Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Management of Relocation in Cognitively Intact Older Adults

Judith E. Hertz, PhD, RN, FNGNA, FAAN; Mary Elaine Koren, PhD, RN; Jeanette Rossetti, EdD, RN; Kathryn Tibbits, RN, ANP-BC, FNP-BC

Abstract

Relocation, a major life transition that can affect health positively and negatively, is moving from one permanent home to another. Many older adults will relocate at some time during their life. Relocation is also a complex process that requires careful consideration and planning before the move (i.e., pre-location) and adjustment to the new home after the move (i.e., post-relocation). The current article is a summary of content based on a comprehensive evidence-based practice guideline focused on management of relocation in cognitively intact older adults. The guideline was designed to be used across diverse settings by nurses and other providers. Pre-relocation guidelines include assessment for the need for relocation, interventions prior to moving, and outcomes for evaluation of the pre-relocation process. For post-relocation, content focuses on assessment of risks for not adjusting after the move as well as intervention guidelines to promote adjustment and outcomes for evaluation. Implications include advocacy for older adults by using the guideline, disseminating it, and conducting future research. [Journal of Gerontological Nursing, 42(11), 14–23.]

Abstract

Relocation, a major life transition that can affect health positively and negatively, is moving from one permanent home to another. Many older adults will relocate at some time during their life. Relocation is also a complex process that requires careful consideration and planning before the move (i.e., pre-location) and adjustment to the new home after the move (i.e., post-relocation). The current article is a summary of content based on a comprehensive evidence-based practice guideline focused on management of relocation in cognitively intact older adults. The guideline was designed to be used across diverse settings by nurses and other providers. Pre-relocation guidelines include assessment for the need for relocation, interventions prior to moving, and outcomes for evaluation of the pre-relocation process. For post-relocation, content focuses on assessment of risks for not adjusting after the move as well as intervention guidelines to promote adjustment and outcomes for evaluation. Implications include advocacy for older adults by using the guideline, disseminating it, and conducting future research. [Journal of Gerontological Nursing, 42(11), 14–23.]

A high proportion of older adults will relocate from one home to another during their lives. Regardless of age, relocation to a new home is a major life transition, stressful, and can impact health outcomes positively and negatively (Cheek & Ballantyne, 2001a,b; Hodgson, Freedman, Granger, & Erno, 2004). Sometimes these moves are well-anticipated and triggered by life changes, such as retirement, but other times health problems or widowhood lead individuals to move closer to family. In addition, relocation to more supportive environments (e.g., assisted living facility [ALF], nursing home) often occurs when caregivers require help in meeting older adults' needs (Koenig & Cunningham, 2001).

Since 2005, research on indicators and risks for relocation has identified complex patterns and combinations of factors that are likely to lead to relocation. These factors are sometimes classified as push-pull factors (Bekhet, Zauszniewski, & Nakhla, 2009; Bekhet, Zauszniewski, & Wykle, 2008; Groger & Kinney, 2007). Push factors (e.g., declining health, lack of functional abilities) are those that force individuals into a different home; pull factors (e.g., desire to “downsize” to a more manageable size home, live with others in the same age group, be closer to family members) attract older adults to a new living environment. Relocation-related activities are complex and need to be tailored to the relocating older adult's unique needs, desires, and abilities.

Some authors recommend that health care providers view relocation as a family crisis requiring crisis intervention (Cheek & Ballantyne, 2001a,b). In contrast, when relocation is planned and older adults feel a sense of decisional control, adjustment following the move is more apt to be viewed as a transition rather than a crisis (Bekhet et al., 2008; Castle & Sonon, 2007; Hodgson et al., 2004; Oswald et al., 2007). Therefore, there is a need to make living and housing information for older adults accessible to the public to facilitate less hurried consideration of options before relocation (i.e., pre-relocation) (Magilvy & Congdon, 2000).

In addition to advance planning for the move, numerous other characteristics are associated with adjustment after relocation (i.e., post-relocation). Older adults who do not adjust to relocation might exhibit signs of the NANDA-I nursing diagnosis, “Relocation Stress Syndrome,” defined as a response to relocation indicating maladjustment (NANDA International, 2014, p. 319). Numerous interventions to promote adjustment have been proposed but few have been empirically tested.

Many interventions focus on the broader area of transitional care that is provided when an individual moves between care settings rather than from one permanent home to another. Although these interventions are not directly related to relocation (as a permanent transition), some might ease adjustment and result in positive health outcomes (Chiu & Newcomer, 2007; Crotty, Rowett, Spurling, Giles, & Phillips, 2004; Crotty et al., 2005; Nishita, Johnson, Silverman, Ozaki, & Koller, 2009; Parry, Kramer, & Coleman, 2006). Proposed outcomes include use of coping mechanisms, psychosocial adjustment, improved quality of life, reduced rehospitalizations, self-management of chronic conditions, and satisfaction with the move.

Relocation is viewed from diverse theoretical perspectives; more recent perspectives include life course theory (Bloem, van Tilburg, & Thomese, 2008) and adjustment/adaptation theories (Brandburg, 2007; Hersch et al., 2004; Tracy & DeYoung, 2004). In addition, the relocation of older adults has been studied globally as well as in North America. Studies have been conducted in Australia (Crotty et al., 2004; Crotty et al., 2005; McCallum, Simons, Simons, & Friedlander, 2007; Tudor-Locke, Giles-Corti, Knuiman, & McCormack, 2008), Europe (Brown Wilson, Davies, & Nolan, 2009; Martikainen, Nihtilä, & Moustgaard, 2008; Oswald & Wahl, 2004; Oswald et al., 2008), and Asia (Hui & Yu, 2009; Tse, 2007). A common theme is that relocation is a process of transition and change in one's life, which might be stressful and detrimental to health. The relocation process is composed of four components focused on pre- and post-relocation aspects (Figure).


