Journal of Psychosocial Nursing and Mental Health Services

Aging Matters 

Relocation to a Long-Term Care Facility: Working With Patients and Families Before, During, and After

Hsueh-Fen S. Kao, PhD, RN; Shirley S. Travis, PhD, APRN, BC; Gayle J. Acton, PhD, APRN, BC

Abstract

Permanent relocation of a dependent older adult to a long-term care facility can occur for a number of reasons, including the need for postacute care or a higher level of care than can be provided in a less-restrictive environment, and/or the inability of family members or others to care for the individual in a noninstitutional setting. Outcomes of institutional placement may be either negative, such as the older adult experiencing relocation stress syndrome, or positive, such as improved management of chronic illnesses and reversal of functional decline. This article offers a review of the factors that predict when and where older adults will relocate for institutional long-term care, an overview of individual transitions to institutional care, and suggestions for seamless transitions during the preinstitutionalization, transitional, and postinstitutionalization phases of relocation, which are guided by a transactionist approach to stress and coping.

Abstract

Permanent relocation of a dependent older adult to a long-term care facility can occur for a number of reasons, including the need for postacute care or a higher level of care than can be provided in a less-restrictive environment, and/or the inability of family members or others to care for the individual in a noninstitutional setting. Outcomes of institutional placement may be either negative, such as the older adult experiencing relocation stress syndrome, or positive, such as improved management of chronic illnesses and reversal of functional decline. This article offers a review of the factors that predict when and where older adults will relocate for institutional long-term care, an overview of individual transitions to institutional care, and suggestions for seamless transitions during the preinstitutionalization, transitional, and postinstitutionalization phases of relocation, which are guided by a transactionist approach to stress and coping.

Many efforts to estimate the likelihood of admission to a nursing home suggest that between 36% and 55% of people age 65 and older can expect to spend at least some time in such a facility before death, with the likelihood of admission increasing with advanced age ( Murtaugh, Kemper, Spillman, & Carlson, 1997 ). Approximately one half of nursing home residents are age 85 and older ( Federal Interagency Forum on Aging-Related Statistics, 2000 ; National Center for Health Statistics, 2000 ). Relocation experiences to a nursing facility are common occurrences for many families and their older adult members. For most individuals, relocation to a nursing facility is not by personal choice, and the final choice of destination is often driven by factors that have little to do with the older adults’ personal control over the decision ( McAuley, Pecchioni, & Grant, 1999 ; McAuley & Travis, 1997 ; Reinardy, 1995 ).

The information in this article is drawn from the nursing, health, and aging literature related to individual stress and coping and the nursing home relocation process to help nurses anticipate the needs of older adults who are transitioning to institutional long-term care. Although the majority of these transitions occur with discharge planning teams in acute care settings ( Jones, 2002 ), this article offers suggestions for interventions that can be generalized across diverse situations, including admissions from community-based sites and home care, and intrainstitutional and transinstitutional relocation.

When and Where Older Adults Relocate to Institutional Long-Term Care

According to Jones ( 2002 ), Kart and Dunkle ( 1995 ), McAuley, Travis, and Safewright ( 1997 ), and Travis and McAuley ( 1998 ), older adults who relocate to institutional long-term care generally:

  • Are dependent on others for three or more of their basic activities of daily living (i.e., bathing, dressing, toileting, transferring, continence, feeding).
  • Have significant cognitive deficits.
  • Lack adequate social support to provide care in a home-based or community-based setting.
  • Have experienced a recent hospital stay for a serious illness that requires extended care after discharge.

Relocation to a nursing home is commonly viewed as an unpleasant experience ( Davis, Thorson, & Copenhaver, 1990 ), which involves loss of privacy, limits on independence, and decreased autonomy ( Tickle, 1993 ). For individuals whose relocation was prompted by a change in cognitive functioning or physical health, adaptation to their new surroundings is particularly difficult; often results in a worsening of their health and emotional problems ( Mirotznik & Kamp, 2000 ; Young, 1990 ); and can include iatrogenic events, such as increased falls ( Friedman et al., 1995 ), following admission to a nursing facility.

