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ch 12 - 14 book notes

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Simon Fraser University
PSYC 357
Wendy Thornton

PSYC 357: ADULTHOOD AND AGING CHAPTER 12: LONG-TERM CARE - Institutional facility provides individuals with medical or psychiatric care along with programs intended to restore their lost functioning - Hospitals are short-term institutional facilities to which people are admitted with the understanding that they will be discharged when they no longer need round-the-clock treatment - Residential facilities are for when an individual moves permanently after losing the ability to live independently INSTITUTIONAL FACILITIES FOR LONG-TERM CARE NURSING HOMES – type of medical institution that provides a room, meals, skilled nursing and rehabilitative care, medical services and protective supervision - Includes treatment for problems that residents have in many basic areas of life including cognition, communication, hearing, vision, physical functioning, continence, psychosocial functioning, mood and behavior, nutrition, and dental care o To manage these problems, residents typically need to take medications on a regular basis o Also receive training in basic care, assistance with feeding and mobility, rehabilitative activities, and social services - Nursing homes are thought of as permanent residence for the older adults who enter them, but only 30% of residents are discharged and able to move back into the community after being treated for the condition that required their admission - ¼ of people admitted to nursing homes die there - 36% move to another facility Skilled nursing facilities: most intensive nursing care available outside of a hospital. Nurses in these settings apply dressings/bandages, help residents with daily self-care tasks, and may provide oxygen therapy. Also responsible for taking vital signs including temperature, pulse, respiration and blood pressure Intermediate care facility: health-related services are provided to individuals who do not require hospital or skilled nursing facility care but do require some type of institutional care beside food and a place to live RESIDENTIAL CARE FACILITIES – 24 hour supportive care services and supervision to individuals who do not require skilled nursing care. They provide meals, housekeeping, and assistance with personal care (e.g. bathing and grooming). Some residential care facilities may provide other services such as management of medications and social and recreational activities - Board and Care Homes – group living arrangements designed to meet the needs of people who cannot live on their own in the community but who also need some nursing services o They provide help with activities of daily living (e.g. bathing, dressing, and toileting) o Typically understaffed, and the staff who work in these settings are not required to receive training - Group Homes – independent private living in a house shared by several other individuals. Residents split the cost of rent, housekeeping services, utilizes and meals - Assisted Living Facilities – housing complexes in which older persons live independently in their own apartments o Residents pay a regular monthly rent that usually includes meal services in communal dining rooms, transportation for shopping and appointments, social activities, and housekeeping service o Some facilities have health services available on location o Professionally managed and licensed and may represent one of several levels of care provided within the same housing community o Philosophy is to combine private, residentially oriented buildings with high levels of service allowing residents to continue living in the same facility even if changes in health or physical and cognitive functioning occur (however, many facilities don’t achieve these goals, because they are too expensive for 1 the moderate and low-income older adults, and those that are affordable do not offer high levels of service or privacy) - Adult Foster Care – includes meals, housekeeping, and help with dressing, eating bathing, and other personal care o Advantages because of their home-like feeling, but because they are small and rely on a live-in caregiver for help with personal care, cooking, housekeeping and activities, that caregiver’s resources may be spread thin o If one resident becomes ill and requires more nursing care, other residents may suffer from lack of attention o Lack of privacy compared to a residential care setting COMMUNITY-BASED FACILITIES (p. 263) HOME HEALTH SERVICES – services provided to older adults who are ill or disabled but are able to maintain an independent life in the community - Variety of services, some free, available within broad category of care - “meals on wheels” the provision of a hot meal once a day; so called “friendly visiting “which a volunteer comes to the home for a social visit and assistance with shopping. Other home-based services include laundry, cooking and cleaning - Researchers found that home health care that simulates the type of restorative services provided in nursing homes such as physical therapy, speech therapy, occupational therapy, rehabilitation and intervention targeted at particular areas of functional declined can help to maintain the older person in the home longer, staving off institutionalization or emergency room care o Teaching older adults who are receiving home health care a variety of strategies to maintain their functional ability, such as fall prevention, muscle strength training, and home safety can help maximize mobility and reduce costs associated with institutionalization GERIATRIC PARTIAL HOSPITAL – daily outpatient therapy provided with intensive, structured multidisciplinary services to older persons who have recently been discharged form a psychiatric facility - May serve as an alternative to hospitalization - Therapists focus on medication management and compliance, social functioning, discharge planning and relapse prevention GERIATRIC CONTINUING DAY TREATMENT – clients attend a day treatment program 3 days a week but are encouraged to live independently during the remaining days of the week (less intense than geriatric partial hospital) DAY CARE CENTERS – individuals receive supervised meals and activities on a daily basis Older adult may maintain considerable autonomy but still have support nearby living in a separate apartment in a relative’s home. nd - Accessory dwelling unit aka “in-law apartment” is a 2 living space in the home that allows the older adult to have independent living quarters, cooking space, and a bathroom SUBSIDIZED HOUSING – provided for individuals with low to moderate incomes. People using subsidized housing live in low-rent apartment complexes and have access to help with routine tasks such as housekeeping, shopping and laundry CONTINUING CARE RETIREMENT COMMUNITY (CCRC) – provides different levels of care based on the residents’ needs - Within the same CCRC, there may be individual homes or apartments in which residents can live independently, an assisted living facility, and a nursing home - Residents move from one setting to another based on their needs, but they continue to remain part of their CCRC community - typically are on the expensive side - Many require a large down payment prior to admission and also charge monthly fees - Residents moving into CCRCs typically sign a contract that specifies the conditions under which they will receive long-term care. 3 options --- 2 1. One option provides unlimited nursing care for a small increase in monthly payments 2. contract includes a predetermined amount of long-term nursing care 3. resident pays fees for service which means full daily rates for all long-term nursing care - Advantages: provides social activities, access to community facilities, transportation services, companionship, access to health care, housekeeping and maintenance. May travel, take vacations and become involved in activities outside the community - CCRCs are accredited by a commission sponsored by the American association of Homes and Services for the aging. To be accredited, a CCRC must pass a 2.5 day test that evaluates the facility’s governance and administration, resident services, finance and health care - THE FINANCING OF LONG-TERM CARE Structure of Medicare: MEDICARE – title XVIII of the Social Security Act entitled Health Part A: Hospital Insurance Insurance for the Aged and Disabled - Funding come from payroll taxes, premiums, general revenue from Part B: Medical Insurance Part C: Medicare Advantage Plans income taxes and some payment from the states Part D: Prescription Drug Coverage - Medicare has been subject to numerous legislative and administrative changes designed to improve health care service to older adults, the disabled and the poor MEDICARE PART A (HOSPITAL INSURANCE OR HI) – coverage of inpatient hospitalization and related services - Coverage includes cost of semiprivate hospital room, meals regular nursing services, operating and recovery room, intensive care, inpatient prescription drugs, laboratory tests, X-rays, psychiatric hospital, and inpatient rehabilitation - All other medically necessary services and supplies provided in the hospital are also completely covered. Luxury items, cosmetic surgery, vision care, private nursing, private rooms, and rentals of television and telephone are not included in coverage - Coverage in a skilled nursing facility is included in Part A only if it occurs within 30 days of a hospitalization of 3 days or more and is certified as medically necessary o Includes rehabilitation services and appliances (walkers, wheelchairs) in addition to those services normally covered for inpatient hospitalization - Patients must pay a copayment for days 21-100 of their care in this setting MEDICARE PART B (SUPPLEMENTARY MEDICAL INSURANCE SMI) – medical benefits to individuals age 65+ with payment of a monthly premium - Includes preventive treatments (e.g. glaucoma and diabetes