Components of the relocation process for older adults.

Figure.

Components of the relocation process for older adults.

Purpose

The purpose of the current article is to summarize the revised and updated evidence-based practice (EBP) guideline, Management of Relocation in Cognitively Intact Older Adults (Hertz, Koren, Rossetti, & Tibbits, 2015). Readers are advised to obtain the full guideline, which includes copies of the assessment tools and other forms used in the current article along with process and outcome measures. The guideline may be purchased from the Csomay Center for Gerontological Excellence (access http://www.iowanursingguidelines.com).

The purpose of the EBP guideline is to provide strategies that can be applied by nurses and other health care personnel (e.g., physicians, social workers, case managers, discharge planners) in community-based, acute care, and long-term care settings. The goal is to help cognitively intact adults (older than 65) plan for and adapt to relocation from one home to another. The guideline excludes individuals living with a dementia-related diagnosis because their relocation needs and transitions differ from individuals who are not diagnosed with dementia. Guidelines are provided for pre- and post-relocation assessment, interventions, and outcome evaluation.

Key Definitions

For consistency, the following definitions are used:

  • Relocation is moving from one permanent residence to another permanent residence. This move can include moving from a single-family dwelling (i.e., house) in the community to an independent living apartment in a congregate housing unit, a continuing care retirement community (CCRC), ALF, or nursing home. Relocation might also include moving from an apartment to a CCRC, ALF, or nursing home, or moving from any one of the above types of residences to another. Relocation might also include a permanent move from one level of care in a CCRC to another level (e.g., independent living to assisted living). Relocation is sometimes precipitated by a hospitalization for an acute or chronic health problem so that the actual relocation immediately follows a hospital stay.
  • Pre-relocation is the time period when older adults begin to consider moving to another residence from their current residence until the time when the move actually takes place.
  • Post-relocation is the period of time that begins when older adults actually move from one residence to another and the time thereafter.
  • Cognitively intact older adult refers to any individual older than 65 who does not have a dementia-related diagnosis or score indicating cognitive dysfunction on a standardized assessment tool such as the Mini-Cog (Borson, Scanlan, Watanabe, Tu, & Lessig, 2006) or Montreal Cognitive Assessment (Nasreddine et al., 2005).

Pre-Relocation Guidelines

The first two components in relocation take place before relocation (i.e., pre-relocation). The primary foci are to identify older adults who exhibit indicators of a need or risk for relocation and then implement and evaluate an EBP intervention to plan for relocation.

Risks for Relocation: Pre-Relocation Indicators and Assessment

Why do older adults relocate to another residence? Numerous factors have been identified conceptually and through descriptive, correlational, and longitudinal studies. Presence of these factors indicates that relocation may be warranted. Primary indicators are listed and summarized below as well as guidelines for using assessment tools.

Key Indicators

Demographics of age, race/ethnicity, gender, socioeconomic status (SES), marital status, and level of education are associated with relocation. Since 2005, identifying individuals at risk for relocation has become more sophisticated and linked to complex combinations of demographic characteristics. Individuals of an older age (Akamigbo & Wolinsky, 2006; Cai, Salmon, & Rodgers, 2009; Gaugler, Duval, Anderson, & Kane, 2007; Luppa, Luck, Weyerer, König, Brähler, & Riedel-Heller, 2010; Luppa, Luck, Weyerer, König, & Riedel-Heller, 2009; Waldorff, Siersma, & Waldemar, 2009), women (Bloem et al., 2008; Smith & Stevens, 2009; Tang & Pickard, 2008), and widows (Bloem et al., 2008; Erickson, Krout, Ewen, & Robison, 2006; Rosenberg et al., 2006) are more likely to relocate. African American and Hispanic individuals are less likely to relocate (Akamigbo & Wolinsky, 2006; Ball, Perkins, Hollingsworth, Whittington, & King, 2009; Friedman, Steinwachs, Rathouz, Burton, & Mukamel, 2005). Educational level (Erickson et al., 2006; Martikainen et al., 2008; Smith & Stevens, 2009) and SES (Anderson & Tom, 2005; Ball et al., 2009; Carpenter et al., 2007; Gaugler et al., 2007; Martikainen et al., 2008; Munroe & Guihan, 2005; Sarma, Hawley, & Basu, 2009; Tang & Pickard, 2008) are not consistently identified indicators of relocation risk.

Functional limitations in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as well as mobility deficits, history of falls, incontinence, and declining cognitive abilities are potential risks for relocation. Individuals experiencing difficulties with ADLs and IADLs are more likely to relocate (Cai et al., 2009; Cheek, Ballantyne, Byers, & Quan, 2007; Munroe & Guihan, 2005; Smith & Stevens, 2009); those with three or more ADL dependencies are at greater risk for relocation (Gaugler et al., 2007; Luppa et al., 2010; Luppa et al., 2009). In addition, individuals with difficult mobility (McCallum et al., 2007; Munroe & Guihan, 2005); history of falls (Smith & Stevens, 2009; Stoeckel & Porell, 2010); and declining cognitive abilities, such as subjective memory loss (Anderson & Tom, 2005; Cai et al., 2009; Gaugler et al., 2007; Luppa et al., 2010; Waldorff et al., 2009), are at risk for relocation. Furthermore, men with incontinence are at greater risk (Luppa et al., 2009) for relocation.

