In 1 984, the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration of the US Public Health Service awarded a contract to the University of North Carolina Research Associates at Chapel Hill to develop and pretest a nursing assessment interview questionnaire designed to assist nurses in identifying the self-care behaviors practiced by older persons residing in the community. The rationale for the contract was based on several factors, chief among them was the fact that such a tool did not exist. Secondly, such data could serve as the basis for the development of health promotion/disease prevention activities with high-risk elderly populations aimed at keeping them functionally independent in the community for the longest possible time. Thirdly, access to a data base of such information could have major economic and educational implications for the elderly and their families, federal and state governments, and healthcare providers, a)! of whom share in the responsibility to reduce healthcare costs and to maximize the elderly's functional independence and general well-being.
During the summer of 1 988, the Division of Nursing entered into a cooperative agreement with the National Institute on Aging (NIA) to fund the second phase of this contract. Phase Il activities include:
* Assuring the reliability and validity of the instrument, and
* Developing a national sample data base of information on elderly self-care behaviors from which age/sex specific self-care norms and predictors can be developed.
These data are considered of high value to the federal government and were determined to require collaborative agency effort to implement.
In August 1 988, the University of North Carolina Research Associates at Chapel Hill was awarded a 3-year grant by the NIA to implement Phase II. During the Fall of 1990, interviews were conducted on a random sample of approximately 4,000 community-based elderly throughout the US, representing rural, urban, and suburban elderly. The final project year will consist of data analysis, preparation of the final report, and dissemination of the project's results.
It is anticipated that a data bank of the collected self-care information will be developed at the NIA, which will then be made available to scholars, researchers, and educators who have an interest in selfcare of the elderly. Dr Franklin Williams, director of the NIA, stated that the data base on self-care practices of noninstitutionalized older persons will serve as a unique resource to those who are interested in exploring these issues. Knowledge of the antecedents and consequences of self-care behaviors can contribute to our understanding of factors that enable older persons to maintain and promote their health and functioning. Furthermore, the availability of age/sex specific self-care norms and predictors can be useful in planning appropriate services for older persons that support their independent living in the community.
The ever-increasing proportion of aged in our population weakens our capacity for looking after older people in traditional ways, and the development of new cost-effective methods and policies are necessary. The Surgeon General's Report, Healthy People, states that "the long-term goal of health promotion and disease prevention strategy for our older people must not only be to achieve further increases in longevity, but also to allow each individual to seek an independent and rewarding life in old age unlimited by many health problems that are within his or her capacity to control."1
The concept of self-care is uniquely joined to preventive care for the elderly and will enhance their dignity and self-esteem by allowing them to become partners in their care with health professionals. What Fuchs said about the American people in general is particularly true about the elderly; namely, that the greatest potential for improving the health of the American people is to be found in what they do or don't do for themselves.2 The elderly have demonstrated great untapped resources in terms of desiring to remain independent in their own homes for as long as possible and in their surprising resilience in the face of cumulative losses sustained over relatively short periods. Nurses have traditionally borne the major responsibility for the daily care of the elderly, both in institutional and community settings. Therefore, it seems appropriate and reasonable that nurses explore the untapped potential of the elderly for promotion of their selfcare.
Prevention of disease and promotion of health have always been high priorities for nurses. At the turn of the century, public health nurses routinely used self-care concepts with patients and their families, who assumed a great part of the responsibility for their own health care. Societal changes, including hospitals developing into high-tech, critical care centers after World War II, contributed to individuals and families appearing to lose more of their independence in caring for their own well-being. Reimbursement policies followed the trend of the diseaseoriented, medical model of institutional care as well. We are now dissatisfied with both, and the need for change is evident everywhere in the current health-care delivery system. With rising demands for health care on the one hand and finite capabilities on the other, nurses appear to be the most likely health-care professionals to succeed in advocating for and in teaching self-care concepts to the elderly and their families.
The Special Project Grant Program, within the Nursing Education/ Practice and Resources Branch of the Division of Nursing, offers a unique opportunity to the nursing profession to address the challenge offered by an ever-increasing elderly population. The Nurse Education Amendments of 1 985, enacted by Congress in 1985 and implemented in 1987, provide for federal grant support to "demonstrate methods to improve access to nursing services in noninstitutional settings through support of nursing practice arrangement in communities."3 This legislative authority, Purpose 5 under the Special Project Grant Program of the US Public Health Service Act, currently supports 1 2 nurse-managed clinics around the country that address health promotion/disease prevention activities with various high-risk populations. Only two of these currently focus on the elderly; however, neither of these two focus on self-care promotion among the elderly.