screenings, bone scans, mammograms, and colonoscopies), laboratory tests, chiropractor visits, eye exams, dialysis, metal health care, occupational therapy, outpatient treatment, flu shots, and home health services, a one-time physical examination MEDICARE PART C (MEDICARE + CHOICE PROGRAM) – additional medical insurance available for purchase through Medicare - Aka medical advantages, coverage through private health plans - Individuals who have both Part A and B can choose to get their benefits through a variety of risk-based plans included HMOs, preferred Provider Organizations (PPOs), private fee-for-service plans, and health insurance policy administered by the federal government MEDICARE PART D – subsidy for prescription drug privileges MEDICAID – federal and state matching entitlement program that pays for medical assistance for certain individuals and families with low income and resources - Initially formulated as a medical care extension of federally funded programs providing income assistance for the port, with an emphasis on dependent children and their mothers, the disabled and the 65+ - Has expanded, now is available to a large number of low-income pregnant women, poor children, and some Medicare Beneficiaries who are not eligible for any cash assistance program 3 - Changes have also focused on increased access, better quality of care, specific benefits, enhanced outreach programs and fewer limits on services - For older adults, services include inpatient and outpatient hospital services, physician services, nursing facility services, home health care for persons eligible for skilled nursing services, laboratory testing, X-ray services, prescribed drugs and prosthetic devices, optometrist services and eyeglasses, rehabilitation and physical therapy services and home and community-based care to cover certain chronic impairments Medicaid is the largest source of funding for medical and health0related services for those in need of assistance LEGISLATIVE ISSUES IN CARE OF OLDER ADULTS (p. 268) 1987 Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) NURSING HOME REFORM ACT (NHRA) – US federal legislation passed in 1987 which mandated what facilities must meet physical standards provide adequate professional staffing and services and maintain policies governing the administrative and medical procedures of the nursing facility - Significant component of this legislation was the provision of safeguards to assure quality of care and protection of residents’ rights - Each resident must be provided with services and activities to attain or maintain the highest practicable phsycial, mental and psychosocial well-being - Conditions of the Nursing Home Reform Act Specify that nursing homes must be licensed in accordance with state and local laws, including all applicable laws pertaining to staff, licensing, and registration, fire safety and communicable diseases. - One of more physicians must be on call at all times to cover an emergency and there must be 24-hour nursing care services, including at least one full-time registered nurse 1997 BALANCED BUDGET ACT - Changes that involved moving the prospective payment system to rates paid to skilled nursing facilities Skilled nursing facilities: treatment site that provides the most intensive nursing care available outside of a hospital - Covered nursing home services, excluding payment for physicians and certain other practitioner services. Under the prospective payment system, each facility receives a fixed amount for treating patients diagnosed with a given illness regardless of the length of stay of type of care received. - Prior to the Balanced Budget Act changes, nursing homes filed bills to Medicare based on fee for service. The intention of the change in payments was to curb the rapidly rising cost of Medicare as well as to adjust the payment to the specific needs of the patient. By payment more for the patients whose medical expenses are legitimately higher than those who have less expensive medical needs, nursing homes could therefore provide better health care, adjusted for the needs of the individual resident CONGRESSIONAL HEARINGS ON NURSING HOME ABUSE - In Sept 2000, Senate Committee on Aging held a hearing on the outcomes of the Nursing Home Initiative - Revealed that the initiative had resulted in improvements to state survey on federal oversight procedures, including survey and federal oversight procedures, including increases in the number of surveyors, improved tracking of complains, new methods to detect serious deficiencies and improve organizational of nursing home overnight activities 2002 NURSING HOME QUALITY INITIATIVE Nov 2002, program intended to help consumers find the highest quality nursing homes - Combined new info for consumers about the quality of care provided in individual nursing homes with resources available to nursing homes to improve the quality of care in their facilities 2007 GAO REPORT 2007 – GAO concluded that efforts to strengthen federal