AURELIO, LYCA MAE BSN III-D

HOME CARE/NURSING HOMES

Health in Aging (2021). Nursing Homes. https://www.healthinaging.org/age-friendly-healthcare-

you/care-settings/nursing-homes

Nursing homes have changed dramatically over the past several decades. These changes have
been driven by government regulations and consumer pressures. When compared to nursing
homes of past decades, today’s nursing homes are highly regulated and high-quality,
sophisticated institutions for the care and treatment of older adults who have severe physical
health concerns and/or mental disabilities. Assisted-living facilities do not have the same
regulations that guide care in nursing homes.

The Most Common Reason for Living in a Nursing Home

Some type of disability when it comes to performing the activities of daily living (ADLs) is the
most common reason that older people live in nursing homes. Not surprisingly, people living in
nursing homes generally have more disability than people living at home. Over 80% of nursing
home residents need help with 3 or more ADLs (such as dressing and bathing). About 90% of
residents who are able to walk need assistance or supervision.  More than half of residents
have incontinence (the inability to control bowels or the bladder), and more than a third have
difficulty with hearing or seeing.

In addition to physical problems, mental conditions are common in nursing home residents. In
fact, dementia remains the most common problem, and affects an estimated 50-70% of
residents. More than three fourths of nursing-home residents have problems making daily
decisions, and two-thirds have problems with memory or knowing where they are from time to
time.  

At least one-third of nursing home residents have problematic behaviors. These behaviors may
include being verbally/physically abusive, acting inappropriately in public, resisting necessary
care, and wandering. Communication problems are also common—almost half of nursing home
residents have difficulty both being understood and understanding others. Depression is
another condition that affects nursing home residents. Research has shown it may occur more
in nursing home residents than in individuals living in the community.  

Length of Stay

Length of stay varies greatly in nursing homes. About 25% of people admitted to these facilities
stay only a short time (3 months or less). Many people who stay for a short time are initially
admitted to the nursing home for rehabilitation or for terminal (end-of-life) care. About half of
residents spend at least one year in the nursing home, and 21% live there for almost 5 years.
Interestingly, function often initially improves in many residents who stay for a longer time.  

Risk Factors for Admission

There are several risk factors for admission to a nursing home:

 Age. The chance of being admitted to a nursing home increases with age. For example,
about 15% of people 85 years and older live in nursing homes, compared with just 1.1%
of people 65-74 years of age.

 Low income.

 Poor family support, especially in cases where the older adult lacks a spouse or
children.

 Low social activity.

 Functional or mental difficulties. 

 Race/ethnicity. People who are Caucasian are more likely than others to be admitted to
a nursing home.

 Geriatric syndromes (such as frailty, frequent falls, pressure sores, dementia, etc.) also
increase the risk for nursing home admission.

Characteristics of Nursing Homes

Nursing homes increasingly offer medical services similar to those offered in hospitals after
surgery, illness, or other sudden medical problems. Older adults need a higher level of care, and
hospital stays are shorter than they used to be. Medical services vary a lot among nursing
homes, but usually include:

 skilled nursing care

 orthopedic care (care for muscle, joint, and bone problems)

 breathing treatments

 support after surgery

 physical, occupational, and speech therapy

 intravenous therapy and antibiotics

  wound care 

Nursing homes provide nutritional counseling, social work services, and recreational activities,
as well as respite care, hospice care, and end-of-life care. However, it is important to know
goals of care in a nursing home and what to expect during a stay at a nursing home. Nursing
homes are not hospitals, and you may not get the same intensity of care in terms of testing,
evaluations by physicians, nurse practitioners or other team members. Also, nursing homes do
not have in-house pharmacies as well as diagnostics such as laboratory services, radiology
services in their facility. They mostly contract with programs in the community for these
services. Care is tailored to what is needed based on state of health and skilled care needs.