Physical and mental health status indicators have been linked to an increased probability of relocation, especially in moving from one home to a more supportive home or level of care (Anderson & Tom, 2005; Andrews, Bartels, Xie, & Peacock, 2009; Bloem et al., 2008; Cai et al., 2009; Cheek et al., 2007; Fjelltun, Henriksen, Norberg, Gilje, & Normann, 2009b; Gaugler et al., 2007; Harris, 2007; Luppa et al., 2009; Martikainen et al., 2008; McCallum et al., 2007; Nihtila et al., 2008; Slade, Fear, & Tennant, 2006; Smith & Stevens, 2009; Waldorff et al., 2009). Specifically, mental health issues of schizophrenia, a psychiatric diagnosis in general, mental health symptoms (e.g., sadness, crying), and depression are relocation risks (Andrews et al., 2009; Cai et al., 2009; Fjelltun et al., 2009b; Harris, 2007; Martikainen et al., 2008; McCallum et al., 2007; Nihtila et al., 2008; Waldorff et al., 2009) as are physical illnesses of diabetes, hypertension, cancer, stroke, falls, and hip fractures (Cheek et al., 2007; Gaugler et al., 2007; Luppa et al., 2009; Martikainen et al., 2008; Nihtila et al., 2008).

Individuals with lower self-rated health (Akamigbo & Wolinsky, 2006; Cai et al., 2009; Luppa et al., 2010), a sudden decline in health in self or significant other (Ball et al., 2009; Bekhet et al., 2009; Carpenter et al., 2007; Cheek et al., 2007; Groger & Kinney, 2007; Rosenberg et al., 2006), history of hospitalization or nursing home stay within the past year (Akamigbo & Wolinsky, 2006; Friedman et al., 2005; Luppa et al., 2009; Smith & Stevens, 2009), and lack of knowledge regarding health condition or treatments (Smith & Stevens, 2009; Zuckerman et al., 2006) are also at risk.

Current characteristics of housing are linked to probability of relocation. Individuals who live alone (Cai et al., 2009; Martikainen et al., 2008; Nihtila et al., 2008; Tang & Pickard, 2008), struggle with home maintenance (Bekhet et al., 2009; Carpenter et al., 2007; Erickson et al., 2006; Groger & Kinney, 2007), and feel unsafe (Carpenter et al., 2007; Fonad, Wahlin, Heikkilä, & Emami, 2006; Munroe & Guihan, 2005) are at greater risk. In contrast, those who own their home (Cai et al., 2009; Luppa et al., 2009; Martikainen et al., 2008; Nihtila et al., 2008; Stoeckel & Porell, 2010); live in adaptive, accessible housing (Choi, 2004; Erickson et al., 2006; Groger & Kinney, 2007); and express satisfaction with size, location, and neighbors (Erickson et al., 2006; Stoeckel & Porell, 2010) are less likely to relocate.

Personal and family desires are factors influencing relocation risk, especially if family members are concerned about the older adult's ability to remain in the current home (Cheek et al., 2007; Erickson et al., 2006; Fjelltun, Henriksen, Norberg, Gilje, & Normann, 2009a; Slade et al., 2006). Older adults' desire for independence might trigger relocation when coupled with the refusal for additional assistance in the current home (Cheek et al., 2007).

Social support and connectedness to family/friends influence relocation decisions. A desire to be closer to family (Erickson et al., 2006; Groger & Kinney, 2007), feelings of loneliness (Bekhet et al., 2009), not having children at home (i.e., empty nest) (Bloem et al., 2008), and desires to join friends or maintain social connections (Bekhet et al., 2009; Carpenter et al., 2007; Groger & Kinney, 2007) can lead to relocation. Having more living children or a spouse in the home often reduces relocation risk (Akamigbo & Wolinsky, 2006; Gaugler et al., 2007).

Supportive services or caregiver access and quality influence relocation. Linked to relocation are a high level and demand for services (Luppa et al., 2010); lack of supportive services, including knowledgeable caregivers (Bekhet et al., 2009; Sarma et al., 2009; Smith & Stevens, 2009); poor quality care (Bilotta, Nicolini, & Vergani, 2009); and older adults' fear of overburdening family (Groger & Kinney, 2007). In addition, caregivers who are overburdened or need respite influence the risk for relocation of older adults (Fjelltun, Henrikson, Norberg, Gilge, & Normann, 2009c).

Access to housing options is an additional relocation risk factor. Closeness, availability, reputation, and amenities in housing influence relocation decisions (Akamigbo & Wolinsky, 2006; Bekhet et al., 2009; Cheek et al., 2007; Groger & Kinney, 2007). A lack of housing might force the older adult to remain in the current home or move to a less desirable home. Akamigbo and Wolinsky (2006) found that in the southern and central United States more older adults moved to nursing homes compared with other parts of the country.

Assessment Guidelines

Assessment of older adults for relocation indicators should take place in community-based, acute care, and long-term care settings. Examples of community-based settings are physicians' or other primary care offices, health departments, senior centers, and congregate housing units (e.g., senior apartments). Acute care settings include hospitals, rehabilitation units following an acute illness, and skilled nursing visits by a home health nurse. Long-term care settings include ALFs, traditional nursing homes, and the areas of CCRCs that deliver long-term care services. Health care providers are often the first to recognize older adults' need to relocate because of changes in service use and health status.

