Journal of Gerontological Nursing

KNOW YOUR COMMUNITY RESOURCES 

GERIATRIC DAY CARE: A COMMUNITY APPROACH TO GERIATRIC HEALTH CARE

Eloise Rathbone-McCuan; Julia Levenson

Abstract

It is generally recognized that our society has been ** ineffective in generating strategies for providing preventive health care to the elderly. The absence of an active cadre of physicians specializing in chronic disease medicine is obvious. There are signs on the horizon which support that this trend is changing, but we will continue to find the proportion of geriatric medical specialists in the minority for a number of years. The physician manpower problem is compounded by the fact that most communities lack adequate outpatient facilities to provide the appropriate preventive care. Most existing outpatient facilities {i.e., clinics and health centers) are able to provide little more than emergency or crisis oriented service to aged persons.

In order to improve geriatric health care, two strategies are necessary. Present hospital and institutional resource-the general hospital and the nursing home-must be upgraded. In addition, new methods for delivering short-term and long-term community-based geriatric health care must be actively sought. Day care centers represent an approach to providing health and social care that allows persons to receive the needed long-term care supports while remaining in the community.

Day Treatment for the Elderly

In the United States, day treatment centers for the elderly are rare. Historically, the day treatment center has roots in the European day hospital movement.1-5 Originally applied to the geriatric mental patient, the concept has recently been expanded to include the physically impaired and chronically ill aged. For the past six years the Levindale Adult Day Treatment Center (ATC) in Baltimore has provided a service package that offers the chronically ill and disabled person a source of long-term care other than the hospital or the nursing home.6 »7 The target population of the ATC includes persons who suffer from a diverse number and combination of functional impairments. The intensity of these impairments (physical, social, and mental) varies among the population but renders the majority of patients marginal in their ability to function independently. Because they require a highly supervised and protective environment their residency in the community would be tenuous were not service supports available. Prospective patients (and their families) making application to Levindale can select either day care or inpatient services as the setting for long-term care. The opportunity to have some choice in this decision is an important benefit both to the prospective patient and to his family.

The overall objective of the day care is to stabilize the aged person's functional deficits and to enable him or her to maintain as much independent functioning as possible. The key to successful service outcome is the ability to prevent the individual from slipping below the realistic level of independence and, wherever possible, help the person fulfill his potential for independent living.

Role of the Community Physician

No direct physician services are provided under the auspices of the Levindale ATC. Instead, community health resources are utilized with the medical care component being provided by community physicians treating individual patients. Some of the health care resources of the adjacent institution are integrated and coordinated with services from community physicians, clinics, and hospitals, to create an "interlocking" system of health care.

In order for an individual to be considered eligible for participation in the ATC, the individual must have an ongoing physician relationship. Ideally, this relationship will have existed over time, allowing the physician to know the patient as an individual and to know his medical history. If this is not possible, the physician relationship should exhibit the potentiality of developing into the close family-patient-day care staff-physician quadriatic relationship that supports community maintenance. Prior to admission into the day care facility, the intake…

It is generally recognized that our society has been ** ineffective in generating strategies for providing preventive health care to the elderly. The absence of an active cadre of physicians specializing in chronic disease medicine is obvious. There are signs on the horizon which support that this trend is changing, but we will continue to find the proportion of geriatric medical specialists in the minority for a number of years. The physician manpower problem is compounded by the fact that most communities lack adequate outpatient facilities to provide the appropriate preventive care. Most existing outpatient facilities {i.e., clinics and health centers) are able to provide little more than emergency or crisis oriented service to aged persons.

In order to improve geriatric health care, two strategies are necessary. Present hospital and institutional resource-the general hospital and the nursing home-must be upgraded. In addition, new methods for delivering short-term and long-term community-based geriatric health care must be actively sought. Day care centers represent an approach to providing health and social care that allows persons to receive the needed long-term care supports while remaining in the community.

Day Treatment for the Elderly

In the United States, day treatment centers for the elderly are rare. Historically, the day treatment center has roots in the European day hospital movement.1-5 Originally applied to the geriatric mental patient, the concept has recently been expanded to include the physically impaired and chronically ill aged. For the past six years the Levindale Adult Day Treatment Center (ATC) in Baltimore has provided a service package that offers the chronically ill and disabled person a source of long-term care other than the hospital or the nursing home.6 »7 The target population of the ATC includes persons who suffer from a diverse number and combination of functional impairments. The intensity of these impairments (physical, social, and mental) varies among the population but renders the majority of patients marginal in their ability to function independently. Because they require a highly supervised and protective environment their residency in the community would be tenuous were not service supports available. Prospective patients (and their families) making application to Levindale can select either day care or inpatient services as the setting for long-term care. The opportunity to have some choice in this decision is an important benefit both to the prospective patient and to his family.