HOSPICE FACILITIES

Chilton, L. (2021). Palliative Care for Older Adults.

https://www.medscape.org/viewarticle/464726

Defining Palliative Care

Palliative care is defined as care serving to ease discomfort or relieve pain without curing. The
palliative care movement started in Britain as a result of the pioneering work of Dame Cicely
Saunders, who was both a nurse and a physician, and who focused on comfort rather than
cure. The primary goal of palliative care is to provide the best quality of life possible at the end
of life for both patients and families of terminally ill patients.

Illness and dying may affect the elderly and their families differently from younger individuals.
The highly specialized field of palliative care nursing for the older adult was addressed by
Marianne Matzo, PhD, APRN, BC, FAAN, Professor, New Hampshire Community Technical
College, and Associate Professor in the Graduate School of Nursing, University of
Massachusetts, in Worcester, Massachusetts.

The World Health Organization definition of palliative care was introduced by Matzo as an
approach that relieves suffering and improves the quality of life of patients and their families
facing life-threatening illness. Dying needs to be thought of as a normal life process. Palliative
care uses an interdisciplinary approach that offers a support system to help the dying patient
and his/her family cope during the end stage of a terminal illness. In addition to a focus on
symptom relief and pain management, palliative care includes psychological and spiritual care,
as well as bereavement counseling as needed.
Growing Trend Toward Nursing Home Care and Home Care of Elders at End of Life

The chronically ill, aging population is growing. It is estimated that the number of individuals
over the age of 85 years will reach 9 million by the year 2030. These patients need a continuum
of care that includes the final stages of terminal illness.

Since the 1980s, there has been a shift in care from acute care settings to home and long-term
care settings for individuals who are dying. The site of death for most Americans (64.1%) in
1989 who died from a chronic disease was the hospital. By 1997, only 8 years later, the number
of individuals who died in a hospital due to a chronic condition had decreased to 51.8%. Today,
more individuals are dying at home and in nursing homes rather than in hospitals.

Approximately 23% of individuals die at home today, while approximately 24% die in nursing
homes. In 1989, only 17% died at home and 18% spent their last days of life in a nursing home.
With almost half (47%) of individuals with terminal illness dying at home or in nursing homes
today, there is a growing need for palliative care in these settings.

In addition, nearly 1 in 2 persons who reaches the age of 80 years or older will spend time in a
nursing home prior to death. On any given day, there are 1.5 million Americans in nursing
homes. Federal reimbursement policy has resulted in shorter hospital stays and the increased
use of nursing homes for dying elders. It is projected that 40% of Americans will die in nursing
homes in the future.

Institutionalization adds to the cost of care for the terminally ill person. It is estimated that 1.3
trillion dollars were spent in 2001 on dying patients. Additionally, 11% of the US health dollar is
spent in the last year of life, with most of it being spent on hospital and nursing home services.
Much of this expense is on high tech medical care rather than palliative or comfort care.

Where Do Elders Die? Preferences at End of Life

In the United States, more than 80% of all individuals have expressed that they would prefer to
die at home and avoid hospitalization during the terminal phase of an illness. However, these
wishes are usually not followed at the end of life. Older individuals prefer to have family
members for caregivers at the end of life. They do not want to burden their family with huge
financial burdens.

Where people actually die tends to depend on their state of residence rather than on patient
preference. Individuals in Alabama, Hawaii, Oregon, Idaho, Nevada, New Mexico, Utah, Rhode
Island, and Washington DC are more likely to die at home. Those people living in North Dakota,
South Dakota, Nebraska, Iowa, Illinois, Louisiana, Mississippi, Tennessee, and Georgia are least
likely to die in a family home.

The proportion of deaths occurring in nursing homes also varies from state to state. Individuals
in Nevada, Louisiana, Mississippi, Alabama, and West Virginia are least likely to die in a nursing
home. States where individuals are most likely to die in a nursing home include Washington,
Arizona, South Dakota, Nebraska, Minnesota, Wisconsin, Connecticut, and Massachusetts.

Functional decline is an important determinant for site of death. Individuals who are impaired
for at least 12 months before death are more likely to die in a nursing home. If the patient has a
disease with a rapid and late decline, they are more likely to die at home. Cancer patients are
more likely to die at home because of a more predictable trajectory of the disease. Most older
people would prefer to die in their own homes rather than in a nursing home or a hospital.