To identify individuals who are likely to benefit the most from use of this EBP guideline, essential areas for assessment include: (a) the older adult's views and satisfaction with current living arrangement; (b) demographics; (c) current living arrangement; (d) current health status, including mental health, self-rated health, recent changes/crises, and prescribed therapeutics; (e) functional abilities and limitations; (f) availability of supportive services or caregivers to meet needs; (g) social and family connections; and (h) access to housing.

An assessment tool and flowsheet for tracking pre-relocation risk data (published in the complete guideline [Hertz et al., 2015]) should be used as a screening tool during the first encounter with the older adult and then updated periodically. Frequencies of follow-up assessments are individualized but general guidelines are to validate data in community-based settings at each visit, every 3 to 6 months in congregate housing, daily in acute care settings, and every 1 to 3 months in long-term care settings. Reassessment is also indicated with major changes in the older adult's situation in life (e.g., death of spouse or caregiver, change in functional abilities, acute illness). The flowsheet provides a quick snapshot of patterns of change in relocation risk.

Interventions: Pre-Relocation

The aims of pre-relocation interventions are to assist individuals who exhibit pre-relocation “risk” indicators with relocation decision making and planning for the actual relocation to a new residence. The primary focus of this EBP guideline is on application with the older adult, rather than with the older adult's family members or significant others. Preparing to relocate is a nonlinear process and includes identifying the need to move, locating a new residence, and preparing for the actual move (Dupuis-Blanchard, 2007). The practice strategies apply to all types of settings and are summarized with a brief explanation of each in Table A (available in the online version of this article).


Pre-Relocation Intervention Guidelines
Pre-Relocation Intervention Guidelines

Table A:

Pre-Relocation Intervention Guidelines

Outcomes: Pre-Relocation

Outcome indicators are those indicators expected to change or improve from consistent use of the guideline. The major outcome indicators that should be monitored over time are:

  • Older adult will plan for relocation in advance.
  • Older adult will be involved in relocation decision making as desired.
  • Older adult will verbalize knowledge of housing options.
  • Older adult's identified relocation needs and available resources will match type of housing.
  • Older adult will express satisfaction with relocation decision.

The full EBP guideline (Hertz et al., 2015) contains tools for monitoring outcomes over time as well as tools to facilitate and monitor knowledge and application of the guideline by providers.

Post-Relocation Guidelines

The final two components in relocation take place after relocation (i.e., post-relocation). The primary goals are to identify older adults who exhibit indicators of adjustment (or maladjustment and/or relocation stress syndrome) after relocation and implement and evaluate an EBP intervention to promote adjustment after relocation.

Risks for Maladjustment: Post-Relocation Indicators and Assessment

All individuals experience a period of adjustment after relocation to a new residence. The following indicators denote potential or actual factors influencing older adults' adjustment. Individuals exhibiting some or all of the following characteristics might demonstrate maladjustment as well as relocation stress syndrome (Manion & Rantz, 1995). As with the pre-location risks, the primary post-relocation maladjustment indicators are listed and summarized below. Then, guidelines for using assessment tools are provided.

Key Indicators

Age and SES are associated with greater risk for maladjustment after relocation (Castle, 2004; Laughlin, Parsons, Kosloski, & Bergman-Evans, 2007; Tracy & DeYoung, 2004; Tse, 2007). In particular, individuals older than 86 were more likely to die after relocation (Laughlin et al., 2007) and, not surprisingly, those with lower SES were more likely to be unable to pay for needed services and were less likely to live in a higher quality nursing home (Tracy & DeYoung, 2004; Tse, 2007).

Decisional control has been consistently linked to relocation adjustment (Bekhet et al., 2008; Brown Wilson et al., 2009; Hodgson et al., 2004; Oswald et al., 2007; Shippee, 2009a,b). The perceived degree of involvement in decisions regarding living arrangements should closely match the older adult's desire for involvement. Forced moves without desired input from older adults, especially to more supportive housing, are related to poor adjustment post-relocation (Bekhet et al., 2008; Dobbs, 2003; Oswald et al., 2007; Shippee, 2009a).

Degree of attachment/meaningfulness of past and present home can influence adjustment after a move (Dobbs, 2003; Fonad et al., 2006; Oswald & Wahl, 2004; Oswald et al., 2007; Tracy & DeYoung, 2004; Tse, 2007). Individuals need to feel a part of, or attached, to their new home and find meaning in their new living environment. Those who do not feel attached might have more problems with adjustment after a move.

Environmental characteristics of the new home can influence older adults' adjustment (Dupuis-Blanchard, 2007; Fonad et al., 2006; Groger & Kinney, 2007; Hersch et al., 2004; Shippee, 2009a,b; Waldron, Gitelson, Kelley, & Regalado, 2005). Specific characteristics include the location of the new home compared to the previous home (i.e., local versus long-distance relocation), with long-distance movers experiencing more adjustment issues (Dupuis-Blanchard, 2007; Groger & Kinney, 2007; Waldron et al., 2005). In addition, the availability of services or amenities, physical space considerations (i.e., privacy), attractiveness (e.g., outdoor beauty), and number of residents in congregate housing play a role in adjustment. Fewer residents in congregate housing can facilitate adjustment (Dupuis-Blanchard, 2007), whereas a relocation pathway from independent to more supportive housing might impede adjustment (Hersch et al., 2004; Shippee, 2009a,b).

