rT"' he elderly ill and disabled who ·** prefer an independent life style often have difficulty finding a suitable milieu not only after discharge from dependent care settings but also when the accustomed home environment impedes self-care. Fostering self-management for this group of persons has been a long-term commitment of the Onondaga County Department of Health located in the City of Syracuse in central New York State. Early in the 1970s this Department established an Evaluation Visit Program within a Health Housing Evaluation Unit in its efforts to extend home health services to the elderly ill and disabled. The main goal of the Visit and the Unit, initiated under a direct grant from the U.S. Department of Health, Education, and Welfare, was to offer alternatives to institutionalized care to develop more efficient health service delivery to the target groups.
Discouraging diagnoses and unfavorable medical and soçial histories were common in the Visit group, yet the achievement of self-management was the rule rather than the exception for the more than 100 individuals enrolled overa five-year span. Understandably, some could not be recommended for independent living and some rejected this life style during the process of evaluation. A few died during participation or failed to adapt adequately after completion. But four out of five of the "completers" were or are now successes, maintaining themselves fully or partly in their own quarters. And deaths following completion have occurred either after brief hospitalization or at home subsequent to a substantial period of independent living,
A six-part behavior description devised for the Program helped to assess progress in: (1) management of premises and food; (2) diet; (3) finances; (4) medications and treatments; (5) personal cleanliness; and (6) social acceptability. The level of competence sought as a criterion for independence or near independence was one familiar to the Unit staff, namely that characteristic of elderly ill and disabled living at home in the community. Thus, modest gains in problem areas made it possible to recommend participants for housing placement on Visit completion.
To help achieve the maximum level of independent functioning the Evaluation Visit Program offers a broad array of services and the facilities of the Unit, located in a residential complex. At the outset Unit services were planned principally for the nearly 400 residents of the Toomey Abbott Towers, a Syracuse housing authority apartment project developed with the aid of federal funding specifically for residential accommodation and health service delivery to the elderly ill and disabled. The Unit facilities, occupying the second floor of the apartment building, consist of three treatment rooms equipped for medical and nursing care, a dental and podiatry treatment area, a multipurpose suite furnished for social, educational, and nutritional programs; a demonstration apartment with kitchen bedroom and bathroom; a physical therapy suite and occupational therapy suite; information, record and reception areas and a social work office. A van equipped for the transportation of the impaired is also available for Unit use. A cluster of apartments on the fourth floor of the building, leased by the Syracuse Housing Authority to the Department, provides quarters for both short- and long-term residents in the Visit Program. Requests for Program and Unit services are made by service agencies, care facilities, hospitals, physicians, nurses, social workers, individuals, or families.
The permanent residents of the Toomey Abbott complex, some of whom are Program "graduates," constitute the largest number of persons served by the Unit on a regular basis. Nursing, social work, aide service, and other Unit services are provided for an average of 75 or more residents. Service is rendered to the degree determined necessary to maintain independence or near independence, at times until death. All who make use of any Unit services must be under medical supervision, but from time to time a resident requests service from the Unit without prior physician referral. In such instances information on Unit regulations and available medical service is given, and a nursing evaluation which frequently involves immediate hospital care. Even larger numbers of residents in the complex make use of special immunization clinics and diagnostic screenings when provided by the Department and the services of the Departmental dental hygienist as well as those of a visiting podiatrist. Physicians may use Unit facilities but rarely do so.
The Unit also serves a group of nonresidents who obtain special services while still living at home, an "outpatient" group of 20 to 30. Physical and occupational therapy are the chief services for this group, and some members join with the residents, including Visit participants, in nutritional and other services. Visit Program participants constitute a small group, up to a maximum of eight, who receive intensive service from staff. At times four or fewer persons may be active in the Program because of the delays and complexities involved in dovetailing discharge plans with moving and storage of furnishings and the receipt of needed medical and social records.
