. Many of your older patients have family caregivers.
Family caregivers provide about 80% of the help elders get with activities of daily living (Coleman & Pandya, 2002). One in five caregivers provides at least 40 hours per week of care (Gregory & Pandya, 2002).
What does this mean?
Family caregivers are important partners in keeping your elder patients healthy and you need to get to know them. If you do not know who the caregivers are, ask. If they are sitting out in the waiting room, introduce yourself. When your patient needs a lot of care at home, ask the caregiver what you can do to be of help. They may need information about their relative's medication or training for doing daily tasks like catheterization. A little help along the way can go far to prevent a crisis later.
Fact #27. Your patients who are caregivers may be neglecting their own health needs.
Caregivers are at greater risk for depression and self-neglect (American Association for Geriatric Psychiatry, 2002; Gallant & Connell, 1997). They may feel socially isolated if they cannot leave the person they are caring for alone. They may put off their own care while tending to the greater needs of a relative. They may be injuring themselves moving their relative into and out of bed or chairs.
What does this mean?
Find out who among your patients are caregivers. They may be elders themselves caring for spouses or younger people caring for parents or grandparents. If they seem to be having trouble keeping up with their own needs, refer them to their local senior center for help in getting more services for themselves and their relative. Or, if you know the person they are caring for, maybe you can provide some counsel about whether it is time for their relative to enter a nursing home.