According to Jones ( 2002 ), most long-term residents (46%) are admitted to a nursing home from a hospital. However, this point of entry conceals the fact that many older adults were living in private homes or residential communities (e.g., assisted-living or adult communities) prior to their hospitalization. In these cases, nursing home placement is just one part of a cascade of stressful events (e.g., illness, hospitalization, relocation to institutional care), which tend to occur during a very short period of time. In addition, to add to the stress older adults may feel regarding relocation, they may require admission to nursing homes in other counties or states that are located closer to their adult children or other relatives or that have an available bed ( McAuley et al., 1999 ). Such “migrations” across counties or states add stress and burden to an already disruptive event in the lives of older adults and their family members ( McAuley & Travis, 2000 ).

Perhaps the most extreme response to such moves is relocation stress syndrome (RSS), an accepted nursing diagnosis in the North American Nursing Diagnosis Association classification scheme ( 2001 ). Defining characteristics that occur 80% or more of the time include anxiety, depression, apprehension, loneliness, and increased confusion ( Jackson, Swanson, Hicks, Prokop, & Laughlin, 2000 ). Other events that occur 50% to 70% of the time include many affective disorders (e.g., sad affect, withdrawal) and physiological consequences (e.g., sleep disturbances, weight loss, gastrointestinal disturbances) ( Jackson et al., 2000 ).

Of course, not all relocation experiences are unpleasant. What seems to be important is the amount of control new residents experience, as well as the degree of support of the family in the decision-making process ( Brugler, Titus, & Nypaver, 1993 ; Davidson & O’Connor, 1990 ). Preparation before the move, when possible, also appears to enhance positive outcomes following relocation to a nursing facility ( Chanfreau, Deadman, George, & Taylor, 1990 ; Grant, Skinkle, & Lipps, 1992 ; Jackson et al., 2000 ).

Individual Transitions to Institutional Care

Most theorists separate the relocation process into three stages. Depending on the circumstances of the move and the older adults’ functional and health status, each stage may be compressed into an intense transition process of just a few days or extended over a period of weeks or months ( McAuley et al., 1997 ; Travis & McAuley, 1998 ).

Preinstitutionalization

Before the actual move, older adults and their family members must cope with myriad entry procedures, including admission screenings to determine admission eligibility, financial issues, and final placement decisions. If the older adult is living in a private residence, the need to sell a home and dispose of personal belongings can add elements of personal loss and grief to the stress equation.

After a facility has been selected and a bed is available, many consultations and decisions are necessary regarding legal affairs, which includes advance directives and durable power of attorney designations. Family members often engage in extensive searches to find an appropriate, or simply acceptable, vacancy in a nursing facility that is within reasonable proximity to home ( Travis & McAuley, 1998 ). These searches and the associated decisions regarding a loved one’s long-term care can create enormous stress for the dependent family members and the entire family unit ( Travis & Piercy, 2002 ). It is during this same time that the dependent older adult may begin to exhibit common RSS symptoms such as withdrawal, depression, and feelings of helplessness and powerless ( Davis et al., 1990 ). In addition, family members may also be coping with feelings of stress and guilt due to placement activities.

Although long-term care services, in general, and institutional long-term care, in particular, tend to be underused by racial and ethnic minorities, this trend may change in the next decade due to societal demographic shifts. Currently, approximately 86% of nursing home admissions are White ( Jones, 2002 ). However, as with all other health care interventions, nurses must be cognizant of the many differences in values and beliefs that exist in an ethnically diverse society and continually monitor their practices to ensure they are providing culturally and ethnically appropriate care ( Spector, 2000 ).