Palliative Care Services in the Home

Palliative care services that are brought into the home can assist patients and families in coping
with the problems associated with terminal illness. Palliative care is the broader term that
includes all stages of terminal illness. Palliative care includes care for all individuals who have a
terminal disease, and applies the principles of caring rather than curing early in the disease
process, while hospice care is focused on the very end of life, usually the last 6 months. Ideally,
palliative care would proceed into hospice care as the patient nears the end of life. Hospice
care is usually provided in the home setting, but is also provided in freestanding hospice
centers, hospitals, and nursing homes. Treatment options are evaluated in the light of relief of
symptoms and in the context of individuals' values. An individualized plan of care is developed
for each patient to meet his or her needs of pain control and symptom management.

The hospice team provides specific services for the patient at the end of life. In addition to pain
control and symptom management, hospice team members help the patient and family with
spiritual, psychosocial, and emotional needs. Families are taught how to care for the patient in
the home. Medical supplies, equipment, and medications are provided by hospice. Special
services such as physical therapy and speech therapy are provided as needed. If symptoms or
pain becomes too difficult to manage in the home, or the caregivers need some respite time,
short-term inpatient care may be made available. Additionally, hospice provides bereavement
counseling to surviving friends and family.

Hospice care is covered under Medicare, Medicaid, private insurance plans, and managed care
organizations. The Medicare hospice benefit is especially helpful to elders who use the majority
of hospice services. Medicare benefits cover all of the services that hospice provides, including
medications, medical supplies, and equipment such as hospital beds and commodes. The
hospice Medicare benefit was created in the 1980s as a cost containment measure as well as a
service to improve the quality of care for the dying patient. This benefit is for persons with a 6-
month survival expectancy. Regulations require a 6-month prognosis and a decision to forego
coverage for prolonging care. This benefit can be repeated in 6-month intervals by order of a
physician according to Medicare legislation. Only 1 in 5 individuals will use their hospice benefit
in the United States.

Hospice care focuses on comfort and pain control for the dying patient. Pain control, including
the use of analgesics and comfort measures, may be better achieved in the home rather than in
a hospital setting where the focus of care is on healing. Individuals may be closely monitored by
family members for signs of discomfort.

Role of the Nurse Practitioner in Palliative Care

The gerontological nurse practitioner (GNP) has the educational and experiential background to
provide support for older dying patients and their families through the use of palliative care.
When patients are in a hospital or nursing home, the GNP can support and educate staff on
palliative care and pain control measures. GNPs can be a resource for providing psychological
support to families and patients. The GNP can use the palliative care model to reduce the
length of stay in an institution by informing patients and their families of the option to use
hospice services in the home setting, and can serve as a liaison between hospital or nursing
home and home hospice care services.

Additionally, the GNP can clarify the goals of end-of-life care with patients and families. NPs can
help families to select medical treatments that meet their goals. GNPs are in a position to assist
families with decisions to withhold or withdraw treatments that do not meet their goals, and
can assist the patient and family with spiritual, psychosocial, and emotional needs. As a trusted
healthcare provider who is known by the patient and family members, the GNP is in a unique
position to provide these services as well as to suggest short-term respite inpatient services as
needed. Additionally, the GNP may provide bereavement counseling to surviving friends and
family.

Finally, the GNP is qualified to conduct research to improve the quality of care for elders at the
end of life. There have been relatively few studies conducted related to palliative care. The
paucity of research in this area may be due to perceived ethical challenges in studying terminal
patients. However, a study focusing on cost effectiveness and economic outcomes of palliative
care for oncology patients in the home setting found that nurse coordination of palliative care
saved 40% of costs normally associated with this group of terminal patients. More research
needs to be conducted by GNPs related to outcomes of palliative care. GNPs need to be an
active part of the hospice team and should initiate or participate in research related to
outcomes of older individuals who use palliative care and hospice services.

