Life becomes an all-pervasive attitude of each person as he/she seeks to make a contribution to humanity through his/her talents and ideas."1 The crucial question to be explored in this discussion is whether licensed practical and vocational (LPN/LVNs), as well as registered nurses (RNs), will respond with the full devotion and thoughtful nursing service that will be required for the rapidly increasing aging population. Will these important groups of care givers respond en masse to take action to help solve the nation's health problems and improve long-term care for patients by deepening and enlarging health care perspectives and sharpening and resharpening assessment skills, such as through continuing education?
Economics of Aging Issues
The central concern here is the need for many to take deliberate, progressive steps toward the humanistic goal so quality in health care will be as efficiently developed as possible and yet be balanced with cost. Although the economics of aging issues are legion, including many organizational and political issues related to implementation of the Social Security Act and Public Law 92-603, section 249F (Professional Standards Review), I shall focus only on relevant nationwide issues on quality of care in long-term care facilities.
Long-term care is operationally defined as health and social services provided to chronically disabled, usually elderly persons and the mentally ill, mentally retarded, and the young, physically handicapped. In 1975, federal, stale, and local governments spent $5.7 to $5.8 billion on long-term care. Private expenditures totaled $5.9 to $7.7 billion for long-term care. These costs will jump from $25.8 to $31.0 billion in 1980 as a result of the increasing percentage of aging in the population, increased utilization of services, and inflation.2 In light of the fact that federal spending may be $7.2 to $7.6 billion in 1980, the immediate health costs questions before the government policy makers associated with the nursing home dilemma include:
1. How shall we ensure the delivery of health care and social services that long-term care patients need more compassionately and effectively, yet reduce spiraling costs?
2. Will health care providers, including LPN/LVNs and RNs, and the public accept the proposed revisions of the federal regulations that govern the standards of long-term care facilities who participate in Medicare and Medicaid so that they will be focused on the patient's or resident's needs to reduce helplessness and depersonalization?
3. How cari we provide a continuum of care, so the alternatives to institutionalization can be fully developed and utilized in communities, so that we do not continue to subject an increasing number of the elderly to longer but emptier lives? How can we enable the elderly, as members of the general public, to fulfill their growing desire for individual independence, selfreliance, and self-determination so they will make their own decisions concerning health care?
On February 28, 1979, T. Franklin Williams and others of the University of Rochester presented data that 20 to 40% of the nursing home population could be cared for at less intensive levels if adequate community-based care were available. Evidently, the barriers preventing complete community care are threefold: insufficient community-based services, inadequate organization of community services, and disability-induced impover- ishment of individuals. How then shall viable alternatives to institutionalization be achieved through community action measures?
Nature of Future Society
To meet future needs, new forward planning measures for community services should be set, coordinated, and implemented for the elderly through social policies on the community, state, and regional levels. As chairman of a Committee on Mental Health and Illness in October 1977, Pfeiffer recommended that the high risk elderly in the community be entitled to special assistance in planning for access to the services they need.
More Prototype Projects Needed
First, more models for sustained community agency responsibility for regularly monitoring and assuring needed services for the de-institutionalized chronically mentally ill and those with severely reduced physical and emotional capacities due to extreme old age can be developed and tested.4 To date, findings from federally supported models (under the 1972 Amendments to the Social Security Act, Public Law 92-603, Section 222) to evaluate alternatives in long-term care, specifically geriatric day care and homemaker services, have been encouraging. Death rates were reported to be lower in the experimental group than in the control group for all three study groups. Day care services apparently postponed or avoided increased physical dependency. Also, the greatest benefit in keeping patients alive was among those who were severely dependent but still expected to improve.