Psychosocial health/mood, including symptoms of depression and perceived losses with grieving, influence adjustment post-relocation (Barredo & Dudley, 2008; Bland, 2005; Hong & Chen, 2009). Losses early in life and prior to the move are linked to poor adjustment (Barredo & Dudley, 2008). Losses can include deaths of significant others, changes in normal roles, functional ability decline, comorbidities, and reduced personal space and privacy (Bland, 2005; Hong & Chen, 2009).

Physical health is also related to post-relocation adjustment (Castle, 2004; Crotty et al., 2004; Dupuis-Blanchard, 2007; Fonad et al., 2006; Tudor-Locke et al., 2008). Pain and length of stay in a hospital (Castle, 2004), complex medical regimens (Crotty et al., 2004), and hearing and vision impairments (Dupuis-Blanchard, 2007; Fonad et al., 2006) are specific examples. In addition, participation in healthy habits, such as physical activity, was less likely in women and obese individuals after relocation (Tudor-Locke et al., 2008).

Personal life experiences and coping abilities influence individuals' post-relocation adaptation. Past experiences with moving, perceived benefits of moving, and being able to draw on a repertoire of coping strategies increase the likelihood for post-relocation adjustment (Dupuis-Blanchard, 2007; Groger & Kinney, 2007; Hersch et al., 2004; Hodgson et al., 2004). Physiological indicators (e.g., salivary cortisol, pulse rate) demonstrated that relocation is stressful (Hodgson et al., 2004).

Socialization/engagement after relocation is related to adjustment (Dobbs, 2003; Dupuis-Blanchard, 2007; Dupuis-Blanchard, Neufeld, & Strang, 2009; Fonad et al., 2006; Groger & Kinney, 2007; Shippee, 2009a,b; Waldron, Gitelson, & Kelley, 2005; Waldron, Gitelson, Kelley, & Regalado, 2005). This socialization includes opportunities for involvement in different types of relationships (e.g., to feel secure, casual interactions, opportunities to be supportive of others, friendship) (Dupuis-Blanchard et al., 2009). Women and men might have different patterns of relationships; women might communicate more with friends and men with their children (Waldron, Gitelson, & Kelley, 2005). Individuals who moved from independent living to more supportive, dependent living arrangements (Shippee, 2009a) and those with limited mobility or hearing and vision deficits (Fonad et al., 2006) may lack social relationships, be less engaged, and have poorer adjustment. In general, relationships with new and old friends, as well as close ties and perceived support from family and friends, impacts adjustment (Dobbs, 2003; Dupuis-Blanchard, 2007; Groger & Kinney, 2007; Waldron, Gitelson, Kelley, & Regalado, 2005).

Assessment Guidelines

Similar to the pre-relocation assessment, older adults should be assessed in community-based, acute care, and long-term care settings if they have recently relocated to a new home. Because some individuals do not adjust “quickly” after relocation, any older adult who has relocated within the past 5 years should be assessed. This assessment can help target individuals who would benefit from a plan to promote adjustment to relocation.

Essential areas for post-relocation assessment include: (a) demographic characteristics; (b) current health status and functional abilities, including mental health (e.g., depression, life satisfaction, self-esteem, cognitive impairment); (c) social network and relationships; (d) sense of control; (e) perceived stress and adjustment; and (f) perceived satisfaction with the move and attachment to new home.

An assessment tool and flowsheet for tracking post-relocation maladjustment risk data (Hertz et al., 2015) should be used as a screening tool during the first encounter after relocation and then updated periodically. Frequency of follow-up assessments are individualized but general guidelines are to update data at least weekly for the first month after relocation then monthly for the next 6 months to 1 year. However, in settings such as physicians' offices, data should be validated during each office visit. During home health skilled nursing visits, data should be updated at least weekly. Reassessment is also indicated if there is a sudden change in the older adult's life, such as the death of a spouse or caregiver, change in functional abilities, or acute occurrence or exacerbation of an illness. The flowsheet provides a quick snapshot of patterns of change in risks for post-relocation maladjustment.

Interventions: Post-Relocation

The aims of post-relocation interventions are to facilitate adjustment in individuals who exhibit indicators of potential or actual maladjustment. There is a period of adjustment to relocation that can take 6 months or longer (Hammer, 1999; Hong & Chen, 2009; Laughlin et al., 2007; Meehan, Robertson, Stedman, & Byrne, 2004). Negative health-related outcomes following relocation, including mortality, have been tracked for up to 6 years (Hong & Chen, 2009), but most have examined outcomes for 12 to 18 months post-relocation (Laughlin et al., 2007; Meehan et al., 2004). In one study, more than one half of older adults who were interviewed did not feel “at home” in long-term care after residing there for 2 to 7 years (Hammer, 1999). The practice strategies apply to all types of settings and are summarized with a brief explanation of each in Table B (available in the online version of this article).


Post-Relocation Intervention Guidelines
Post-Relocation Intervention Guidelines

Table B:

Post-Relocation Intervention Guidelines

Outcomes: Post-Relocation

Outcome indicators are those indicators expected to change or improve from consistent use of the guideline. The major outcome indicators that should be monitored over time are:

  • Older adult will be satisfied with the move.
  • Older adult will report adjustment to the move.
  • Older adult will maintain/develop a social network and activities.
  • Older adult will exhibit stability or improvement in health status.
  • Older adult's physical and psychosocial needs will be met.
  • Older adult will remain in the new home for at least 6 months after relocation.