HOSPITAL CARE

Ausmed. (2020). Providing Best Care for Older People in a Hospital Setting.
https://www.ausmed.com/cpd/articles/best-care-older-people-hospital

The Risks of Hospitalisation for Older Adults

Older adults may feel highly distressed coming into an acute care setting. In addition to the pain
or illness they are experiencing, they may also be concerned about the implications of being
hospitalised, and how it will affect their independence, routine and sense of self (Age UK 2012).

The patient may be frightened, confused, frustrated or angry. It is important to empathise with
these emotions and care for them in a way that is sensitive to their distress (Age UK 2012).

Older adults are also at high risk of developing complications during a hospital stay. These
include:

 Falls;
 Disorientation;
 Delirium;
 Healthcare-acquired infections;
 Malnourishment or dehydration;
 Depression;
 Incontinence;
 Pain; and
 Pressure injuries.

They may face other challenges that impede on their lifestyle, including:

 Loss of confidence;
 Loss of independence;
 Change of routine;
 Reduced activity and stimulation; and
  Overall functional decline.

When caring for an older adult in hospital, the aim is for them to return home at the level of
functioning they had before admission, or better (QUT 2017).

Specific Issues Related to the Hospitalisation of Older People

Transfer of Care

Transitions between aged care and acute care, or any other settings, are high-risk and can result
in miscommunication or other adverse consequences such as:

 Delayed treatment;
 Delayed follow-up of test results;
 Unnecessary repeats of tests; and
 Medication errors.

Dignity and Autonomy

All patients have the right to dignity and autonomy, regardless of age. However, in acute care
settings, this may be a low priority for staff (Tauber-Gilmore, Norton & Proctor 2017).

Generally, older adults are at a high risk of losing dignity when in care (Šaňáková & Čáp 2018).

Dignity and autonomy play a significant role in a patient’s overall condition. Positive, respectful
interactions will increase the patient’s confidence, motivating them to maintain independence
and stay physically and mentally active. On the other hand, neglectful, condescending or
apathetic care will quickly correlate to deterioration and functional decline (Age UK 2012).

A literature review identified the following key components of dignity, based on the views of
older adults:

 Autonomy and control;

 Privacy;
 Relationships;
 Care and comfort;
 Communication; and
 Identity.
Empowering older adults, providing them with choice and treating them with dignity is
essential in reaching desirable patient outcomes. Older adults want to be treated as people, not
nuisances (Age UK 2012).

Care that promotes dignity Care that reduces dignity

 Responding to the patient’s needs,
wants and fears.
 Using respectful language.
 Being empathetic to the patient’s
distress due to life changes, loss of
independence etc.
 Involving the patient in decisions.
 Explaining concepts to the patient.
 Treating the patient as part of a
partnership.
 Treating the patient as an
individual.
 Providing care that is accessible to
all patients regardless of sensory
impairment, language barriers etc.
 Being culturally aware.
 Engaging with the patient.
 Asking how the patient would like
to be addressed.
 Ignoring the patient’s comments or
complaints.
 Speaking to the patient like a child.
 Treating the patient like a burden or
nuisance.
 Telling the patient what to eat or when
to go to bed.
 Neglecting the patient or rushing care
to save time.
 Treating the patient as a passive
recipient (e.g. feeding the patient
rather than helping them eat).
 Treating the patient in a way that
humiliates or degrades them.
 Treating the patient in a way that
humiliates or degrades them.
 Reducing the patient to their condition
or illness.
 Using offensive or condescending
language.

Cognitive Impairment

About 40% of older adults over 65 experience confusion during hospitalisation, usually due
to dementia or delirium (Murray et al. 2019).

These patients may be particularly overwhelmed. In addition to pain, illness or emotional

distress, they may also:

 Experience disorientation, fear, anxiety or drowsiness;

 Experience hallucinations;
 Display uncharacteristic behaviours;
  Refuse care;
 Try to leave the facility;
 Become disruptive or aggressive;
 Display responsive behaviours such as wandering, yelling, hitting, kicking, sexually
inappropriate behaviours and restlessness than can be difficult for staff to manage.