Immediately After Institutionalization

The most adverse psychological effects of relocation may occur immediately after the move, when the older adults’ feelings of helplessness, abandonment, and vulnerability are most acute ( Jackson et al., 2000 ). Negative responses are especially common among involuntarily admitted residents, whose anger and sense of injustice may be intense ( Mikhail, 1992 ). It is not known how long this stage may last for any individual resident. Predictions of physical, social, and mental disorganization following admission to a nursing facility range from 6 to 8 weeks ( Brooke, 1989 ) to as long as 3 months from the day of admission ( Jackson et al., 2000 ). In addition, family members may also be coping with adverse reactions to the admission process.

Often families are distressed about the admission itself, as well as the physical, social, and mental changes that may occur in newly admitted residents.

Postinstitutionalization

A central factor in new residents’ psychological responses to nursing home placement continues to be their perception of how much control over their lives will be lost as a result of the move ( Mikhail, 1992 ). For involuntarily admitted residents, it is especially important to identify areas in which they can exercise control in the patterns of their daily lives. It is loss of control that sustains residents’ anger and allows conflicts regarding care to arise ( Mikhail, 1992 ).

For older adults with cognitive impairment, the relocation process may become entangled in faulty memory, reasoning, and judgment skills. Way-finding in a new environment, developing new social relationships, and feeling safe in a new setting will present significant care planning challenges for staff who work with these residents ( Cohen-Mansfield & Marx, 1992 ).

Assuming there are no confounding events, such as death of a roommate, roommate changes, rehospitalization, decline in cognition or associated behavioral problems, or relocation to another unit in the facility, assimilation into the long-term care routine usually occurs within 8 to 12 months following admission ( Brooke, 1989 ; Dimond, McCance, & King, 1987 ). As discussed in the next section, coping theory provides a framework for understanding why relocation does not affect all older adults the same way and offers conceptual guidance for the interventions of interdisciplinary teams across care settings who are responsible for the various relocation stages involved in nursing home placements.

Interactionist Versus Transactionist Models of Stress and Coping

The two most popular approaches to coping are the interactionist and the transactionist models. The transactionist model is most fitting for the type of person-environment issues that confront older adults in dependent-care situations, although either could apply to relocation situations.

The Interactionist Model

The interactionist model emphasizes ways of perceiving and thinking about one’s relationship with the environment ( Folkman, 1992 ). Coping is regarded as a function of personal and/or environmental characteristics for the purpose of regulating emotions. One of the criticisms of this model is that it assumes that people appraise and respond to situations consistently. Having the “right” personal characteristics enables one to cope with life problems effectively.

The Transactionist Model

The transactionist model of stress and coping also begins with one’s cognitive appraisal of the person-environment situation. However, this model views this appraisal as continuously changing as the encounter unfolds and new encounters build on previous ones ( Lazarus & Folkman, 1984 ). In other words, the transactionist model views coping as a constellation of processes that change over time and across occasions, the primary purpose of which is to solve problems and regulate emotions. At each point in time, thoughts and emotions are influenced by the current context and perceptions.

From this perspective, appraisals and coping strategies are not static attributes. Ongoing reciprocal relationships, with each affecting and being affected by the other, are consistent with the tasks necessary for effective transitions through the stages of relocation. This view also accommodates cloudy or faulty perceptions of reality associated with delirium, cognitive decline, or physical disease, which may change over time. Thus, staff members are forced to consider the ways in which the environment may affect residents’ behavior and responses on any given day, at any given time.

Seamless Transitions to Nursing Home Care

As shown in the Figure , nursing home staff play a critical role in residents’ adjustment to the new institutional setting. There can be nothing “routine” about team meetings if residents’ individual needs are addressed appropriately.

The role of the interdisciplinary team in providing seamless transitions to nursing home care.

Figure.

The role of the interdisciplinary team in providing seamless transitions to nursing home care.

One of the most disturbing shortcomings in health care today is the profound lack of care coordination across settings ( Sparbel & Anderson, 2000 ). Therefore, in the preinstitutionalization stage, if a resident is being admitted from another institution, there must be greater care coordination between the discharging and admitting facilities, so the prospective resident and family members can effectively participate in decision making and have their choices respected.