A screening team considers referrals for the Visit after up-to-date records are available and a list of medications and treatments specified by physicians are on hand. In rare instances an Evaluation Apartment may be used without the formal referral as an emergency housing placement by the Department. The team holds meetings weekly on Wednesdays at 10:00 A.M. at the Unit to review applications and to determine if the type of care required can most appropriately be rendered in the Unit setting rather than elsewhere. Rigid admission criteria for the Visit are of less importance than the team consensus of the individual's potential for an independent life style when an opportunity to learn or relearn needed skills is made available in a setting adapted to the physical and psychological requirements of the elderly ill and disabled. Progress in the Visit is also assessed in detail at team meetings as well as critical changes in the health status of residents and outpatients served by the Unit.
The team consists of a consulting internist and psychologist, Department directors of Nursing and Social Work, and the Public Health Nurses and social worker assigned to the Unit by the Department. Others join the meeting on occasion to discuss matters relevant to the interests of patients-family members, friends, professionals, patient advocates-when the team can allot time for these considerations.
The typical Evaluation Visit participant comes to the Unit for orientation and preliminary assessment after the screening team has accepted the referral. A Program apartment is usually provided as soon as possible thereafter for a predetermined time interval of about two to six weeks, during which the level of independence is constantly evaluated and improved by appropriate services. If, however, adequate competence is evident at the prelirninary assessment the person is not enrolled in the Program but may receive any needed assistance from the Unit in finding housing. Now and then a patient's deficits are so obvious that further evaluation is deemed unproductive and the referral is refused or deferred. Flexibility in assessment and in the use of the apartments is always maintained to assure the patient optimum opportunities for success.
A timid person may, for example, come to the Unit for outpatient services several times before undertaking the Visit, or may use the Visit apartment for a period of several days before attempting full-time overnight residence. Patients admitted primarily to assist in the completion of short-term outpatient treatment in area hospitals are given minimal preliminary assessment, have few contacts with staff, and often return to their homes on weekends on nontreatment days. Occasionally a patient may be referred for independent housing after evaluation in the Demonstration Apartment area only without formal acceptance into the Visit Program. The weekly team meetings and frequent staff conferences, both scheduled and informal, assure a constant flow of information on performance and provide a basis for needed modifications in service.
Nursing and social work are the: main sources of patient teaching and continuing evaluation and are available daily on weekdays, holt days excepted, during workin hours. These professionals work i close cooperation with each other with personal or clinic assign physicians, and with the physic and occupational therapists an health aides assigned to the Unit" well as with the consulting psy chologist who is regularly a vailab". A trained health aide is available o evenings and weekends. In so' instances nursing visits and ai assistance are provided on weeken as well in order to maintain progr* or to maintain the maximum ind pendence possible as is necessary i cases of worsening health stat Social, educational, recreation and nutritional activities take pi one or more times weekly for bo Program and Unit patients at tim with the cooperation of other age cies or volunteers. The train" receptionists, clerical maintenan and transportation personnel al provide helpful contacts.
Not too long after the inception of the Health Housing Evaluation Unit it became apparent that the psychological impairments of the elderly ill and disabled would con- stitute a special type of barrier to independent living. The services of the writer, a psychologist, were then obtained as a consultant on a limited time basis to provide (1} consultation to staff, including fre- quent a t tendance a t Screening Τ earn meetings, (2) psychological evalua- tion of patients in the Unit, and (3) psychological "perceptors" for the staff. These objectives were met by allotting several hours weekly for informal contacts with patients and staff in the treatment areas described previously during scheduled treat- ment hours or with individuals in apartments. Patients of special con- cern to staff could thus be observed frequently and regularly rather than minimally, and since the psychol- ogist's visibility was thus enhanced, needed service contacts were readily arranged with less anxiety for the person and greater efficiency. En- counters with residents other than Unit patients in the building also provided observations useful in assessment procedures.
Such a psychological service is therapeutic in the broadest sense in that it provides evaluative observa- tions as well as supportive contacts and preventive interventions or rec- ommendation when needed for structured therapy. On-the-spot dis- cussions, weekly notes on patient behavior, and relevant psycholog- ical information helped to augment staff effectiveness. Regular memo- randa to Department supervisors and meetings with the screening team furthered the understanding of needed modifications in the Visit program and Unit services to better meet the psychological health needs of the elderly ill and disabled.
