Screenings, Savings, and Service: Nurses Meeting Rural Older Adults in Their Communities

Method

The ECU GWEP team of RNs was deployed to communities throughout eastern North Carolina to provide preventive health screenings and education using community-based services. The education provided was tailored toward the participant and may have included reading materials or tools for individuals who were unable to read. Partnerships were established with rural Federally Qualified Health-care Centers (FQHCs). ECU GWEP nurses were intentionally embedded into two separate FQHCs located in northeastern and southeastern North Carolina. The presence of team nurses in the communities targeted for the study allowed them to become familiar and trusted faces among residents in the study counties.

The assessments at the FQHCs included annual wellness visit screenings plus screenings for depression, cognitive impairment, and fall risk. As the work progressed at the FQHCs, subsequently more community-based contacts were made with older adult service agencies such as the Area Agency on Aging, Alzheimer's NC (now called Dementia Alliance of North Carolina), local senior centers, and churches. The ECU GWEP nurses moved into the communities to provide services. Partnering with known resources in the local communities further enhanced nurses' trustworthiness and provided access to perform screenings.

Due to the challenges of completing the clinic-level comprehensive assessments in some of the community sites, the assessments were shortened to a three-part community screening that included fall risk, depression, and cognition assessment along with collection of basic demographic information.

At FQHCs and community events, nurses originally planned to screen older adults, age ≥65, who were self-referred or referred by their primary care providers. There was a high demand of screenings requested by younger participants with numerous comorbidities; therefore, the sample age limit was lowered to ≥55 years. Eligible participants were community-dwelling older adults (age ≥55) attending FQHC appointments, senior centers, community outreach events, and faith-based events who were referred or self-referred to nurses for screening.

Screening tools used were the Centers for Disease Control and Prevention (CDC; 2016) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall risk screening, the Patient Health Questionnaire-2 (PHQ-2; American Psychological Association, 2018), and the Mini-Cog^© (Borson, 2016). The current study was approved by the university and medical center institutional review board. Each participant signed an informed consent and an identifying number was given to each person. Demographic information collected included identifying number; initials; year of birth; race; gender; occupation; zip code; whether participants had a primary care practitioner (yes/no); and whether they identified as logger, farmer, fisherman, or none. The agricultural occupation was a separate aim of the larger ECU GWEP grant and this information was included to support service to agricultural residents. Blood pressures were taken as a complementary service to the community screenings. Nurses were prepared to deliver education and referral information based on screening results for each participant. The three screening tools used in the current study are evidence-based, well-accepted, and frequently used tools.

Results

Nine hundred ninety-four individuals were screened during the study and were predominantly female, African American, and older than age 55 (Table 1). Among the sample, 568 at-risk scores were identified. Four hundred five individuals scored at risk with a score ≥4 on the STEADI questionnaire, 116 scored ≤2 on the Mini-Cog, and 47 individuals scored ≥3 on the PHQ-2 (Table 2). All individuals scoring at risk for falls and cognitive changes received individualized education and referral for appropriate intervention. For example, participants who scored at risk for falls received immediate discussion of their risk and strategies to reduce falls in the home. The discussion included ideas such as clearing pathways between the bed and bathroom and removing trip hazards such as throw rugs and clutter. Families were included in the education whenever they were present. Individuals with cognitive impairment were referred to family caregiver specialists from the local Area Agency on Aging and encouraged to follow up with health care clinicians. Individuals who screened at risk for depression were given educational information about depression and its management and referred as appropriate for medical care. Handouts on depression were read and discussed as well as given to participants.

Table 1: Sample Demographics (N = 994)

Table 2: Participants Who Screened at Risk for Cognitive Impairment, Falls, and/or Depression

Discussion

The use of the screening tools and provision of education at point of contact were found to be efficient and feasible. Most participants received recommended education and referral based on the screening results. The current study provided access to resources for many participants who had been unaware of the need and/or location of resources. The results are a clear indication of the importance of screenings and the critical need in this region.

All individuals who scored at risk for falls in the current study were referred to their providers or to an evidence-based fall prevention program. Although this study was not designed to track completed referral visits, the importance of fall prevention is clear in the literature. It is estimated that the average hospitalization cost related to a fall is >$30,000 (CDC, 2017). If the referrals from the current study created interventions that prevented falls, an estimated cost savings of $1,485,337 could be realized. Falls are the number one cause of nonfatal and fatal injuries in older adults (CDC, 2017). Of older adults who fall, 37.5% will report a fall that resulted in injuries that required medical treatment (Bergen, Stevens, & Burn, 2016). The average cost of a medically treated non-fatal fall is conservatively estimated to be $9,780 per person (Burns, Stevens, & Lee, 2016). Additional impacts of fall prevention could include maintenance of independence, higher quality of life, and prevention of death.