During Congress' discussion of this new demonstration authority for nursing, it was noted that nurses are the largest health-care provider, the most under-used, and could perhaps be the most cost-effective with highrisk populations such as the elderly, the homeless, and minorities. According to Congressional Reports, Congress was especially concerned that the disease prevention and health promotion skills of nurses be more adequately used to develop cost-effective and innovative healthcare delivery services for the elderly. Preventive health care for the elderly, which includes the promotion of self-care, was particularly noted. Congress also stated that these demonstration projects should provide information on accessibility, effectiveness, payment policies, cost, and problems encountered in the implementation of the projects. The Congressional Record further noted that such projects should provide the federal government and private payers with experience and data to study proposals for future changes in reimbursement policies.
This legislation opens the door for the nursing profession to demonstrate what it can do for high-risk populations in a relatively independent practice setting. Costing out these nursing services and furnishing valid and reliable outcome data regarding the effects of nursing interventions could allow for third party reimbursement for the services provided through nurse-managed clinics. Currently, these projects are funded for a maximum of 5 years. Initially, grants are awarded for 3 years with the option of an additional 2 years of funding if the need can be documented in a continuation proposal. Any money generated through these projects can either be used to offset project costs, or can be placed in an escrow account to continue the project after federal funds cease. It is essential that strong community linkages be developed early in the project's design that provide for the building of an infrastructure to enable the nurse-managed clinic to become self-supporting.
Additional benefits are available through this legislative authority. Nursing students can obtain wonderful practice experience at these clinics and faculty can develop unique research protocols. Graduate students can tap into faculty research projects for their theses and can gain beneficial research experience while acting as research assistants to their mentoring faculty. The spin-offs from this kind of project are endless and could stimulate creative minds and pioneering spirits. The more nursing capitalizes on available opportunities to make the profession more competitive with others, the less likely the prospect of losingbright students for nursing and, maybe, the less likely that we will have future nursing shortages.
As systems for the prospective reimbursement of health-care providers become the standard, more elderly who become ill will be cared for at home for all or part of their illness. The critical factor that will determine if these programs are successful (ie, whether they are able to effectively reduce health-care costs with no attendant increases in negative health outcomes) is whether persons who are cared for in non institutional settings are able to do for themselves those things necessary for health maintenance and enhancement without further risk to their health.
Self-care is one means of reversing the trend toward the "medical ization" of common illnesses in our society today. Because the elderly represent approximately 1 3% of our population and consume approximately one third of this nation's health-care resources, it is considerably important to public policy to ensure that persons in this age category maintain the highest possible levels of health and functional capacity to diminish their dependence on institutional health and social services. Even small incremental changes in average rates of institutional care requirements can account for substantial changes in national health-care costs. Chronic conditions and disabilities, frequent companions to aging, are the most common problems faced by our health-care system today. They often require longterm management where self-care skills, attitudes, and knowledge can be extremely important. The attitudinal readiness and physical capacity to perform basic self-care tasks can significantly alter the dependence of an elderly person with a chronic illness or disability. In fact, it could mean the difference between being institutionalized for a whole package of costly and often unneeded care or being allowed to remain in one's own home, where most elderly wish to remain.
If nurses can demonstrate their success with the elderly, it is reasonable to assume that reimbursement for health promotion and disease prevention activities with high-risk populations is a real possibility. At the Surgeon General's 1 987 Workshop on Self-Help and the Public Health, Dr Koop stated that self-care will eventually be the "other health-care system" in this country and that it will accept the burden of disease prevention and health promotion in the US.4 Nurses should be in the forefront of this exciting opportunity to promote needed changes in our health-care delivery system, in the mechanisms for reimbursement, and most of all, in moving the profession forward toward independent nursing practice and a more professional status in our society.
- 1 . Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, DC: DHHS; 1979:71.
- 2. Fuchs V. Who Shall Live? Health, Economics, Social Choice. New York: Basic Books; 1974.
- 3. Special Project Grants Application Kit. Rockville, Md: DHHS, HRSA, BHPR, Division of Nursing; 1 990.
- 4. SeIf-HeIp Horizons. Fairfax, Va: George Mason University; January 1 990.