Long Term Care – Alvin House

(11-14-16)

Water For Elephants, Sara Gruen (2006)

Jacob Jankowski, the novel’s protagonist, is a “ninety or ninety-three” and a resident in a nursing home at the beginning of the story

Where shall we live as we grow old?

While popular culture makes frequent references to older adults retiring, packing up, and moving to “someplace warm”–the reality if that the majority of older adults do not relocate across state lines (Erber, 2013), but those who do may seek out milder climates and year-round recreational opportunities
Litwak & Longino (1987) spoke of three stages of long-distance migration:
- amenity migration: the first stage usually occurred soon after retirement in the “young-old” (65-74) group of seniors in good health, with intact marriages, and adequate financial resources; moving to join age peers in retirement communities with recreational and social opportunities
- independence migration: the second stage occurred in seniors (mid to late 70’s) beginning to experience some physical and/or cognitive difficulties, may have had spouses die and face dwindling financial resources; and who return to the cities of origin or places where they can receive support/care from family members. This “reverse migration” from the “sun belt” back to the “rust belt” allows the senior to continue to live on their own (with some help doing so)
- dependency moves: if we survive long enough (not all will) we will be faced with more severe disabilities that exceed the help family or informal caregivers can provide, and will need to move into a more supportive environment (assisted-living facility or nursing home); these moves are often local and may be voluntary or involuntary
Aging in place: seniors who remain in the same locale and continue to live in the same housing unit are described as “aging in place”
independent living
- requirements for living independently
  - maintenance of self (food, hygiene, medication)
  - maintenance of economic & community stability (paying bills, shopping, transportation to appointments)
  - maintenance of psychological health (needs for socialization, stimulation, positive activities)
  - cognitive competency: judgment, executive functions, risk appraisal, memory
- home modification
  - a “person-environment interaction” or “competence-environmental press” model suggests to options for enhancing adjustment in individuals beginning to experience difficulty with the tasks of daily life:
    - increase competency: skill development/skill support (getting into habit of taking your medication at the same time each day, teaching yourself to always put your keys in the same place)
    - modify the environment to make the task easier (setting reminders on your phone to take your medication, putting hook by door to hang keys on, where you will see it on the way out)
  - modifying the environment can sometimes create a better “fit” between the person’s competencies and the press (demands) on them
    - assistive devices such as hand rails in bathroom, easy to operate door handles
    - shifting from oven to microwave cooking
    - more extensive environmental modifications (widening doorways to accommodate wheelchairs, lowering counter tops, installing wheelchair ramps) may be unavailable to low-income individuals and funding may not be available (even though the cost of such intervention is significantly lower than placement in nursing homes or assisted living facilities)
  - home health services
    - community nurses
    - “meals on wheels”
  - subsidized senior housing
    - low cost public housing for seniors
    - some degree of institutional assistance is often available within the housing “unit”, especially with securing resources available in community
- residence with family
  - transitions and acceptance of new role in family
  - “granny flats” or “echo housing” (Erber, 2013): small apartments that are attached or semi-attached to their relatives’ main living quarters: gives access to support but also some privacy and independence (for both “families”)
  - adult day care centers
- institutional facilities
  - residential care facilities
    - assisted living facility: live independently in own apartment in a housing complex, communal dining room
    - nursing home: medical institution with room, meals, skilled nu ring care, rehabilitation services, medical services
  - skilled-nursing facilities
    - intermediate care facilities
  - What does it take to provide a good quality of life for senior residents in a institutional facility?
    - coping with individual differences and group needs
    - What makes for a “good life?”
    - Is it clinical depression or personal acceptance? How much self-determination do we need, want; how much do we want to take care of each other?
  - Adjustment in an institutional facility
    - How do we measure “quality of life?”
      - self report of mood, life satisfaction, self-esteem
      - rating of mood behaviors
        
        Burrows et al. (2000) Minimum Data Set Depression Rating Scale
      - activity level/participation
      - ADL decline, deterioration in decubiti, use of physical restraints
        
        activities of daily living
      - life expectancy, death
    - personal factors associated with adjustment of the individual resident
      - demographic factors have not consistently been found to be effective predictors of successful adjustment ( Johnson et al., 1998)
      - acceptance of the placement decision
        
        increased if viewed as legitimate or voluntary, desirable or important, reversible (Chenitz, 1983)
        
        increased with anticipation, participation, exploration, and information (Nolan et al., 1996)
      - perceived self-efficacy (Johnson et a., 1998; Philippe & Vallerand, 2008), autonomy (Kasser & Ryan, 1999), self-determination (O’Connor & Vallerand, 1994)
    - institutional factors associated with adjustment of the individual resident
      - staff burnout & staff-patient conflict predict patient abuse (Pillemer & Bachman-Prehn, 1991)
      - staffing levels
      - staff moral
      - programs: cognitive stimulation, socialization activities, mindfulness training, reminiscence experiences
  - working with the interactions of individual (cognitive, health) factors and situational (characteristics of the environment) factors in understanding and promoting the best possible adjustment, functioning, quality of life

How shall it be paid for?

in our past it was the responsibility of the individual to provide for themselves in their advanced years
- retirement savings and income
- family contributions
- long-term care insurance
Medicare is the federal funding agency created in 1965 by Title XVIII of the U.S. Social Security Act to provide medical services for the elderly population
Medicaid (Title XIX) of the Social Security Act of 1965 established an entitlement program providing medical care for low income individuals and families

How shall we manage it?

1987 Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) included the Nursing Home Reform Act (NHRA)
1998 Nursing Home Initiative
2002 Nursing Home Quality Initiative program
2007 Government Accountability Office (GAO) report, Nursing Home Reform
What are we striving for?
- Control of abuse, neglect, exploitation, and substandard care?
- Providing optimal care?
Continuing questions and issues:
- What are the problems with our current systems?
- What is the future for our current systems?
- How shall we provide for our future and the future of other citizens?
  - “A colleague once told her, Wilson said, ‘We want autonomy for ourselves and safety for those we love.’ That remains the main problem and paradox for the frail. ‘Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.'” (Gawande, 2014, p. 106)
- Special issues:

“One has to decide whether one’s fears or one’s hopes are what should matter most.”
(Gawande, 2014, p. 232)