In the current study, approximately 5% of participants scored at risk for depression on the PHQ-2 and approximately 12% had screening evidence of cognitive impairment. Although these are not large percentages, they are still worth the referral for care. The screening was easy to accomplish and could easily be replicated in other settings. Medical illnesses are often correlated with risk for depression and in turn, depression is correlated with poor physical health outcomes and increased health care costs (Smith et al., 2014). Depression is costly to individuals and society by way of reduced interpersonal relationships, emotional suffering, therapy and treatment costs, lost wages, reduced productivity, and even loss of life (Siu, 2016). Depressive symptoms are seen more often in the older adult population versus other age groups, causing decreased self-care ability, irritability, psychomotor retardation, and pseudodementia (Tusaie & Fitzpatrick, 2016). Further evaluation and effective management of depression in these individuals could yield qualitative improvement in physical, cognitive, and social function and reduce the risk of morbidity and suicide. There are indirect costs associated with depression that are difficult to quantify, such as caregiver burden, costs of medications and therapy, and loss of productivity (Zivin, Wharton, & Rostant, 2014). A community-dwelling older adult with depression who lives at home can cost an extra $1,330 annually, and the cost is further amplified by caregiver burden.

Screening for cognitive impairment allows for appropriate diagnosis, early intervention, and planning that would improve quality of life, maximize functional performance, and improve patient and caregiver outcomes. In 2018, the total costs of care in the United States for people with dementia were $277 billion (Alzheimer's Association, 2018). Through screening, early intervention, and early treatment, the onset of complex dementia symptoms can be delayed. Early intervention may lead to increased functionality that allows in-home care, delaying institutionalization. During the last 5 years of care for people with dementia, the estimated cost per person was $287,000. Early intervention can lead to reduced health care costs due to lower dementia care levels for a longer period of time and reduced time spent in costly higher-level dementia care. Estimated savings based on the number of positive screenings are approximately $33 million (Alzheimer's Association, 2018). Discovery of dementia, cognitive impairment, depression, and fall risk was needed among participants of the current study and the resulting evidence supports the ease and use of these screening tools in a community setting.

Limitations

The current study was limited by using convenience sampling for the screenings. The service area was across 41 counties, many with little to no access to screenings; therefore, participants included anyone who wished to be screened. Results could not be generalized to other populations from this work. The study design did not allow for follow up with any given participant. Anecdotally, in subsequent work, referral agencies have reported participant use of their services, such as the family caregiver specialist, through various Area Agency on Aging. The intentional ability to follow such a population in a longitudinal study would provide further evidence of the impact of screening and education in each community. Costs savings were estimated based on known costs of falls, depression, and dementia care. To know the exact amount of cost savings, further longitudinal research is warranted. It should be noted that actual costs and savings are difficult to compute due to numerous other comorbidities and variation of injuries, type of depression treatments, and duration, as well as the numerous variables in dementia care.

Conclusion

Since the completion of this work, the current authors' team has been used to build on the needs identified to create community-based education for the region. Topics most often requested include the management of depression, anxiety, stress, and cognitive changes; strategies for aging in place; and effective caregiving. With the proportion of older adults expected to grow in the United States, it is vital that evidence-based care be implemented at the community level for early intervention and prevention.

The response to the ECU GWEP grant overall has been overwhelming and has demonstrated the need for screening and education in the authors' region. The use of evidence-based tools in screening assisted ECU GWEP nurses in this process and could be readily replicated in other settings by health care staff. The findings from the current study demonstrated that the health risks of the aging population in rural eastern North Carolina are consistent with known risk factors in the general older adult population for falls, depression, and cognitive changes. The authors' ability to complete the large number of screenings was due to having nurses travel to where older adults congregate and perform leisure activities. These findings indicate the importance of nurses meeting the needs of people where they live and work. According to the 2017 Gallup poll, nurses remain one of the top three most trusted professions (Brenan, 2017). Nurses were widely accepted in the community and readily able to act as advocates and navigators, bridging gaps in the access of preventive screenings and increasing the possibility of early intervention.

The grassroots work of the ECU GWEP nurses through community-based health screening empowered older adults through education, guidance, and support, and increased access by linking individuals to proper resources. The authors believe this work demonstrates the feasibility of community screening and suggests that having nurses readily available for community-based preventive screening could potentially increase early detection, early intervention, and cost savings in the areas of fall prevention, depression, and cognition.