As the numbers of older people increase in the United States, the eyes of the nation and the Healthcare industry in particular have begun to focus on the elderly population. A major priority has become the need to develop coherent systems of long-term healthcare services. These services include preventive healthcare teaching, better and up-todate training for those who care for elder individuals, appropriate, accessible and adequate health care, and support for those family members caring for the elderly. Southern Baptist Hospital has developed a one-of-a-kind program - respite care - as a method of support or relief for those caring for the elderly person at home.
Review of the Literature
Respite care is a newly defined service within the long-term care area that came into focus in the mid-1970s.1,2,3 It is unique in the field of health care because it provides services to those who give care as well as to those who receive care.4 Respite means relief and therefore encompasses a wide range of services. Definitions vary, but in general respite care refers to care provided on an intermittent basis to provide relief to the family or care giver from the responsibility of caring for a chronically ill or disabled person.
Hildebrant5 put it well when she said, "There seems to be no clear consensus on a model for respite care." It may be delivered in the home or a facility and may be medical, social, or combined in nature. The type of respite care provided is usually based on the physical and psychological needs of the dependent person as well as on the convenience, availability, and cost of the service.6
Institutional settings providing respite care include congregate care facilities, nursing homes, and acute care hospitals. They may set aside a few of their beds, which are then reserved in advance for short-term respite care. Costs can range from $30 to $90 per day and vary based on the community, the rates of the acuity, and the level of care required by the client. Despite the often high costs for respite care, which is not considered a reimbursable service by Medicare (except when connected with a hospice program) or by most private insurance carriers, there is a demand by private pay clients for this type of service.7
According to Grad and Sainsbury,8 the families of older clients have more than twice the number of severe problems than do those families of younger clients. The likelihood for institutionalization increases without some type of support for those families.9 Respite care can provide needed support and enables home care to be an alternative to institutionalization by improving the mental and social relationship of the care givers, thereby decreasing the stress that accompanies the care giving.1,7 In general, families have expressed satisfaction with institutional respite programs.6,10-12
In an effort to validate the need for respite care in our community, surveys were conducted of the social service departments of the various hospitals in New Orleans, of physicians, and of area nursing homes. We were looking at the number of elders returning home in the care of relatives and requests for shortterm care either in hospitals or nursing homes.
In response to this expressed need, Southern Baptist Hospital now offers a respite care program within the hospital as one method of support or relief for those caring for the elderly person at home. Our program began as a weekend program that accepted clients for approximately 48 hours with admittance on Friday afternoon and discharge by the following Sunday evening. We are now accepting clients for up to two weeks, every three months. To be eligible for admittance to the program, the client must have a care giver who is responsible for his or her care, be able to pay for the services rendered while in the program, a physician who is in good standing with the hospital, and be 60 years of age or older.
An application is sent following an inquiry by the care giver. Upon receipt of this application by the respite care coordinator, a home visit by a nurse is arranged. This visit allows the client and family to meet a member of the respite staff and for the staff to gain information that will enable them to provide continuity of the care received at home. During this visit an assessment of the client, his or her medications, treatments, dietary preferences, and daily activities is completed.
Because we are hospital based, we are able to provide not only nursing care and dietary therapy, but also social services, physical therapy, recreational therapy, speech therapy, and spiritual care as needed. In addition, the staff may 'call upon the attending physician or any of the nurse specialists.
Although many seemingly insurmountable problems were encountered while setting up this program, each was solved without major difficulty. The last thing that any nurse or physician wants to hear is "more paperwork!" In our in-services for the staff we continuously stressed the fací thai, although there were no additional forms, some of the forms were different from those being currently used in the hospital. Our hospital was just converting to a computerized daily medication sheet for each inpatient with the necessary medications being refilled daily by the pharmacy.
In an effort to keep the cost of our program to a minimum, the patients bring their medications from home and these medications are kept at the nurses' station. To avoid confusion, the respite program uses a monthly form, which is handwritten at the time of admittance and used continuously throughout the respite visit. This form will soon be placed on the computer and used for all patients on the skilled nursing unit.
Another difference is the care plan form. Because the patients do not spend their day in bed or in testing procedures we felt a plan of care that placed emphasis on the psychosocial aspects of care was necessary. The nurses were able to adapt to both of these forms rapidly.
As a convenience to our physicians, the patient's medications and the hours of administration are recorded from the prescription bottles onto a physician's order sheet at the time of the preadmittance home visit. Also included are any overthe-counter drugs and treatments that the family is doing for the client at home. The admitting physician reviews this list upon admittance, makes any necessary changes, and then signs the orders. A short-form history is also begun at the time of the home visit, which the physician reviews and signs.
Location and staffing also presented a problem. Our respite program was originally located on one of our acute medical units, which already had high numbers of elder patients assigned to it. Although not placed in rooms with sick patients, respite clients were cared for by the same staff. The nurses on the unit received in-service on respite care, more specifically in dealing with older, chronically ill clients, as well as the forms and necessary paperwork.