Discussion and Implications

Gerontological nurses in diverse settings should use the EBP guideline on relocation (Hertz et al., 2015) as a means to advocating for older clients. The guideline also has implications for educators through dissemination and researchers.

Advocating for Older Adults via Application in Practice Settings

As noted in the introduction, a high proportion of older adults will relocate at some time in their lives. Relocation is stressful for individuals of all ages and can produce negative health outcomes. Although some health outcomes may be positive, especially in the long term, the process is stressful and taxes personal resources and coping skills during pre- and post-relocation processes. Older adults typically need time to adjust and cope with highly stressful life events. Despite these “facts,” providers in health care settings often overlook this frequently occurring, but stressful life event. This practice gap presents an opportunity for gerontological nurses to advocate for their clients by introducing the guideline in the practice setting where employed.

Simply asking older clients about their current home situation is a first step prior to fully implementing the guideline. Nurses might also discuss this topic with their colleagues (nurses and those from other disciplines) in the setting where employed. As clients and providers become sensitized to the importance of this issue, the willingness to include this as a best practice in the particular setting might emerge.

Standards of care demand that gerontological nurses have an obligation to advocate for older adult clients as whole persons and to assist them in making carefully considered relocation choices along with helping them adapt to a new living arrangement. In fact, simply bringing this issue to the attention of the health care team and advocating for adoption of the guideline into practice settings could partly meet this obligation.

The guideline, itself, is aimed at reaching older adults across the continuum of care. As has been learned, even moving within a particular residence, such as from one level of care to another in a CCRC, can be stressful for older adults (Hersch et al., 2004; Shippee, 2009a). Sharing the guideline with colleagues regardless of setting could lead to more widespread adoption of it, thereby improving the health and quality of life of older adults.

Application of this guideline also addresses the trends of providing person-centered care and integration of EBPs into that care. In reviewing the content of the pre- and post-relocation components of the guideline, there is a clear evidence base threaded throughout for focusing on tailoring assessments and interventions to each unique individual and as a pathway to promoting less stressful and healthier relocation processes.

Dissemination Through Education

Dissemination of the current guideline and its content can be accomplished through multiple routes. Of course, this publication is one means to that dissemination and discussing it with colleagues, as previously mentioned, is another. Publication in newsletters at older adult housing communities and senior centers and in lay publications for older adults or their caregivers would also be valuable in dissemination. In addition, educational programs can provide a vehicle for disseminating the guideline.

Staff development educators could design continuing education programs focused on the guideline content. In educational programs for undergraduate and graduate nursing students, the guideline could be used as an example of EBP, or to address commonly occurring needs in older adults and methods for addressing those needs. Clinical simulations could be designed to test students' ability to apply evidence-based approaches to a relocation case. The guideline could be applied in leadership-type classes as a source of information for planning a practice change project. Interdisciplinary courses could take the guideline, read and analyze it, then hold in-depth discussions or proposals on the role of various health care providers in using the guideline in a particular practice setting. These are only a few examples.

Future Research Implications

The content of the current guideline is an update of the original published in 2005. Although it was obvious that the complexity and sophistication of research aimed at identifying relocation risks increased since 2005, it was also obvious that few had investigated how to intervene after risks were identified. Furthermore, there were no intervention studies to promote adjustment after relocation. Therefore, in some cases, the older studies were cited as evidence due to the lack of newer studies.

There is a dire need for systematically testing approaches to aid adjustment. Perhaps, as the guideline is implemented in various practice settings, data can be systematically collected and reported to provide this much needed evidence.

Another aspect of research on relocation is that many of the studies were designed without an explicit organizing framework or theoretical/conceptual basis. Therefore, findings from data collection, analysis, and study methods were difficult to synthesize. Explicit theoretical/conceptual frameworks could aid interpretation of data and findings and assist in making comparisons among studies and synthesizing the results in a meaningful way. Despite this gap, some findings recurred consistently to form an evidence base.

Conclusion

Relocation to a new home is a common issue for older adults. Even in their personal lives, most providers interact with family, friends, and neighbors who will be or are in the process of relocation. The current updated EBP guideline provides direction for how to promote smoother relocation processes and more positive health outcomes in older adults and significant others. The goal is to apply the guideline in real-life situations.

References

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Pre-Relocation Intervention Guidelines

Focus of InterventionBrief Description and Key Aspects of InterventionReferences
Prepare resources to work with relocating older adults. Prior to assisting older adults with relocation decisions, the designated health care provider should gather appropriate information and resources.

Develop a long-term care or housing information file for the community.

Gather information from senior services and organizations (e.g., AARP, Area Agency on Aging, senior centers).

Develop relationships with key individuals in client's ethnic/racial community.

In acute care settings, appoint a nursing home liaison to help with the transition to long-term care settings.

Develop a pre-relocation support program or use a transition coach who is knowledgeable about resources and pre-relocation issues.

Chalmers & Coleman, 2006; Cheek & Ballantyne, 2001a,b; Johnson & Tripp-Reimer, 2001; Laughlin, Parsons, Kosloski, & Bergman-Evans, 2007; Magilvy & Congdon, 2000
Assess relocation needs. Determine to what type of residence the older adult will relocate. Consider (a) whether older adult lives in urban or rural area, (b) if decision is made in a crisis, (c) what resources are available, (d) older adult's socioeconomic status, (e) older adult's preference, and (f) older adult's health status. Match the older adult's needs to the characteristics of the new residence.

How does the older adult feel about relocation? What are the individual's preferences? What are the older adult's goals?