The overall objective of the day care is to stabilize the aged person's functional deficits and to enable him or her to maintain as much independent functioning as possible. The key to successful service outcome is the ability to prevent the individual from slipping below the realistic level of independence and, wherever possible, help the person fulfill his potential for independent living.

Role of the Community Physician

No direct physician services are provided under the auspices of the Levindale ATC. Instead, community health resources are utilized with the medical care component being provided by community physicians treating individual patients. Some of the health care resources of the adjacent institution are integrated and coordinated with services from community physicians, clinics, and hospitals, to create an "interlocking" system of health care.

In order for an individual to be considered eligible for participation in the ATC, the individual must have an ongoing physician relationship. Ideally, this relationship will have existed over time, allowing the physician to know the patient as an individual and to know his medical history. If this is not possible, the physician relationship should exhibit the potentiality of developing into the close family-patient-day care staff-physician quadriatic relationship that supports community maintenance. Prior to admission into the day care facility, the intake screening must reveal the above. If it does not, the professional personnel handling intake assumes responsibility for assisting the family in trying to channel the aged person into such a relationship. At the point of intake, screening and evaluation of eligibility must be made by the physician and arrangements for health care coordination must be solidified so that the center staff are assured of access to a physician of record for each patient.

In addition, each applicant must have a family member or family surrogate situation available to him at the time of entry into the program. This assures the aged person of a community setting capable of providing essential care during those periods of time in which the patient is not present in the center. This resource is of great importance for the type of patient treated at the center because most are not capable of fully independent functioning even though a few of the patients do live alone in their homes or apartments.

The day care service structure must include a wide range of staff in order to provide nursing, social, dietary, pharmaceutical, recreational, diagnostic and transportation services. An adequate participant-staff ratio and a wide range of health and social services are necessary to insure the patient sufficient service resources for community maintenance. During the five years Levindale has provided day care, the role of the nurse has been integral to the success of the service. The nurse assumes such functions as provision of medical treatments and procedures, medication distribution, coordination with community services, and liaison with the physicians as relates to the individual health needs of each patient.

It is desirable, but certainly not always possible, to locate the day care center in a community environment that has a comprehensive, integrated network of services. Unfortunately, however, community health and social service systems leave much to be desired. Typically, "fragmentation of services in the community makes it difficult for a potential recipient to find the service, or combination of services needed to prevent premature institutionalization for the elderly the cracks between segments of a service continuum are gaping holes impossible to avoid."8

The range of existing community service resources does influence the planning of a day center. A day center cannot rely on a nonexistent community service network. The fewer services available in the community the more necessary it is for day care centers to provide these services or default in their risk of developing a comprehensive health care plan.

An interlocking service approach enables a day care center to include services that are aspecially vital to the maintenance needs of the patient populace. At Levindale reliance on community physicians was a practical health care decision. Geographic boundaries of the target population had ample community services and private physicians. The planning of the day care center was built on a concept of coordination with community resources and on the available pool of community physicians.

Patterns of Physician/Family/Center Interaction

In those cases where the input from the patient's private physician has not been adequate the consequences for the patient were often serious and the day care service less effective. A poor physician-patient relationship or lack of coordination between the day care center and physician tended to result in a decrease in the length of stay in the day care program, a higher rate of absenteeism, a greater likelihood of acute hospitalization, and a more rapid loss of functional capacities.

During the past six years, three patterns of interaction between the physician, the family, and the center staff have occurred with great regularity. The first two patterns were "family-private physician interaction" and "the nurse coordinator-private physician interaction." Neither pattern alone produced the best results. The former pattern excluded the day care nurse and the latter precluded an ongoing interest on the part of the family. Either the nurse was unable to provide careful monitoring and implementation of prescribed care plans or the family relied too much on the nurse and were ill-equipped to care for the patient at home.

In the family-private physician approach, it was found that the family was too willing to assume the full responsibility of communicating with the physician. This pattern of communication resulted in delays in providing the day care staff with sufficient information regarding the patient. Physician-family communication tended to be limited and episodic and did not generate an ongoing pattern of involvement. The physician tended to avoid contact with day care staff and failed to use potential service resources available at the day care center.

