For the past six years, the University of Massachusetts at Boston and a local Council on Aging have collaborated in a mutually beneficial healthcare endeavor. The Council on Aging serves as a base site for a community health nursing clinical experience for the university's senior-level baccalaureate nursing students. The students, under faculty supervision, provide an estimated $100,000 of nursing care to the elders of the city each year. The council provides physical space, secretarial support, and telephone service hi return.
Students learn about gerontological nursing while providing comprehensive health promotion and health maintenance services to elderly city residents. The students collaborate closely with other health- and elder-care providers. The elders benefit by receiving cost-free, skilled nursing care and referral services for which they are not eligible under their healthcare insurance. The city benefits by saving substantial financial resources, which can be diverted to meet other pressing needs.
Changing Structure of the Healthcare System
Healthcare costs have risen in this country and are continuing to rise. Currently, the healthcare industry accounts for more than 10% of the gross national product.1 Most healthcare insurance for elders, specifically Medicare, provides coverage for illness care. Because health promotion costs are not readily reimbursable, traditional healthcare providers have focused on providing illness care.2 As the number of elders in our society continues to increase , the gap between healthcare needs and those services included in traditional healthcare insurance coverage continues to widen. The typical elder pays more out-of-pocket costs for healthcare services each year.3
Costs of providing nursing education have also increased dramatically. Current federal cost-containment measures are forcing many healthcare institutions to reexamine their priorities, and many healthcare institutions are reevaluating how much they are able to spend on educating nursing students.
Although both the Council on Aging and the School of Nursing recognize that fees could be charged to community residents, each party believes that the current arrangement provides considerable nonmonetary benefits. Clients are, therefore, not charged a fee for services provided.
As the locus of health care shins from the hospital to the community, priorities for care in the community also change. With more seriously ill patients going home sooner, community health nurses find themselves having to set priorities in a new way. The well elderly who were previously provided with health promotion services have become a lower priority than those clients in the acute or early recovery phases of illness.
Students who are assigned to this clinical placement spend an entire semester during their senior year in the program. One faculty member is responsible for a group of eight students. The faculty member and the students generate the caseload, provide and evaluate all nursing care, and maintain all necessary records. The faculty member is the clinical supervisor and, as such , is ultimately responsible for the success of the program. The faculty member meets with students individually to review the students' caseloads on an ongoing basis, and discusses the students* attitudes, feelings, communication skills, nursing care plans, and clinical decision-making skills. Each student meets with the faculty member on a weekly basis by appointment. The student brings clinical data to these meetings and works with the faculty member to achieve mutually agreedupon learning goals.
The faculty member also meets with the students as a group for a conference each day of the clinical experience. As caseloads are discussed, mutual problem solving occurs and nursing care plans are developed. Students learn from agency personnel, their faculty member, and one another. The peer group is an important vehicle for learning. Students often learn about valuable community resources from one another as they hear their fellow students plan care for assigned clients.
Clients have all agreed to student visits. They may terminate the studentclient relationship at will. Clients have access to the faculty supervisor and are free to telephone the faculty member as necessary. Faculty are available to accompany students on visits at the request of either student or client or if the faculty member needs to confer with the client. Records are kept at the Council on Aging, and all records are treated as confidential.
Students maintain verbal and written contact with other healthcare providers as necessary. Faculty review written referrals and assume ultimate responsibility for student practice.
As the fine reputation of the student nurses' care spread by word-of-mouth, the rate of client referral increased. The current active caseload numbers 65 families. Client referrals come from a variety of sources, such as the Council on Aging, Department of Elder Affairs area agency, mental health agencies, and the community health nursing agency.
The council receives telephone calls from concerned friends and family members of elder residents asking for assistance with such concerns as recent widowhood, depression and isolation, chronic illness, and confused behavior. Many of the elders thus referred are not eligible for care from other, more conventional agencies due to Medicare guidelines or their own inability or unwillingness to pay. Some elders who refuse any intervention that is labeled "psychiatric" are willing to be visited by the students.
The Department of Elder Affairs and the community health nurses frequently refer clients who do not meet their mandated guidelines for services or who receive income in excess of agency limitations. Sometimes they refer elders to whom they provide service two or three days a week and request that students visit on the alternate days.
Area mental health agencies have referred elders who have been deinstitutionalized or who simply are not sufficiently organized to make regular mental health appointments. Since the students visit the elders in their homes, the mental health professionals are assured that, at the very least, the clients are under supervision for basic needs and receive counseling commensurate with the students' abilities.