The term, "high risk or vulnerable," refers to the older population in the community whose condition could deteriorate quickly, and without some special supports, they are likely to become candidates for institutionalization. To further illustrate how this group can be cared for, Harvey L. Ross' California project is exemplary, namely, Volunteers for Services to Older Persons (VSOP) that is developing and evaluating a model case service management system to help sustain vulnerable older persons in the community. Nonprofessional case service managers, both volunteers and paraprofessionals, identify and enroll vulnerable older clients in VSOP's case load, assess their needs for services and implement individualized case plans.5 Admittedly, achieving a more humane focus in all long-term care settings is a herculean task. It means active treatment programs to replace custodial care for the mentally ill, and flexible policies and procedures to integrate hospital care with family and therapeutic community life.
Potentiating A Comprehensive Patient Appraisal System
Second, notable is the National Academy of Science's Institute of Medicine's recommendation that "eligibility for federal reimbursement of long-term care should be based on a comprehensive assessment process."6 Moreover, it is possible to develop this type of holistic assessment based on the concepts of a Patient Care Manage-FIGURE ment System (PCMS), performed by an interdisciplinary health care team, that uses the tripartite process of patient assessment, care planning, and care evaluation (Figure 1). Effective use of a PCM system apparently facilitates the:
THREE INTEGRAL PARTS OF THE PATIENT CARE MANAGEMENT CONCEPT
- Involvement of all health care personnel, the patient, and family (whenever practicable) in a unified, comprehensive evaluation process that is focused on the outcomes of care;
- Systematic monitoring of changes in the patient's status, especially whenever the appraisal cycle of periodic reassessment, patient care planning, and care evaluation is repeated; and
- Formulation of a baseline for developing or modifying standards of care and adjusting administrative practices, if necessary, to improve the quality of care.
An appraisal instrument for PCMS should be used so that the facility's health care team can obtain a holistic, objective picture of the patient. Since 1974, a number of PACE (Patient Appraisal and Care Evaluation) formats have been developed to facilitate assessment. PACE I underwent feasibility testing in 19 states and was subsequently refined. The PACE II sample instrument has six main content elements: (!) admission data, including demographic characteristics of the patient; (2) medical data, including clinical tests and measurements; (3) impairment record; (4) functional capacity, that is, the patient's capacity to carry out Activities of Daily Living, nutritional status, adjustment, etc; (5) patient cafe data, including services that the patient is receiving; and (6) discharge data, so that the patient can be appropriately placed and provided continuity of care. Figure 2 illustrates a portion of a schedule that is designed to help staff determine a patient's readiness for discharge, so the first part of the form provides space for recording Instrumental Activities of Daily Living.7
Based on an integrated, interdisciplinary approach to patient care, the PCMS concepts are spelled out in a forthcoming manual.* It proposes a systematized assessment of each patient's needs, in a sample PACE II format supplemented with three suggested schedules; a plan of care to meet those needs; and periodic evaluation of the outcomes of care.
Furthermore, the PCM process is a way of thinking, and the sequential procedures proposed can lead to problem identification and ultimately to individualized patient
*Λ complete, rei'ised PACE iI instrument, two case studies, definitions, and instructions are scheduled to be published in a new Patient Care Management Manual in 1980. care. Identifying, describing, and documenting the patient's needs, therefore, comprise only one part of the PCM system. For instance, if a patient's range of joint motion needs to be examined methodically, a health professional can refer to the terminology, illustrations, and instructions in the PCM Manual, so that the recording of clinical observations will tend to result in a consistent, comprehensive document. (One part of the range of motion test is illustrated in Figure 3.) Nevertheless, whatever patient assessment instrument is used by a facility's staff to apply the PCMS principles, the assessment must be followed by care planning and evaluation of the problem and the patient's progress.