In the nurse coordinator-private physician approach, the nurse coordinator often related to the physician without the direct involvement of the family. The communication between the two took place because the family was either unable or unwilling to become involved. A situation was created whereby the nurse was able to implement the physician's recommendations during the patient's eight hours in the day care center, but was unable to be assured of the follow-up during those periods when the patient was the primary responsibility of the family unit. Both patterns made it more difficult to involve the patient as an active participant in his own health care. Such a condition is most undesirable because it perpetuates dependence and excludes the patient from activities that are vital to his or her well-being.

The four-way interaction pattern of family, physician, patient, and nurse coordinator is the most desirable for delivering health care in a geriatric day care center. While successful interaction depends on the cooperation of all parties, it is the nurse coordinator who establishes patterns of open communication by sharing information with both the physician and the family. In order to establish this pattern of communication, the nurse must be involved with the physician and the family from the onset. By being thoroughly familiar with the patient's medical history and current status and with the medical care plan, she is able to undertake preliminary diagnosis of the patient's ongoing medical needs and decide whether physician intervention is required. The center nurse is able to assume much of the burden for coordinating community resources, a function which few physicians have the time to undertake. She can also help the family to understand the medical needs of the patient and can assist in developing techinques for managing the patient outside of the day care setting. If the nurse coordinator is successful in creating family confidence, she will be able to serve as a filter for the physician and relieve him of unnecessary requests for medical intervention.

The responses of private physicians and clinic physicians to this program have been excellent. Private physicians with geriatric patients in the program are pleased with the quality of care and are optimistic that more centers will be opening to make room for more of the disabled aged living in the community. The successful utilization of the private physician and the interest shown by the physician is a result of an effective informal health care team approach that: (1) allows the patient to continue to receive services from a familiar physician; (2) insures that there is a physician accessible to the patient during those periods when the patient is not present at the day care center; (3) helps to avoid unnecessary expenditure of the physician's time; (4) does not antagnoize the physician by forcing the loss of a patient; (5) assures a greater potentiality that the patient will have prompt access to community resources; (6) can reduce some of the costs of physician visits; and (7) can allow the patient access to a physician who is appropriately trained to deal with the patient's unique pathology. Lastly, but not least, the private physician is a vital social contact for many aged persons and provides a relationship that should be supported as fully as possible.

Case Examples

Presented below are some case vignettes which demonstrate this arrangement in action:

Patient No. /

Patient No. 1 was an 85-year-old man who entered the day care program in order to be closer to his wile who was a terminal cancer patient in the adjacent chronic hospital. He felt thai he would be able to visit his wife regularly without burden to his family. In addition to his social needs, he had numerous medical problems for which he had regular contact with his private physician. When his wife became unconscious he left the program, returning after her death in a much weaker physical state. Due to his deteriorated condition, the nurse found it necessary to keep in constant touch with his physician. At one point, he was rushed to the hospital after the nurse observed blood in his stool. The diagnosis of carcinoma of the stomach was made and treatment began. One week after discharge from the hospital he returned to the day care center because he wanted to be in the protective environment which the RN's regular communication with the primary physician and the family created. One month after his readmission to the day care center he became very ill while riding on the bus enroute to the program. The nurse was called and upon her arrival his vital signs were negative. She rendered cardiac massage. He was revived and taken to the emergency room where the primary physician evaluated that he had experienced a heart standstill and had received cardiac massage at the critical moment. This patient was admitted to the hospital and remained under observation and treatment lor three weeks. Post discharge, he remained at home for one week and then returned to the program where he was maintained successfully for nine months until he was readmitted to the hospital for gastrointestinal bleeding. At that point, the family decided they could no longer maintain him at home. He was admitted to the chronic hospital where he died four months later.

Patient No. 2

Patient No, 2 was a 65-year-old female with multiple sclerosis, diagnosed in J955. When she entered the day care center, she was wheelchair bound and had many episodes of incontinence. Her physical condition necessitated daily physical medicine. This patient was placed on a regime of bowel and urine control which proved successful in reducing incontinence. Transportation provided by the center allowed her to have access to the facilities of Childrens Hospital located two miles from the center. This woman had a very strong nçtwork of community supports. Her primary physician made regular visits to her home and shared his updated findings with the nurse. Whenever the center could not provide her with transportation, either the priest 01 sisters from her former parish would transport her to and from the day care program. After this patient fell at home and fractured her right knee and femur she was hospitalized and later transferred to a local nursing home. She continued to maintain contact with the day care staff as well as former participants, but she realistically recognized her inability to continue to live at home and attend the day care program.

