When a community health nurse makes a home visit to the visually impaired elderly diabetic to fill the insulin syringes for the following week, what other nursing intervention does she provide?
The nurse may begin the visit by asking, "How have you been this week?" Subjective data are thus collected while the she/ he checks the urine for glucose and records blood pressure, pulse, respiration, and breath/ heart sounds. She/he checks injection sites, observes for pedal edema and signs of skin breakdown or infection, asks about symptoms for hyper-/ hypoglycemia, and checks on availability of appropriate food and diet compliance. The nurse evaluates old and new problems, checks with the physician on the insulin dose, or enlists social support systems to buy groceries.
As in any chronic disease management, the goal of weekly patient monitoring by the nurse is to maintain control of the disease while preventing complications. This study examined whether weekly nurse management made a difference in the health outcome of the elderly diabetic patient. Data were collected on two groups of patients at the end of one year. One group's weekly home visits were discontinued by a Medicare ruling while the other groups weekly home visits continued.
It is estimated that the incidence of diabetes in the elderly is 1 7% after age 75 and 26% after age 80.' Diabetes is not diagnosed readily in the older adult since the classic symptoms of polydipsia, poly uria, and polyphagia may not be present. Without classic or acute symptoms, the older adult may have prolonged hyperglycemia, which has been correlated strongly with damage to small vessels, nerves, and the lens of the eye. This damage leads to long-term complications such as cardiovascular disease, peripheral neuropathy, and diminished visual acuity. Combined with normal aging changes, the older adult is especially vulnerable to functional disabilities as the disease progresses. Impaired vision from lens changes and retinopathy, for example, make it difficult for the elderly diabetic to read color changes accurately on urine glucose strips, such as Testape, or to draw up the correct amount of insulin in a syringe. In this study, visually impaired elderly diabetic patients whose skilled nurse visits to prefill insulin syringes were discontinued by a Medicare ruling were visited after one year to determine health outcomes.
In January 1980, 44 elderly visually impaired diabetic patients in a southwestern metropolitan area had weekly home visits by a community health nurse for the purpose of prefilling a week's supply of insulin syringes. This was a Medicare reimbursable service. Without warning, however, the Health Care Financing Administration (HCFA) ruled that the cost of home visits by professional nurses for the purpose of prefilling insulin syringes no longer would be reimbursed by Medicare. The HCFA ruling further stated that home visits by nonlicensed personnel, such as nurses' aides, to prefill insulin syringes would be reimbursable by Medicare. However, because the state nursing practice act limited the administration of medications to licensed nurses, use of nonlicensed aides to prefill insulin syringes was not an option for the diabetic patients. Therefore, all 44 cases were reviewed for financial eligibility and level of care classification. As a result of this evaluation, 17 of these 44 patients had weekly nurse visits continued under another form of payment such as Medicaid, private insurance or individual patient changes. Twenty-three patients were considered no longer eligible for Medicare coverage, and had weekly visits discontinued. Four patients had weekly visits continued because of more severe illnesses that qualified them for a skilled care classification. Thus, 39 patients had health problems that were not considered severe enough to classify their level of care as "skilled." These health problems included open wounds, significant fluctuations in elevated blood sugars, newly diagnosed diabetes, or other acute or chronic diseases that required professional nurse supervision.
The following question was used as the basis for the study. After one year, did the patients who had seen a community health nurse weekly have a different health outcome than those who were seen only intermittently, or not at all?
The existence of two groups of elderly diabetics, one who had weekly nurse monitoring, and one group who was not seen regularly, if at all, provided a unique opportunity to compare health outcomes after one year. However, because this was a sample of convenience, the results of the study may not be applicable to other groups of elderly diabetics.
The "Continued" group (N= 17) was defined as those patients who had weekly nurse visits, but who did not qualify for skilled care under other diagnostic criteria. Those skilled care patients (N=4) were excluded from the study since they were more severely ill. The "Dropped" group (N=23) were those patients who were not seen weekly by the community health nurse. Six of the Dropped group were seen episodically as they were discharged from the hospital or referred for other health problems, but none of them were seen more than four times in the year following the Medicare ruling. Three patients in the Dropped group could not be located; therefore, only 20 patients were surveyed.
