Journal of Gerontological Nursing

Guest Editorial 

Long-Term Care for Older Adults

Meridean Maas, PhD, RN, FAAN

Abstract

Anew paradigm for the long-term care and quality of life of older adults is needed. Current long-term care services for older adults, based on a medical-custodial paradigm, are problematic. Long-term care of older adults has changed little from 25 years ago (Kane, 1987) and is still

...characterized by inaccessibility, poor care, unskilled personnel, high out of pocket costs and inadequate linkages to other services, p. 74

As the number of older adults continues to increase, the shortcomings of the current long-term care paradigm will become a more serious and costly problem. Older adults and their families have too few options for long-term care services that promote quality of life, health, and function. Because current health-care policies discourage their development, long-term care options managed and provided by nurses with geriatric training are few, despite the need for long-term care options that enable geriatric nursing best practices (Maas, Specht, & Buckwalter, 2002).

The current paradigm and resulting long-term care policies assume medical care is of primary importance for older adults, with accompanying custodial care deemed satisfactory. Nursing homes often resemble hospitals more than homes, and home care focuses primarily on medically driven tasks and custodial services that are usually delivered by minimally trained home health aides. In these settings, medical care prevails to the neglect of less costly preventive and rehabilitative care of older adults in homelike, socially supportive, empowering environments. The current system also is plagued by issues of equity of access that focus on the shortage of inhome and community services (Johnson & Tripp-Reimer, 2001; Kelley, Buckwalter, & Maas, 1999).

Standards for nurses and nursing assistants in nursing homes and assisted living facilities remain unacceptable, despite compelling evidence that higher staff-to-resident ratios are associated with improved resident outcomes (Dyck, 2004; Harrington, Carrillo, Mullan, & Swan, 1998; Harrington et al., 2000; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Kovner, Mezey, & Harrington, 2000). Advanced practice nurses (i.e., geriatric nurse practitioners and clinical specialists) are under-used in long-term care notwithstanding evidence of their positive influence on resident outcomes and cost effectiveness (Rantz et al., 2001).

Nursing is the primary health care service that is needed in nursing homes, but nursing assistants with as little as 75 hours of training provide almost all of the direct care services for residents. Moreover, these workers often are minimally supervised by nurses who have little or no geriatric or leadership training and experience.

The new paradigm must be holistic with an array of strategies that meet the needs of older adults. Nurses who are trained in geriatric best practices are ideally suited to promote health, prevent illness and disability, manage chronic illness, and assist with functional independence for greater quality of life for older adults (Mechanic & Reinhard, 2002). Geriatric nurses also can best coordinate all providers' services in the home as well as in institutions. Nursing interventions, including nurse case management, have been shown to forestall institutionalization, reduce costs, and improve outcomes for individuals with chronic illnesses (Specht, Hall, Bossen, & Lemke, 2001).The use of advanced practice geriatric nurses as case managers and the requirements for nurse staffing in nursing homes for managing care and leading staff should be increased and supported with Medicare and Medicaid reimbursement.

Now is the time for nursing to lead changes that define and adopt a new long-term care paradigm. To that end, the following recommendations are set forth:

* Abandon the medical-custodial paradigm and adopt a new longterm care paradigm that emphasizes the important roles of geriatric nurses and geriatric best practices in interdisciplinary care.

* Fund demonstrations and pilot studies of nurse managed, innovative, homelike environments and services…

Anew paradigm for the long-term care and quality of life of older adults is needed. Current long-term care services for older adults, based on a medical-custodial paradigm, are problematic. Long-term care of older adults has changed little from 25 years ago (Kane, 1987) and is still

...characterized by inaccessibility, poor care, unskilled personnel, high out of pocket costs and inadequate linkages to other services, p. 74

As the number of older adults continues to increase, the shortcomings of the current long-term care paradigm will become a more serious and costly problem. Older adults and their families have too few options for long-term care services that promote quality of life, health, and function. Because current health-care policies discourage their development, long-term care options managed and provided by nurses with geriatric training are few, despite the need for long-term care options that enable geriatric nursing best practices (Maas, Specht, & Buckwalter, 2002).

The current paradigm and resulting long-term care policies assume medical care is of primary importance for older adults, with accompanying custodial care deemed satisfactory. Nursing homes often resemble hospitals more than homes, and home care focuses primarily on medically driven tasks and custodial services that are usually delivered by minimally trained home health aides. In these settings, medical care prevails to the neglect of less costly preventive and rehabilitative care of older adults in homelike, socially supportive, empowering environments. The current system also is plagued by issues of equity of access that focus on the shortage of inhome and community services (Johnson & Tripp-Reimer, 2001; Kelley, Buckwalter, & Maas, 1999).