Patient No. 3

Patient No. 3 was a 65-year-old man who was admitted to the day care center as part of his discharge plan from the Levindale Chronic Hospital. He was suffering from a post stroke condition and immediately upon admission to the center began experiencing increased episodes of urinary incontinence. The RN sent a urine specimen to his primary physician who referred the patient to the urological clinic where it was discovered that he had a urological lesion. The urologist inserted a retention catheter and placed him on medication. The primary physician wanted him to be readmitted to the Levindale Chronic Hospital, but his wife opposed this readmission. Therefore, the RN immediately assumed the responsibility of going to the patient's home and teaching his wife the correct procedures for catheter irrigation and sterilization of the equipment used. The RN encouraged the wife to come to the day care center where she could be supervised while learning to irrigate the catheter, handle the equipment, and apply topical medication. The nurse's approach helped the spouse to gain confidence in the care of her husband. The primary physician conducted an examination of the patient and complimented the staff's handling of this delicate case. The patient continues to attend physical medicine, but has been reduced to once a day because he is able to walk proficiently for longer distances. His speech remains slightly slurred, but he profits from daily occupational therapy. Most all areas of his activities of daily living exhibit daily improvement.

These vignettes illustrate how effectively the informal health care team can perform in developing and implementing individualized treatment plans. The approach has worked satisfactorily for most day care patients. Treatment plans developed with the involvement of nurse, doctor, family, and the participant prevented medical crises as well as shortened the length of institutional stays. The patient's private physician was integral to the success of service delivery, but needed, and was willing, to rely extensively on the active leadership of the nurse. The family and participant were effectively involved. Levindale is now considering expanded day care services and utilizing a nurse practitioner as the program coordinator in future centers.

Recommendations for Structuring Day Care Centers

If geriatric day care centers like Levindale do not include a physician as a part of the core staff, the following issues are worthy of careful consideration:

1. The screening and admissions process should include input from all service systems currently involved with the elderly applicant. Involved community professionals should participate in assessing the appropriateness of day care as a long-term option.

2. Indepth profiles of current functional health status and previous medical histories should be a part of screening data. Community physicians should not be required to provide this unless they are familiar with the applicant. Too frequently physicians are forced to make determination of health state so the patient can be evaluated for Medicare or Medicaid. If the physician identified by the applicant is incapable of providing said information the intake process should provide a referral to a physician who can examine the applicant and make the necessary medical evaluation.

3. Day care centers should develop admission criteria that are easily quantified to produce a meaningful profile on the patient. This profile should be used as a criterion for admission and also provide the guide for regular patient reassessments while the patient is connected with the center. Information on the physical, social, and mental status of the patient must be gathered and shared with the community physician to develop the health care plan.

4. Day care staffing should include a highly trained nurse who is familiar with geriatric patients but able to function with a community medicine orientation. The nurse must assume tremendous responsibility and be comfortable in generating health care plans rather than passively implementing physicians' orders.

5. Nonmedical staff have an understanding of and concern with the health as well as the social and psychological needs of the patients (and vice versa).

6. The day care center should be administered by a professional person competent to provide leadership and supervision that maintains a high quality of care. Day care patients should have the benefit of case continuity.

7. The discharge process (which can insure that the patient is transferred in such a way as to avoid "warehousing") must be integrated into the day care center sphere of responsibility. This can be done by formally assisting the family in working out a discharge plan.

8. The day care client system must be defined to include both the aged person and the family unit. The objective of day care cannot be adequately met unless the family's need is defined as equally as important as the need of the aged person.

9. Day care centers should have adequate physician and psychiatric consultation. Preferably, this consultation should come from an ongoing medical and/or psychiatric service qualified to provide treatment backup.

References

  • I. McDonald RD, Neulander A, Holod O, et al: Description of a nonresidential psychogeriatric day care facility. Gerontologist 11:322-327. Winter 1971.
  • 2. Greiff SA, McDonald RD: Roles of staff in a psychogeriatricday care center. Gerontologist 13(l):39-44, Spring 1973.
  • 3. Berger ?Μ, Berger LF: An Innovative program for a private psychogeriatric day center. J Am Geriatrics Soc 19:332-336, April 1971.
  • 4. Farndale J: The Day Hospital Movement in Great Britain. Oxford, Pergamon Press, 1961, pp 1-6.
  • 5. Shore H: The day resident program. Professional Nursing Home 10:158-188, 1968.
  • 6. Kostiek A: A day care program for the physically and emotionally disabled. Gerontologist 12(2): 134-138, 1972.
  • 7. McCuan ER, Levenson J: Impact of socialization therapy in a geriatric day care setting. Gerontologist 15(4):338-342, August 1975.
  • 8. Report of the Governor's Commission on Nursing Homes. The Government, The Community, The Institution. Maryland Stale Government. Baltimore, Maryland, 1973.

10.3928/0098-9134-19770701-09

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