Tools and Administration
A health status questionnaire (Figure) using variables related to diabetic complications was administered to both groups 12 to 15 months after the Medicare ruling. This tool, which was developed for this study, was not pretested. The questionnaire was administered to the Continued group on a regularly scheduled visit. The Dropped group was revisited once. Questionnaires were completed by nurse observation or patient report. Patient report variables included vision changes, hyper-/ hypoglycemic episodes, diet compliance, skin problems or infections, pedal edema, number of new medications, number of hospitalizations (including nursing homes) with number of hospitalized days, and level of functional mobility. Nurse-observed variables included blood pressure, pulse, respiration, weight, heart/ lung sounds, and appearance of legs and injection sites.
The patients in both groups lived in the geographic district of the nurse who administered the questionnaire. Because of district reassignment and staff changes, this nurse may not have been the same one who cared for the patient in the previous year.
No significant differences were found between the Dropped and Continued groups in hyper-/ hypoglycémie reaction, weight loss or gain, new medications, pedal edema, or infections as reported by the patient. In addition, no significant differences were found in those patients who reported that their vision was worse and that they "didn't get out as much." Both groups reported similar numbers of doctor, clinic, and emergency room visits. The one-time observation of blood pressure, pulse, respiration, and heart and lung sounds did not vary from the previous year's reading in most patients. Findings on diet compliance, weight, and appearance of legs and injection sites also were similar in both groups.
The major finding was that the Dropped group reported 25 hospitalizations compared to nine for the Continued group. The difference is significant at the p =<.056 level. Further, when comparing the number of hospitalized (acute or nursing home) days, the Drop ped grou p reported 663 days compared to 128 for the Continued group. The MannWhitney U test showed this difference was significant at the p =<.02 level.
HEALTH STATUS QUESTIONNAIRE
The two groups of patiente were very similar in health outcomes. Patients in both groups reported deteriorating vision, episodes of hypo-/hyperglycemia, pedal edema, leg sores, new medications, and similar numbers of doctor, emergency room, and clinic visits. They also reported that they did not get out as much (functional mobility). Thus, it would seem that both groups had severe chronic disease problems. This description of a chronically ill elderly population is similar to the home health care study by Widmer, Brill, and Schlosser.2 They found that onethird of the home care patients were so dependent that they would be placed at the skilled care level in a health facility. The significant difference between the two groups of chronically ill patients in this study is the number of hospitalized days: 663 in the Dropped group and 128 in the Continued group (Table 1). If this number of hospital days is calculated at per them dollar cost for the last quarter of 1980 (45.20/ nursing home day; $381 /acute hospital day), the difference is staggering (nursing home and University Hospital business office, personal communication, July 1982). The Dropped group dollar cost $140,445 compared to $48,768 for the Continued group (Table 2). If the Continued group cost is adjusted to include the home health visits ($2,000/ patient/ year) the dollar cost for the Dropped group is still $57,677 higher. This difference does not include the cost of episodic home health visits for the Dropped group, or the unknown health care costs for the three lost patients in the Dropped group, thus potentially increasing the difference between the two groups.
It is clear that, in this study, the two groups of chronically ill, elderly, diabetic patients had significantly different health care costs. Those patients who had continued nursing home health care visits by the professional nurse had fewer hospitalized or nursing home days during the year of the study. This reflects findings of studies that elderly patients receiving home health care incur lower institutional costs. Bryant, Dandland, and Loe wens te i n compared hospital costs for stroke patients with and without home care. They found overall hospital costs lower for those stroke patients who had home care.3 In describing the "nursing home without walls" program in New York State, Pegel discusses a substantial dollar saving for those patients cared for in their homes.4 The Home Maintenance Program for the Homebound Aged, also in New York, has demonstrated that home care is one-third as expensive as nursing home care.5
ACUTE HOSPITALIZED DAYS OR NURSING HOME DAYS
COST OF HOSPITALIZATION
While the dollar cost is the main thrust of these studies, the personal cost of inadequate home health care can be illustrated through the following case study:
Mrs. H. is a 69-year-old diabetic with severe retinopathy. Almost totally blind, she lives alone. Each week in the 18 months prior to the Medicare ruling, a community health nurse visited Mrs. H. to prefill insulin syringes. During this time, she was fairly stable with only one minor change in insulin dosage. When the nurse visits were terminated by the Medicare ruling in January 1980, a granddaughter was taught to prefill syringes and to provide general diabetic care including diet and foot care. In the next few months, Mrs. H. was referred twice to the community health agency for insulin dosage changes. In the year after termination of weekly visits, Mrs. H. reported that she had had frequent hypoglycémie episodes when a neighbor prefilled the syringes. She also reported frequent falls, as well as a five-day hospitalization for hyperglycemia. Mrs. H. stated that her vision was much worse than it was in the previous year, and that she was "very depressed" because she was so much worse. Because a reliable person couldn't be found to prefill syringes, she had since been maintained on Tolinase, an oral hypoglycemic. After the study visit, Mrs. H. was readmitted tothe health agency with weekly home visits, and restarted on insulin injections one year after she was dropped.