Assess older adult's abilities, strengths, and coping strategies. What strategies worked in the past?

Assess needs for assistance. Functional status will determine needs for an appropriate level of care and services.

Assess sources of current assistance and social support.

Fonad et al., 2006; Hersch et al., 2004; Holmes, Beissner, Welsh, & Krout, 2003; Holmes, Krout, & Wolle, 2003; Johnson & Hlava, 1994; Manion & Rantz, 1995
Plan the move. Early planning and preparation along with involvement of the older adult in decision-making is key to successful relocation. Plan more than 6 months in advance or plan a stay in a transitional care unit after hospitalization until moving.

Assess older adult's ability and desire to be involved in decision making.

Create opportunities for older adults to participate in making decisions, choosing the new residence, and making other choices (i.e., belongings to move).

Provide/discuss information about housing options. Refer older adults and significant others to appropriate resources (e.g., AARP chapter, Area Agency on Aging, senior centers).

Barredo & Dudley, 2008; Castle & Sonon, 2007; Cheek & Ballantyne, 2001a; Crotty et al., 2005; Curtiss, Hayslip, & Dolan, 2007; Ekerdt, Sergeant, Dingel, & Bowen, 2004; Fjelltun et al., 2009a; Hodgson et al., 2004; Johnson, 1999; Johnson & Tripp-Reimer, 2001; Krout & Pillemer, 2003; Laughlin et al., 2007; Oswald et al., 2007
Individualize the plan. Focus planning on what the older adult needs and wants within the realm of what is realistic.

Answer questions and address concerns.

Determine desire for location, quality, and cost.

Include cultural and ethnic preferences and values.

Find a home that is a good match for the older adult's personality and needs; a tool to assess home environment might be useful.

Castle & Sonon, 2007; Delgadillo, Sorensen, & Coster, 2004; Fonad et al., 2006; Hersch et al., 2004; Laughlin et al., 2007
Promote coping while making a relocation decision. Acknowledge that relocation is stressful and use a whole-person approach. Strengthen the older adult's support system and build on his/her personal strengths and coping strategies.

Encourage the older adult to talk about feelings regarding relocation.

Help the older adult reframe the event by focusing on the positive and by emphasizing his/her strengths.

Build on older adult's strengths and expand coping strategies. Because most experience some sense of loss during relocation, provide opportunities to discuss perceived losses and grieve.

Include family and friends in the process to strengthen the support system.

Barredo & Dudley, 2008; Dupuis-Blanchard, 2007; Hodgson et al., 2004; Jackson, Swanson, Hicks, Prokop, & Laughlin, 2000; Laughlin et al., 2007; Lee, Woo, & Mackenzie, 2002; Magilvy & Congdon, 2000; Reinardy, 1992; Rossen & Knafl, 2003; Sullivan & Fisher, 1994
Assist with pre-move preparation. Provide factual information about the new home and fully inform the older adult of what to expect. This provides a sense of mastery over the environment.

Obtain information about the physical layout of the new home as well as dress code, laundry facilities, religious services, access to groceries, and who to ask for assistance.

Facilities should develop materials to be given to prospective residents.

Encourage visits to the new residence before the move or at least provide photographs.

Encourage the older adult to assist with packing to extent possible.

To promote meaningfulness, help the older adult plan which furniture and personal belongings to move.

Develop a specific plan for moving day and encourage the family or significant others to be present.

Dupuis-Blanchard, 2007; Ekerdt et al., 2004; Fonad et al., 2006; Hodgson et al., 2004; Laughlin et al., 2007; Manion & Rantz, 1995; Oswald et al., 2007; Rossen & Knafl, 2003
Facilitate continuity of care. Develop a good working relationship with staff at a chosen residence (if applicable). Collaborate between settings.

Develop a profile of the older adult to share with personnel at the new residence.

For congregate or institutional housing, work with staff at the new residence to develop a culturally appropriate care plan.

Involve a trusted health care team member throughout the move.

When moving to an institutional setting after a stay in an acute care setting, use a transfer sheet that describes the older adult's level of function before hospitalization and at the time of discharge. Also, give a telephone report.

Rely on health information technology systems to convey information to the extent possible.

Chalmers & Coleman, 2006; Johnson & Tripp-Reimer, 2001; Manion & Rantz, 1995; Mitchell, 1999; Staveley, 1997

Post-Relocation Intervention Guidelines

Focus of InterventionBrief Description and Key Aspects of InterventionReferences
Time passage and prolonged interventions may be required following a move. Because individuals respond differently to relocation, health issues and feeling “at home” can occur over an extended period of time.

More intense support might be needed in the first month after relocation.

Interventions should extend over at least 6 months but might be required for several years post-relocation.

Hodgson et al., 2004; Meehan et al., 2004
Tailor interventions to older adults' personal values and preferences as they are a diverse population. Interventions must be individualized.

Interventions should recognize personal values and support autonomy.

Listen to and respect views, values, and needs of the older adult.

Be sensitive to the older adult's desire for involvement in decision making and personal preferences when discussing care.

Respect needs and values related to ethnicity. Identify the older adult's personal interests.

Hammer, 1999; Hersch et al., 2004; Johnson & Tripp-Reimer, 2001b; Oswald et al., 2007; Porter & Kruzich, 1999; Ryden et al., 1999; Sullivan & Fisher, 1994
Maintain stability or continuity of care in all aspects of life.

In residences where assistance is provided, develop and adhere to a plan of care.