By studying the assessment data, the health care team abstracts and records the multidimensional patient information and determines the problems, impairments, and dysfunctions (PIDs). Working in concert with the patient and either his family or a significant other whenever possible, the team establishes priorities, sets goals, and draws up a care plan that is designed to resolve the problems and help move the patient's functional abilities toward the feasible, measurable goals established. The care plan, specifying needed actions and services, identifying who will be responsible for each action, and establishing time-limited goals, is recorded on a Care Planning form. It becomes part of the patient's permanent record to serve as a guide for all care givers. A sample Care Planning form is shown in Figure 4.7
(Only First Part of Suggested Format Is Shown)
Depending on the patient's condition and the PIDs identified, the health care team will determine whether a patient should be reappraised, such as in a month's time or another interval. Through reappraisal of the patient's status, the team and the patient, where feasible, will be evaluating the outcomes of the care given by deciding if the goals have been achieved, wholly or partially, and the reasons for any nonachievement. They will also see if the right services have been provided to improve function (see Figure 5).7
In addition, they need to be acquainted with what they can do for health maintenance and reduce the patient's functional dependency. In such an assessment procedure, which includes determining the individual's functional level of the Activities of Daily Living and services required, it will be possible to monitor the appropriateness of care over a period of time and often prepare a patient for discharge to receive such home-based support services as home health care, homemaker services, adult day care, etc. Research data support the notion that resources ordinarily present in geriatric facilities can be systematically restructured to promote positive functioning.8
For example, a group of 13 experimental and a matched control group of long-term care facilities in a state located on the eastern coast of the United States, are now voluntarily participating in a PACE project. If given appropriate inservice education, state consultation, and administrative support and guidance within a facility, it can be anticipated that these and similar staffs will be successful in adopting patient assessment and care evaluation measures.
Integrating Quality Assurance Methods
Third, quality assurance procedures that can use PCMS common data and its uniform definitions, such as utilization review and inspections of care, should be reviewed to eliminate duplication of paperwork for eventual statewide synchronization of surveys and reviews of long-term care facilities.t The end result must be a meaningful analysis of common core data to determine the quality of care.
Thus far, nurses have not taken the role of geriatric patient advocacy seriously. Geriatrics and gerontology should be taught in all nursing education curricula so that the beginning practitioner will be skilled, knowledgeable, and motivated to render good quality care to the dependent elderly population. The educational outcomes should result from positive clinical educational experiences in long-term care settings under the guidance of role model nurse educators. Unquestionably, larger numbers of nurses are needed in long-term care settings to systematically assess older persons' physical and psychosocial factors and evaluate the outcomes of care.
Finally, the answer to the query posed earlier is a very positive one. Nurses with a tenacious spirit, deep concerns, a pervasive sense of responsibility and a commitment to the health field have a primary place in the future of gerontology. The puzzle remains: if fellow health care providers do not join those of us in the federal government in a productive collaboration to improve the effectiveness and efficiency of the national health care system for those who need long-term care, who will?
- ]. Bahr RT: Aging: Λ positive growth experience. Educ Horizons 56:173-176, Summer 1978.
- 2. I.ong-term care for the elderly and disabled. Budget Issue Paper, Washington. DC. Congressional Budget Office, Congress of the United States, February 1977, ρ ix.
- 3. Issues and Options in Community-Based Long-Term Care, presented at the Forum on Long-Term Care, George Washington University. Washington, DC, 1979.
- 4. Donahue VVT: What about our responsibility toward the abandoned elderly? Gerontologist 18:102-111, April 1978.
- 5. Ross HL: VSOP Project Update #2, November 1, 1978. Los Angeles. California, Cedars-Sinai Medical Center.
- 6. A Policy Statement: The F.lderly and Functional Dependency. Washington, DC. National Academy of Sciences, Institute of Medicine, 1977, ρ 12.
- 7. Working Document: Patient Care Management: Theory to Practice, HSQB 78-010. Washington DC, Department of Health, Education, and Welfare. Health Care Financing Administration, Health Standards and Quality Bureau, Division of Long Term Care, 1978, pp 19. 111-112.
- 8. MacDonald ML: Environmental programming for the socially isolated aging. Gerontologist 18:350-354, August 1978.