When our skilled nursing unit was developed and opened, we encouraged the respite patients to be involved in their activities and programs. Because of the limited bed space we were unable to move the respite program to that unit. With a recent expansion of the skilled unit, which more than doubled the capacity, we have, following an in-service for the staff, moved the respite program. We believe that the respite patients benefit by the atmosphere of the unit, which stresses self-care and activity.
Our first client was a 73-year-old male who lived with his son, daughter-in-law, and their three children ranging in age from 7 to 13. He had been diagnosed as having Parkinson's disease, aiteriolosclerotic cardiovascular disease, and recurrent urinary tract infections. He was incontinent and used diapers. Slightly stooped and very quiet, Mr A. was admitted on a Friday afternoon. The first evening of his admission was particularly stressful for both Mr A. and the staff not only because of his confusion due to the change in his environment, but because of the newness of the program itself. Mr A. wandered in the hallway and at times became hostile with the staff when they showed him "his" room and "his" bed. Insisting that they were wrong, he continued to wander until he was so tired that he accepted their definition of "his" bed and went to sleep.
The nurses, despite their orientation, had some difficulty in realizing that Mr A. was not a "patient" and did not need to stay in bed, but still required care and observation. As Mr A. wandered the halls, he learned his way to the nurses' stations, to the bathroom and back to his room and bed. He became more comfortable with the staff and his new environment. As a result, his hostility decreased and his wandering became purposeful as he visited with the nurses. The staff became more at ease with this new type of client who wore his own clothes and did not stay in his room, who did not conform to their definition of a patient.
By the time his family came to pick him up the following Sunday evening, both Mr A. and the staff were beaming with success. MrA. has been back to visit with us on three other occasions (once for a week-long visit), and each time his family returns with a renewed vitality.
Mr A.'s original admittance was the first time his family had been able to vacation as a group in the three years since he had come to live with them. With each admittance his son has expressed concern about the necessity for placing Mr A. in a nursing home as he becomes more and more difficult to handle at home. The gerontological nurse specialist and social worker were able to intervene in this problem by providing information regarding nursing homes. The respite program has allowed this family time not only to themselves but time to investigate the availability of nursing homes to find just the right one for Mr A. should they feel such a move is necessary.
Each of our clients and their families has been unique, and the program has been used for many reasons. Mrs T., an 86-year-old Alzheimer's patient, is cared for by her daughter and son- in-law. Mrs T. has been a client in the respite program three times. Because of the program, her care givers have been able to attend a family reunion and her daughter, a nursing student, was able to study for her final exams without the responsibility of caring for her mother at the same time.
Mrs H., at 93, cared for herself in her own apartment attached to her son's home. She ambulated with a walker and attended a daycare center during the week . Her son had earned a trip to Hawaii and wanted to take his wife with him. They did not want to leave Mrs H. alone and used the respite program while they took their trip to Hawaii - their first vacation together in many years. Mrs H. arrived on the unit with her bag of "homework" from the daycare center. She was decorating plastic fruit baskets with yam. Her visit was not only helpful for her family, but she and our activity director shared cran ideas and the skilled nursing unit benefited as well.
Occasionally the respite program is used in an emergency situation. Mrs C., 85 years old, was admitted to the program when her daughter was hospitalized with a myocardial infarction. She stayed with us in the program until her son was able to come from his home out of town. She was then able to be discharged to her home.
With each client's visit the staff learns new and better ways to render care that promotes, rather than hinders, independence and self-esteem.
Given our present economy and the governmental regulations regarding Medicare reimbursement, increasing numbers of families are and will be caring for elders at home. Southern Baptist Hospital recognizes that it is not the institutions, but the families that sustain the major share of the burden of care for the dependent and chronically ill elder. Because this responsibility for the care of a parent or spouse can be both physically exhausting and emotionally draining, our respite program offers the care giver a chance to take care of personal business or just relax and rejuvenate, and then return with a brighter outlook and renewed energy. We believe that each care giver deserves this chance - and so does the person for whom he or she cares.
- 1. Cohen S: Supporting families through respite care. Rehabilitation Literature 1982; 43(1-2):7-11.
- 2. (NYSSCA) New York Slate Senate Committee on Aging. Perspective on Respite Care for the Elderly. Albany, 1981.
- 3. Upshur CC: Respite care for mentally retarded and other disabled population. Mental Retardation 1982; 20(1):2-6.
- 4. Warren R, Cohen S: Respite care. Rehabilitation Literature 1985; 46(3-4):66-71.
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- 7. Mehzer JW: Respite Care: An Emerging Family Support Service. Washington, DC: Center for the Study of Social Policy, 1982.
- 8. Grad J, Sainsbury P; Mental illness and the family. Lancet 1963; 1(9):544-547.
- 9. Fengter AP, Goodrich N: Wives of elderly disabled men: The hidden patients. The Gerontologist 1979; 19(2): 175-183.
- 10. Ellis V, Wilson D: Respite care in the nursing home unit of a Veteran's Hospital. Am J Nurs 1983; 83<10): 1433-1434.
- 11. Packwood T: Supporting the family: A study of the organization and implications of hospital provision of holiday relief for families caring for dependents at home. Sor Sci Med 1980; 14(A):13-20.
- 12. Williams L: Study shows respite care helps homes and families. Today's Nursing Home 1983;4(7):1,11.