Standards for nurses and nursing assistants in nursing homes and assisted living facilities remain unacceptable, despite compelling evidence that higher staff-to-resident ratios are associated with improved resident outcomes (Dyck, 2004; Harrington, Carrillo, Mullan, & Swan, 1998; Harrington et al., 2000; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Kovner, Mezey, & Harrington, 2000). Advanced practice nurses (i.e., geriatric nurse practitioners and clinical specialists) are under-used in long-term care notwithstanding evidence of their positive influence on resident outcomes and cost effectiveness (Rantz et al., 2001).

Nursing is the primary health care service that is needed in nursing homes, but nursing assistants with as little as 75 hours of training provide almost all of the direct care services for residents. Moreover, these workers often are minimally supervised by nurses who have little or no geriatric or leadership training and experience.

The new paradigm must be holistic with an array of strategies that meet the needs of older adults. Nurses who are trained in geriatric best practices are ideally suited to promote health, prevent illness and disability, manage chronic illness, and assist with functional independence for greater quality of life for older adults (Mechanic & Reinhard, 2002). Geriatric nurses also can best coordinate all providers' services in the home as well as in institutions. Nursing interventions, including nurse case management, have been shown to forestall institutionalization, reduce costs, and improve outcomes for individuals with chronic illnesses (Specht, Hall, Bossen, & Lemke, 2001).The use of advanced practice geriatric nurses as case managers and the requirements for nurse staffing in nursing homes for managing care and leading staff should be increased and supported with Medicare and Medicaid reimbursement.

Now is the time for nursing to lead changes that define and adopt a new long-term care paradigm. To that end, the following recommendations are set forth:

* Abandon the medical-custodial paradigm and adopt a new longterm care paradigm that emphasizes the important roles of geriatric nurses and geriatric best practices in interdisciplinary care.

* Fund demonstrations and pilot studies of nurse managed, innovative, homelike environments and services for providing greater quality health care and life for older adults.

* Publicize and promote the critical role of geriatric nurses in managing and coordinating holistic care of older adults, and in providing leadership and oversight for nursing assistant staff.

* Extend Medicare and Medicaid reimbursement to nurses and advanced practice nurses with specific gerontological training for nurse case management and interventions.

* Increase geriatric nurse staffing requirements for nursing homes and assisted living facilities.

* Require nurses and advanced practice nurses to have specific gerontological training to work with older adults in all settings.

* Continue and increase funding of institutes and programs such as the John A. Hartford Foundation's funding of the Institute of Geriatric Nursing at New York University and the Building Geriatric Nursing Capacity project to train more nurses for geriatric practice, education, and research.

REFERENCES

  • Dyck, M. (2004). Nursing staffing and resident outcomes in nursing homes. Unpublished doctoral dissertation. University of Iowa, Iowa City, Iowa.
  • Harrington, C., Carrillo, H., Mullan, J., & Swan, J.H. (1998). Nursing facility staffing in the States: The 1991 to 1995 period. Medical Care Research and Review, 55(3), 334-363.
  • Harrington, C, Kovner, C, Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., Burke, R., & Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontoiogist, 40(1), 5-16.
  • Harrington, C, Zimmerman, D., Karon, S.L., Robinson, J., & Beutel, P. (2000) Nursing home staffing and its relationship to deficiencies. Journal of Gerontology Social Sciences, 555(5), S278-S287.
  • Johnson, R., & Tripp-Reimer, T. (2001). Aging, ethnicity, and social support: A review. Journal of Gerontological Nursing, 27(6), 15-21.
  • Kane, R.A. (1987). Quality of life in longterm institutions: Is a regulatory strategy feasible? Danish Medical Bulletin, (Suppl. 5), 73-81.
  • Kelley, L., Buckwalter, K., & Maas, M. (1999). Access to healthcare resources for family caregivers of elderly persons with dementia. Nursing Outlook, 47(\), 8-14.
  • Kovner, C, Mezey, M., & Harrington, C. (2000). Research priorities for staffing, case mix, and quality of care in U.S. nursing homes. Journal of Nursing Scholarship, 32(1), 77-80.
  • Maas, M., Specht, J., & Buckwalter, K. (2002). Long-term health care policy for elders: Now is the time for nursing leadership. Nursing and Health Policy Review, /(2), 81-92.
  • Mechanic, D., & Reinhard, S.C. (2002). Contributions of nurses to health policy: Challenges and opportunities. Nursing and Health Policy Review, /(1), 7-15.
  • Rantz, M., Popejoy, L., Petroski, G., Madsen, R., Mehr, D., Zwygart-Stauffacher, M., Hicks, L., Grando, V., Wipke-Tevis, D., Bosu'ck, J., Porter, R, Conn, V., & Maas, M. (2001). Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontoiogist, 41(A), 525-545.
  • Specht, J., Hall, G., Bossen, A., & Lemke, J. (2001, November). Evaluation of a nurse case management intervention for community elders with dementia and their family caregivers. Paper presented at the annual meeting of the Gerontological Society of America, Chicago, IL.

10.3928/0098-9134-20041001-03

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