enforcement of sanctions had not been effective 4 Ex: nursing homes that were cited for haring or abusing residents can be sanctioned through fines the assignment of monitors temporary management or even termination from their sources of federal and state financing - report showed when violations were reported institutions charged with the violations were often given some type of leeway, either in terms of the amount they were penalized or the length of tie they were granted before being required to pay the penalty CHARACTERISTICS AND NEEDS OF NURSING HOMES AND THEIR RESIDENTS (p. 272) - 2004 percentage rise from 0.9% for persons 65-74 years to 3.6% for persons 75-84 and 13.9% for persons 85+ of people living in nursing homes - 2/3 of nursing homes in US fall into the category of “for-profit” facilities, meaning they seek to have their revenue exceed their expenses. Nonprofit facilities, which includes primarily those run by religious organizations, nd constitute the 2 larges group (26.5%) and government-owned facilities, primarily those run by the Veteran Administrations is 6% - On-line Survey, Certification, and Reporting system (OSCAR) – info from the state surveys of all certified nursing facilities in the IS, entered into a uniform database CHARACTERISTICS OF RESIDENTS - Most common primary diagnosis of nursing home residents when admitted to a nursing home is cardiovascular disease, and the strongest predictors of admission to a nursing home are inability to carry out basic activities of daily living, cognitive impairment, and prior nursing home admission - Alzheimer’s disease is found nearly half of all nursing home residents (45% in 2008), meaning that difficulties in carrying out daily living skills are a significant problem among nursing home residents - 56.8% of residents are chair-bound, meaning that they are restricted to a wheelchair - 5% have special care units devoted specifically to their care NURSING HOME DEFICIENCIES - Government attempts to improve the quality of care provided by nursing homes, monitoring continues on a yearly basis through the listing of deficiencies as reported to OSCAR - 2008 – lack of accident prevention was the #1 deficiency, occurring in 44% of all nursing homes in the US PSYCHOLOGICAL ISSUES IN LONG-TERM CARE (p. 274) MODELS OF ADAPTATION - Adaptation and psychosocial roles are important - Amount of control people feel they have over their environments than with the physical characteristics of the institution. - Feeling that you can control the temperature in your room if you desire may be even more important to your satisfaction that the actual temperature COMPETENCE-PRESS MODEL: predicts an optimal level of adjustment that instructional persons will experience on the basis of their levels of competence (psychical and psychological) compared with the demands or “press” of the environment, or the demands it places upon individuals o Press: stimulation, expectations and activity level, adaptation o Competence: ability to handle stimulation, cognitive abilities and physical abilities, adaptation - Competence and press influence adaptation. In the optimal situation, there is a match between an individual’s abilities and the environment’s demands - A small degree of discrepancy is acceptable, but when the mismatch goes outside this range, the individual will experience negative affect and maladaptive behaviors o Ex: intellectually competent older resident (high competence) will do well in a setting in which autonomous decisions are expected (high press), but a person with a significant cognitive impairment will adapt maximally when the environment is very structured (low press) 5 o This model makes it possible to provide specific recommendations to intuitions about how best to serve residents o It is essentially a biopsychosocial one, allowing room for multiple dimensions of competence and press to be considered when evaluating older adults  Competence may be defined in terms of biological and psychological characteristics such as mobility and cognitive resources  Social factors are the level of press in the environment which include the expectations of staff and amount of stimulation provided by other residents SUGGESTIONS FOR IMPROVING INSTITUTIONAL CARE - Innovations in nursing home care are being developed with the goal of maximizing the fit between the person and environment (Ex: bathing, situation can be distressing when conducted in a way that embarrasses or exposes the resident, can be treated in a more individualized manner, making it a less aversive experience) - Switching from individually plated to “family style” meals can benefit resident adjustment as measured by perceived quality of life, physical performance and increase in body weight - Nurses can be taught to use behavioral methods to help residents maintain self-care and independence (can benefit staff-resident relationship) - Nursing stations removed from view, allowing residents and staff to share lounges - Small group living clusters