The complexity of diabetes in the older adult, the high risk on longterm complication, and the diminished resources and reserves of the elderly certainly indicate the need for professional nurse involvement.6 Nurse management at home is not only less costly, but older people generally prefer it.7 The elderly's fear of institutionalization would seem well-founded. Tobin and Leiberman found that only 50% of nursing home residents maintained their functional ability in one year after admission.8 Even though Simms, Jones, and Yoder report that many nursing home residents over 70 years of age have a good adjustment to the facility, the majority have a poor adjustment.9
Because of lack of alternatives, however, the ill elderly often have no choice but institutionalization. Pegels estimated in 1980 that 300,000 elderly people were institutionalized inappropriately. He further postulates that deinstitutionalization would save $ 1 billion per year if home health care alternatives were available.4 Cutting Medicare funds for nursing management of the diabetic elderly patient at home is an example of the gap in home health care support. If the intent of this cutback was to save money, it would seem that it failed. The cost for the dropped group was approximately 70% higher than the continued group, with a statistically significant difference in the number of hospitalized days between the two groups. Skilled nurse management of the elderly diabetic patient at home in this small study resulted in substantially lower health care costs.
Nursing practice with the chronically ill elderly is complex if it is to be comprehensive. Multisystem disease, cognitive changes with age, and diminishing physical, psychological, and financial resources demand expert nursing management. From this study, it seems that nurses did much more in the home than prefill syringes for the patients who were able to avoid institutionalization. What was not clarified was the etiology of the difference in the two patient groups. Perhaps weekly attention by the community health nurse to changes in physical condition and environmental problems prevented complications that may have ended in hospitalization. Reassurance from the nurse who visited the Continued group weekly also may have contributed to fewer hospital days. However, in order to say that nurses can make a difference in health outcomes, nurses must identify discrete areas of responsibility and document those interventions that affect outcome.
This study compares health outcomes in two groups of elderly diabetic patients after one year: one group who had continued skilled care home visits by nurses to prefill insulin syringes, and one group who had weekly visits for this purpose discontinued as a result of a Medicare ruling. Most health outcome measures were similar in both groups, indicating similar chronic disease problems in the total study population. The number of hospitalized and nursing home days, however, was significantly higher in the dropped group.
While this study demonstrates in a small, convenient sample that nurse management of the elderly diabetic patient at home did make a dollar difference, further study is needed to define the specific nursing actions that might make a difference in patient health outcomes. In addition, this study was limited by lack of a reliable tool to measure health status. If nurses are to defend the premise that nurse management of the chronically ill patient at home results in a better health outcome or lower health care costs, further study is warranted in these areas.
- 1. Williams TF: in Greenblatt TB (ed): Geriatric Endocrinology. New York, Raven Press, 1978, p 103.
- 2. Widmer G, Brill R, Schlosser A: Home health care services and cost, Nur s Outlook 1978, Aug448-493.
- 3. Bryant N, Dandland L, Loewenstein R: Comparison of care and cost outcomes for stroke patients with and without home care. Stroke 1974, 5:54-59.
- 4. Pegels CC: Institutional vs. noninstitutional care for the elderly. J Health Polit Policy Law 1980; 52):205-212.
- 5. Brickner PW, Janeski JF, Rich G, et al: Home maintenance for the home-bound aged: A pilot program in New YorkCity. Gerontologist 1976; 16:25-29.
- 6. Hayter J: Diabetes and the older person. Geriatric Nursing 1981; Jan/ Feb:32-36.
- 7. Bell WG: Community care for the elderly: An alternative to institutionalization. Gerontologist 1973; 13:349-354.
- 8. Tobin S, Lieberman M: Last home for the aged, in: Critical Implications of Institut ionalization. San Francisco, Jossey-Bass Publishers, 1976.
- 9. Simms LM, Jones SJ, Yoder KK: Adjustment of older persons in nursing homes. Journal of Gerontological Nursing 1982; 8(7):382-386.
ACUTE HOSPITALIZED DAYS OR NURSING HOME DAYS
COST OF HOSPITALIZATION