Acute Care Environment

Research suggests that only 14% of hospitals have physical environments that are
appropriate for patients with cognitive impairments (Alzheimer's Australia 2014).

Acute care facilities are busy and fast-paced environments, with noises, lights, signage and
room layouts that can be highly confusing for older adults and significantly contribute to
distress and disorientation, especially for patients with cognitive impairments (Alzheimer's
Australia 2014).

Patients need to feel safe, secure and oriented, which can be very difficult if the toilet is hard to
find, or the patient does not know how to get back to their room (Alzheimer's Australia 2014).

Practical Tips When Caring for Older Adults

When caring for older adults in acute settings, consider the following:

 Ensure age-friendly principles are in place. These may include:

o Written information in large print;
o Adequate lighting at night;
o Beds and furniture at a suitable height; and
o Access to mobility aids.
 Always practice consumer-directed care.
 Identify what is important to the patient; what are their physical, mental, emotional and
social needs?
 Monitor the patient for signs of clinical deterioration.
 Encourage independence. Support the patient to practice self-care and dress, mobilise
and toilet themselves.
 Ensure adequate nutrition and hydration.
 Monitor the patient’s cognitive status.
 Involve the patient’s family and carers as much as possible.
 Manage any pain that the patient is experiencing; this can adversely affect self-care.
 Review the patient’s medications.
Caring for Older Adults with Cognitive Impairment

Older adults with cognitive impairment require extra support and orientation. In addition to the
practical tips above, you should:

 Ensure the patient’s glasses, dentures, hearing aids etc. are clean, working and easily
accessible;
 Minimise bed moves;
 Try to use non-pharmacological strategies when possible to treat confusion;
 Encourage the patient to participate in success-based therapeutic activities, considering
their interests (e.g. music, games);
 Avoid restrictive practices;
 Create a comfortable, safe and relaxing physical environment for the patient,
considering privacy, orientation, lighting, noise etc.;
 Involve family and carers in reorientation and reassurance strategies;
 Normalise sleep patterns;
 Address any underlying causes of the patient’s behaviour (e.g. physical illness or pain);
 Speak to the patient gently, calmly and reassuringly, using simple language; and
 Encourage continence through access to toilets and visual signage.

Conclusion

Older adults who become hospitalised may be highly distressed and are vulnerable to
complications, especially if they have a cognitive impairment. Caring for these patients
appropriately is essential in achieving positive outcomes and preventing deterioration or
functional decline.

RETIREMENT LIVING/HOME/VILLAGE

Health in Aging. (2021). Home Care. https://www.healthinaging.org/age-friendly-healthcare-

you/care-settings/home-care

House Call Services

House calls refer to visits to the home by physicians, nurse practitioners, and physician
assistants to provide medical services. These at-home evaluations can add to a healthcare
provider’s knowledge of the circumstances and home setting of the older person.  This may
allow them to see and address problems that are not obvious during an office visit. For
example, there may be barriers that prevent an older person from functioning as well as they
could, such as cluttered hallways or a home that has no railings when it should.

An at-home evaluation may also reveal caregiver burnout, elder abuse, or the use of
medications that may get in the way of managing or treating a disease. This service also helps
older adults who may have difficulty getting out of the home because they do not have to travel
to see the healthcare team.

Home Health

Home health refers to services provided by nurses and rehabilitation therapists

(physical/occupational/speech therapy) who are part of home healthcare agencies.  Elderly may
benefit from home health if they are dealing with one or more of the following: 

 They have trouble getting around (for example, after a hospital stay or an accident).

 They have wounds that need to be addressed and treated.

 They need injections or other treatments requiring a skilled nurse.

 They need to learn more about your medical condition(s) and how to monitor them at
home to avoid complications (for example, monitoring your diet, weight, blood pressure
or your blood sugar).

 They need help with bathing, dressing, and meal preparation.

 They need care and emotional support when in the final stages of an incurable disease.