improve interior design and access to garden can help maintain independence in residents whose autonomy would be threatened - Green house model offers alternative to the traditional nursing homes by offering older adults individual homes within a small community of 6-10 residents and skilled nursing staff o Designed to feel like a home medical equipment is stored away from sight, the rooms are sunny and bright and the outdoor environment is easily accessible - Institute of Medicine report focuses on 3 key areas: enhancing competence in geriatric care, increasing recruitment and retention, and improving models of care CHAPTER 13: DEATH AND DYING Death: irreversible cessation of circulatory and respiratory functions, or when all structures of the brain have ceased to function Dying: period which organism loses its vitality MEDICAL ASPECTS OF DEATH Anorexia-cachexia syndrome – individual loses appetite (anorexia) and muscle mass (cachexia) - Majority of cancer patients experience cachexia, a condition also found commonly in patients who have AIDS and dementia - Experience nausea, difficulty swallowing, bowel problems, dry mouth and edema, or the accumulation of liquid in the abdomen and extremities that leads to bloating - Also anxiety, depression , confusion, and dementia MORTALITY FACTS AND FIGURES Mortality data – statistics derived from death - Provides a fascinating picture of the factors that influence the course of human life - Cause of an individual’s death must be verified by a coroner or medical examiner, who must code the cause or causes of death, either through external examination or an autopsy - Must be recorded on a death certificate Age-specific death rate – number of deaths per 100,000 of a particular age group 6 Age-adjusted death rate – weight sum based on each age group’s death rate and size within the population - Obtaining the weight averages of the age-specific death rates, with the weights reflecting the proportion of individuals in that age group in the population - Death rate that takes into account the fact that more deaths occur in older age groups- provides a number that controls for the age distribution of a population and so makes it possible to compare the relative health of notion Compression of morbidity – desirable state which people live to be older before they die and also experience less disability prior to their death - Reduction in disability prior to death. This concept means the same thing as the wish that some people express that they want to “die with my boots on” - 2007 statistics: white females have the lowest age-adjusted mortality rate; non-Hispanic black men have the highest; followed by non-Hispanic white mean - Marital status and education are 2 significant predictors of mortality o Age-adjusted death rate for those who never married is substantially higher than for those who were ever married, even taking into account the higher mortality of those who are widowed and divorced o in all age groups those with a college education or better, have lower mortality rates - men in laboring and trade occupations are known to have higher death rates than those of the professional class o Whitehall II Study - Men in lower employment grades have a higher risk of coronary heart disease compared to men in higher employment grades o People in lower socioeconomic classes are also more likely to suffer from communicable diseases, exposure to lead, and work-related injuries (also apply to women) o pattern of jobs people hold throughout adulthood are related to mortality rates  risk of mortality is lower in men who move up from manual to professional or managerial-level occupations o people who report higher levels of subjective distress have high mortality rates CULTURAL PERSPECTIVES Death ethnos – culture’s prevailing philosophy of death - can be inferred from funeral rituals, treatment of those who are dying, belief in the presence of ghosts, belief in an afterlife, the extent to which death topics are taboo, the language people use to describe death (though euphemism such as “passed away”), the representation of death in the arts - Shifts in Death Ethos from Ancient Times to the Present o Ancient rituals preserved the body for the afterlife o Western attitudes from Middle Ages through 20tjh century led to invisible death th o Rise of Death with Dignity movement in 20 century - Egyptians believed that a new eternal life awaited the dead and that the body had to be preserved through mummification in order to make it the permanent home for the spirit of the deceased Death with dignity – idea that death should not involve extreme physical dependency of loss of control of bodily functions - Emerged from the desire of patients and their families to avid a lengthy and protracted dying process Social death – dying become treated as nonpersons by family or health care workers as they are left to spend their final months or years in the hospital or nursing ho
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