Other referral agencies include private physician groups, the continuing care department of the local community hospital, the city housing authority, the public health department, the city police, and past or present clients.
Nursing Care Services
The baccalaureate nursing students provide care to the elders of the community at the three levels of prevention. They participate in health screenings, conduct health education programs, make home visits, and facilitate referrals as needed.
Health Screening - The students are involved in health screening in a variety of ways. They conduct blood pressure clinics on a regular basis at the Council on Aging and its satellite. Evaluations of adherence to medication regimen, diet, and lifestyle are conducted periodically. Referrals to physicians are initiated as appropriate. On several occasions it has been necessary to arrange for immediate transfer by ambulance to the emergency room of the local hospital for elders with serious high blood pressure accompanied by other pertinent symptoms.
Health screening is also accomplished by student participation in area health fairs, where the students use their nursing skills to perform interpretation and referral functions at the conclusion of the screening process. Illese health fairs are heavily attended by elders who are concerned about health status, but who may not wish to pay a hefty physician fee for an annual physical examination that tends to focus on disease processes rather than on functional abilities.
During the past year, the local community health nursing organization requested that the students assist them in a new "keep well" program that took place at nine elderly housing units. The nurses said that they had such limited budgetary resources that the program would not have been possible without the students' participation. Each student was assigned to a designated elderly housing unit and followed the nursing agency's protocol for assessing elderly residents and making referrals to appropriate agencies as needed. Some elders were referred to the students themselves through this program.
Health Education - The students conduct regular health education programs at the Council on Aging and its satellite site. Each topic is publicized in advance in the local newspaper as well as by word of mouth at the council . Programs are consistently well attended and have been evaluated by the elder attendees as interesting, pertinent, and useful. Some of the topics presented to date have been: Blood Pressure and You, Osteoporosis and Senior Women, Elder Abuse, Medications, Alcoholism in the Elderly Population, and Exercise for Elders.
Home Visits - Students make home visits to all potential clients who have been referred. Comprehensive nursing assessments are performed with the clients and their families. Following group and individual supervision, students contract with their clients for nursing care. Community resources are frequently used, including services such as the friendly visitor program, personal care services, and the Council on Aging's transportation' van. As part of the comprehensive client care provided specific agencies, such as the Institute for the Blind, the Multiple Sclerosis Society, or the Center for Family Violence, are also consulted.
Students also make "home visits" to residents of several local nursing homes. Some of the clients thus visited have been followed by students prior to institutional placement; others have been referred by staff or other clients. Nursing interventions in this setting include facilitating intrafamily communication and encouraging participation in facility activities and pursuit of individual activities that were abandoned with increasing age, such as knitting, drawing, and writing poetry. As a result of student intervention, one facility now has new contributors to its monthly newsletter. Another important function of student visits is the students' ability to help nursing home clients interact with the world outside of the institution. One 100-year-old client told her student, "No money could buy what your visits have meant to me."
Referral Services - Many of the agencies to which students refer clients have already been mentioned. Before a referral can be made, the student must investigate potential resources so that the one selected will be the one best suited to the needs of the particular client. Agency investigations serve to acquaint the student with area resources, help the student gain expertise in agency evaluation, and foster good relationships between the city's agencies and the student nurses. Students become astute in finding cost-effective resources, such as self-help groups, and concurrently acquire a sophisticated understanding of system dynamics. They also use one another as resource persons for potential referral sources.
At the end of each school year, students find it difficult to leave their clients and many ethical dilemmas emerge as the gap in student coverage occurs until the fall semester begins. It is at this time that the most important referrals take place. Students are highly selective in their choices, as they have strong feelings about the agency to which they will surrender "their" clients. If students were impressed with the importance of referral up until this point, they have a firm understanding of the importance of the process by the completion of the termination experience.
The University of Massachusetts at Boston School of Nursing and a local Council on Aging collaborate to provide free, professional- level nursing care and referral services to the senior citizens of the city. The baccalaureate students learn many important lessons about the skills and role of the professional nurse, and the Council is assured that elders enjoy health care that would not otherwise have been possible. This collaborative effort results in a situation from which everyone benefits. It serves as a model for creative problem solving in a cost-conscious healthcare system.
- 1. US Department of Health and Human Services, Health Care Financing Administration, Office of Research and Demonstrations, Health Care Financing Review, 1984; 6(2).
- 2. Davis K, Schoen C: Health and the War on Poverty. Washington, DC, The Brookings Institution, 1978.
- 3. Starr P: The Social Transformation of American Medicine. New York, Basic Books, 1982.