Patients vary widely in their utilization of services. An important aspect of the Visit Program and other Unit services is the avoidance of undue dependence in order to facilitate relocation following the Visit and to confine service demands to manageable levels. It is not uncommon for a Visit patient to resist leaving the Evaluation apart- ment or to insist on continued residence at Toomey Abbott, despite emphasis on housing planning and clear agreements prior to acceptance in the Visit program. The complex- ity of the patient's deficits may occasionally elicit a Team recom- mendation for housing in the Unit complex to continue and the Hous- ing authority cooperates with such requests, but no patient can be guaranteed a particular location at the outset of the Visit. Fees for service vary and require individual determination, and considerable ef- fort is necessary to cultivate patient responsibility with respect to man- aging funds, including rents and reimbursable payments for services. Rental fees for the Visit are deter- mined by federal standards, and special arrangements are available in cases of economic hardship. Placement after successful comple- tion of the Visit is usually uncom- plicated although a return to the former premises or care facility may be necessary while suitable housing is located.
In rare instances, the complexity of the patient's service needs com- pels an extension of the Visit beyond the usual six-week limit, to assure continuity in rehabilitation while locating a setting that can assure ongoing success, or to find a care facility suited to the patient other than the inappropriate earlier location for those rejecting inde- pendence or evaluated as unsuited to this life style. The patient is helped to explore all public and private sources including the news media to assure prompt placement, and may be aided by local service agencies. Psychosocial maladapta- tions resulting from drug abuse and chronic psychiatric disability at times reappear after Visit comple- tion and relocation despite ade- quacy in completion of the Visit. The overall experience with such patients is now poorer, however, than with others whose medical histories were free of these problems.
Since the competence of elderly ill and disabled persons in dis- charging the responsibilities of daily life is often questioned, the Housing authority frequently util- izes the Unit to assess such tenants. In making these recommendations on the basis of a Visit or tryout in the Demonstration apartment facil- ities, the standard of performance required is carefully set at a level that is no more exacting than that expected of other tenants in public housing units. The Authority also consults with the Unit in evaluating residents for continued occupation of premises when fellow tenants have expressed concern or com- plained of sanitary mismanage- ment, threatening or disturbing behavior, or upsetting eccentricities. Every effort is made to support the tenant with such services as will permit continued occupancy. In this way, needless eviction pro- cedures are averted and the target groups are spared the necessity of conforming to standards that might not be applied in the case of the unimpaired who find less difficulty in resisting eviction.
The continuing experience of the Unit suggests that interaction among patients, particularly pa- tient tenants in an apartment com- plex, creates a sense of community and emotional security. Since isola- tion and anxiety contribute to the stresses of relocation and of illness, aging and disability patient inter- action can help allay these distresses. In the treatment areas the patients help each other a good deal, en- courage each other, communicate freely, and in general have a recip- rocally comforting effect. This in- teraction continues even among the gravely ill. The provision of ample opportunities for patient inter- action thus alleviates the psycho- logical damage of isolation and monotony so often typical of daily living for the target groups. Even mildly irritating events such as service interruption, staff changes, and unanticipated schedule modifi- cations add to supportive inter- actions.
The perspectives of develop- mental and social psychology sug- gest that a self-managed life style is more humanly appropriate for all but few of the elderly ill and disabled. The Health Housing Evaluation Unit and its Evaluation Visit Program have maintained a realistic opportunity for main- streaming individuals who might have had none but dependent care alternatives or health impairing options. Curiously enough accurate costing studies of the massive public construction projects undertaken to improve human services in health housing and education are lacking though the future may provide random controlled trials of alterna- tive care models. With few excep- tions, however, there is consensus as to the cost advantages of self- management in health delivery to the target groups. Current popula- tion projections are such that health services for the elderly ill and disabled will be available at reason- able levels in the future only if the enhancement and preservation of self-management skills are urgently cultivated.
There are environmental and social barriers that play a significant part in restricting the achievement of self-management in these groups. The Unit has addressed problems in these areas and although needed changes have taken place since its inception, much remains to be accomplished. Few question the social importance of the mainte- nance of physical and psychological health together with a protective fostering of independence for the young and unimpaired. The con- tinuing experience of the Unit underscores their importance for the elderly ill and disabled in the community.
- APA Task Force on Health Research, Con- tributions of Psychology to Health Re- search. American Psychologist, April 1976, pp 263-272.