If a resident is being admitted from his or her home, the environmental changes may be more radical, both physically and emotionally. After institutional decisions are made by the older adult and the family members, a progressive introduction and orientation program for both the resident and family should be implemented. This step will help the resident and family adjust to the new environment. In addition, meetings with the older adult and family members will acknowledge the older adult’s routines and preferences. Experiences during the preinstitutionalization stage are clearly related to subsequent RSS. Without greater efforts by health care providers and organizations to coordinate care during the preinstitutionalization stage, the older adults, their family members, and facility staff may experience increased stress.

After admission to the long-term care facility, continuity of care is maintained through effective communication between the staff from the discharging facility and/or family members, and the team at the new nursing home. Incomplete medical records, redundant discharge and admission procedures, and lack of individualized care plans are flaws in the admission process that can be avoided with better care coordination across settings. Immediately after institutionalization, the nursing home team must continuously assess the environment for existing or emerging person-environment disharmony. Roommate problems, staff-family conflicts, and routinized care that is atypical of the new resident’s usual habits are only a few of the environmental stresses that can affect the relocation process. Because the residents are the vulnerable players in the relocation situation, the nursing staff must modify the environment, to the extent possible, to enable new residents to cope effectively. From a transactionist model approach, the interdisciplinary team must remain vigilant during this phase for ongoing signs and symptoms of RSS, as residents’ relationships with their new environment continue to unfold and evolve.

The postinstitutionalization stage of relocation generally ends with assimilation to the routine and community of the nursing facility. The entire interdisciplinary team is ultimately responsible for setting assimilation goals that are consistent with residents’ health and functioning and in conjunction with the residents’ desires and preferences. The needs of the family must also be addressed at this time.

The transactionist model is useful for understanding the ongoing care coordination that must be used during this dynamic and ever-changing process. Throughout older adults’ stay in long-term care facilities there likely will be many care transitions that include hospitalization, intrainstitutional moves, and shifts to palliative and hospice care. Just as the nursing facility team worked to create a seamless transfer into the facility, the team must also be prepared to do the same for its residents across care settings and between care teams. Similarly, admission teams in hospitals, rehabilitation facilities, and outpatient clinics must pay closer attention to the histories of the residents they receive from long-term care settings. The need to understand the care, choices, and preferences of nursing home residents should be no less important than those of new patients admitted from independent living in the community.

Summary and Conclusions

Institutional relocation can be a stressful event that involves a series of person-environment adjustments. The transactionist model of care, which accounts for both the individual and the nature of the situation, directs the interdisciplinary team to capitalize on residents’ effective coping strategies and to moderate the losses residents experience as a result of, or in conjunction with, the need for institutional care.

Many problems in the current health care system work against effective care coordination to and from long-term care settings, including the lack of accountability and responsibility for following older adults throughout their care trajectories. As discussed above, older adults who need institutional long-term care arrive in various health care settings under some of the most vulnerable circumstances of an individual’s life.

Although the Figure provided in this article suggests a linear path to institutional long-term care, this is, of course, not the case for many older adults. Even those who are permanently placed in nursing facilities experience episodes of acute illness and injury that take them out of the long-term care setting and back again. The threat of RSS can occur many times during the course of older adults’ long-term care stays. Therefore, while this article focuses on stages of initial institutionalization, we close with a reminder that care coordination is an ongoing process for frail older adults and their family members.

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Authors

Dr. Kao is Assistant Professor, School of Nursing, and Dr. Travis is Professor, School of Nursing and Department of Health Behavior and Administration, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina; and Dr. Acton is Associate Professor, School of Nursing, University of Texas at Austin, Austin, Texas.

Address correspondence to Hsueh-Fen S. Kao, PhD, RN, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223; e-mail: hskao@uncc.edu.

10.3928/02793695-20040315-04

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