If assistance is needed in managing health problems, ensure continuity in taking medications, keeping health care appointments, and treating health problems.

Maintain continuity in the older adult's daily patterns of living.

Provide materials to encourage activities or hobbies that are of interest to the older adult.

Crotty et al., 2004; Manion & Rantz, 1995; Mitchell, 1999; Reinardy & Kane, 1999; Ryden et al., 1999
Ensure meeting of physical and psychosocial needs of residents of “service-poor” apartments (e.g., independent living subsidized housing) who may have more unmet physical and psychosocial needs, functional limitations, and needs for services than those in “service-rich” residences (e.g., ALFs, CCRCs) who often actually use fewer services.

Support the older adult's highest level of functioning, and thus, his/her autonomy.

Refer older adults to support services as needed.

Ensure that assistance with personal care is adequate.

Provide additional assistance to individuals with sensory deficits, such as deafness, and those who cannot walk.

Refer older adults to appropriate health care providers for treatment of depression or other health problem management.

Groger, 2002; Holmes, Krout, & Wolle, 2003; Krout & Pillemer, 2003; Mitchell, 1999; Porter & Kruzich, 1999; Rehfeldt, Steele, & Dixon, 2001; Reinardy & Kane, 1999; Ryden et al., 1999
Promote past, present, and future relationships to facilitate adjustment post-relocation. Strong interpersonal relationships and social engagement can improve the older adult's perception of feeling secure in the new home.

Provide opportunities for visits with family and friends, including access to the internet and e-mail to maintain ties. Because of gender differences in preferences for modes of interaction and individuals with whom the older adult wants to interact, provide diverse opportunities.

Plan social activities (e.g., parties, entertainment) and promote informal interactions in public spaces to facilitate making new friendships.

Involve on resident committees in congregate housing to meet others.

Provide special assistance to those with mobility or hearing and vision impairments so they can make new friends.

Foster the new resident's trust in and feeling of support from staff in congregate housing (e.g., apartment building manager) or supportive settings (e.g., ALFs, nursing homes) by listening to understand the resident, responding to requests, and negotiating care.

Listen to the new resident's stories.

Provide opportunities for new residents to help others.

Bigby, 2008; Brown Wilson et al., 2009; Dobbs, 2003; Dupuis-Blanchard, 2007; Dupuis-Blanchard et al., 2009; Fonad et al., 2006; Heisler, Evans, & Moen, 2004; Hersch et al., 2004; Shippee, 2009a,b; Tracy & DeYoung, 2004; Tse, 2007; Waldron, Gitelson, Kelley, & Regalado, 2005; Waldron, Gitelson, & Kelley, 2005
Reduce stressors and promote adaptation by assessing perceived stressful aspects, and by assessing previously used coping strategies and skills. Build new coping strategies and skills to promote adaptation and meeting the older adult's unique needs and desires.

Relocation is stressful and requires interventions, but stressfulness may be time limited. Length of time to adjust varies.

Lower SES and inability to pay for needed services might be viewed as a significant stressor.

Individuals older than 85 and those who moved involuntarily are more likely to perceive stressors after a move.

Determine what challenges the individual faced in the past and how they were addressed. Ask what approaches were used, what he/she did well (i.e., his/her strengths), and what could have been improved (i.e., limitations).

Help the older adult build coping strategies. For example, learned resourcefulness can be taught and those with perceived losses can receive grief counseling.

Provide opportunities to talk about feelings regarding the move, both before and after the move.

Physical activities can be used to promote adaptation to stressors.

Bekhet et al., 2008; Bland, 2005; Hersch et al., 2004; Hodgson et al., 2004; Laughlin et al., 2007; Tracy & DeYoung, 2004; Tudor-Locke et al., 2008
Personalize the environment by furnishing the new home with familiar belongings and objects to make it a “home” and facilitate attachment to the home.

Finding meaning and satisfaction that matchestheolderadult'sdefinition of “home” also promotes adjustment.

Castle, 2004; Dobbs, 2003; Dupuis-Blanchard, 2007; Fonad et al., 2006; Oswald et al., 2007; Tracy & DeYoung, 2004; Tse, 2007
Provide choices as desired to aid adjustment to the new home.

Individualize choices that respect the older adult's desire for involvement.

Examples of choices are: individualized schedules of care, meal choices, and selection of activities in which to participate.

Dobbs, 2003; Oswald et al., 2007; Shippee, 2009a,b; Tracy & DeYoung, 2004
Positive reframing to think about the benefits of the move can promote adjustment.

Talk about positive aspects of the move and what attracted the individual to the new home.

Relieving caregivers' burden or feeling increased safety and security are often positive aspects.

Strengthen the older adult's belief that he/she can adjust to build self-efficacy.

Bekhet et al., 2008; Fonad et al., 2006; Groger & Kinney, 2006; Tse, 2007
Authors

Dr. Hertz is Professor Emeritus, Dr. Koren is Associate Professor, and Dr. Rossetti is Professor, Northern Illinois University, DeKalb; and Ms. Tibbits is Director of Clinical Services, Saint Xavier University Health Center, Chicago, Illinois.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Copyright © 2016 Csomay Center for Gerontological Excellence

Address correspondence to Judith E. Hertz, PhD, RN, FNGNA, FAAN, Professor Emeritus, Northern Illinois University, 1240 Normal Road, DeKalb, IL 60115; e-mail: Jhertz2@niu.edu.

Posted Online: September 06, 2016

10.3928/00989134-20160901-05

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