Home health may be needed for some adults during a brief period of recovery. In select cases,
some adults may benefit from ongoing house call services on an ongoing basis.

Medicare Coverage

In order to qualify for Medicare coverage for home care, a person must be “confined to home.” 
Medicare describes confined to home as having a condition that makes it hard for you to leave
home.  You do not have to be bedridden to be considered “confined to the home.”  You can still
be considered “confined to the home” if you leave your home to see a healthcare professional,
go to a religious service, or go on “occasional outings" (for example, a walk around the block,
family reunion, or other events that do not take place on a regular basis).
For more details, take a look at the Centers for Medicaid and Medicare Services’ booklet
on Medicare and Home Health Care.

Limitations of House Calls and Home Health

Most older adults prefer to remain in their own home. However, situations and conditions may
come up that make care in an institution or facility more appropriate. For example, caregivers
may not be available to adequately address the needs of the older person. Similarly, caregiver
burnout and stress may prevent continued safe care for the older person in the home. 

There are also some serious medical situations that require frequent testing,
breathing treatments, or intravenous medications.  In these cases, receiving care in an
institution may be a better choice than house calls or home health. Sometimes, the home
setting itself may be a barrier to delivering care in the home. For example, home health may be
a poor or risky option for an older person living in an unsafe neighborhood, for someone who
has trouble with alcohol or drug use, or for a person who doesn’t have enough room for
equipment or environmental modifications. 

Finally, care in the home is not always the least expensive choice. Out-of-pocket costs may
make ongoing home care unaffordable. Insurance is more likely to cover care that is given in a
nursing facility or other institutional setting. 

Home Assessment & Modification

People confined to the home often have health problems or disabilities in one or more areas of
their health and functioning. A comprehensive geriatric assessment is particularly valuable in
this situation. A comprehensive assessment can be used to figure out the older person’s initial
level of health and functioning, monitor the course of their illness, and evaluate effects of their
treatments. Also, assessment in the home has some important advantages over office-based
assessment.

Advantages of Home Assessment

The healthcare provider can see how the patient functions in their actual home environment.

This helps the healthcare provider determine if the home is safe and appropriate for the
patient’s particular abilities and disabilities, or if changes need to be made. For example, the
healthcare provider can assess if the older adult can perform activities of daily living (ADLs),
such as bathing or dressing. The provider can also evaluate the caregiver’s abilities to address
the needs of the older person. Home assessment can also identify and address the caregiver’s
needs for counseling, training, and/or support.

Home Modifications

There are two types of changes (modifications) that can be made to make sure that the home is
safer for the older adult.

Environmental modifications 

Environmental modifications can be recommended to improve function. For example, an older

adult’s quality of life and ability to function might be improved by using modifications such as a
hand-held shower, a shower seat, bathtub grab-bars, or a bedside commode. Barriers to using
wheelchairs and walkers (such as door sills) can be identified and removed. Chair lifts and
outdoor ramps can be recommended to help older people manage stairs. The assessment
might also include an occupational therapy consultation. This can be useful in identifying other
personal care and assistive devices for performing activities of daily living (or ADLs) and
housekeeping chores. A number of home safety checklists are also available to help with home
assessment.

Assistive technology 

Assistive technology to improve home safety can also be an option. For example, necklace or
wrist radio devices that allow the older person to call for help. There are also emergency
response systems that require the older person to push a button by a certain time each day.  If
they do not push the button, it will trigger an emergency response or checkup phone call.
Newer technologies can provide help in administering and tracking medications, monitoring
and transmitting vital signs, and connecting older adults to healthcare providers through audio
and visual telemedicine screens. Homes can be equipped with fully automated systems to
adjust heating and lighting, to allow doors to be opened and closed with remote devices, and to
monitor activity throughout the home.

Portable or mobile testing technology (home diagnostics), including x-rays,electrocardiograms

(ECGs), and hand-held laboratory devices are available in some areas. These home diagnostics
allow for a much more comprehensive medical evaluation to be done in the home.