Physician's attitudes toward the ill aged and nursing homes

A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians' attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated to 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent to manage the ill aged, although 50 percent had had no significant degree of exposure to geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place to die. Although 85 percent studied that physicians should be involved in the nursing home displacement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention to the needs of the chronically ill aged.     

Painless dentistry. Fact or fiction?

The complex chronic health problems and functional limitations common in the elderly population place them at risk for complicated hospitalizations and discharge planning. The purpose of this study was to investigate the effectiveness of a discharge planning protocol in identifying elderly patients' home care needs. The sample in this quasiexperimental study consisted of 507 hospitalized patients age 65 years or older. The control group received the usual hospital discharge planning protocol. In the experimental group, nurse/social worker teams coordinated the discharge planning process, using an adapted form of the Discharge Planning Questionnaire (DPQ) to identify the home care needs of elderly patients. Thirty days after hospital discharge, both patient groups participated in a telephone survey to obtain information about health care problems they experienced during home recovery and their use of health care resources. The findings indicated that the majority of the elderly patients had functional dependencies, which required the help of another person to carry out daily household duties and provide assistance with basic needs, especially ambulation. These functionally dependent patients only received home care referrals about 50% of the time. These findings raise questions about current reimbursable services. Logistic regression analysis indicated that patients with increased functional dependency and patient problems during home recovery had a greater likelihood of rehospitalization and emergency department usage. This information about the home care of elderly patients after hospitalization supports the need for comprehensive functional assessment as part of discharge planning. This study also suggests that the nurse/social worker team can provide effective screening and discharge planning coordination of home care. Physician involvement and effective communication networks must be in place.     

Interdisciplinary collaboration and discharge planning communication for elders

The effects of personal characteristics and perceptions of interdisciplinary collaboration on discharge planning communication were examined for nurses, physicians, and social workers in two hospitals. The model for the study explained 61.7% of the variance in discharge planning communication for nurses. For all 142 health professionals, communication openness with social workers, problem solving between nurses and physicians, and collaboration with social workers were important to discharge planning communication. For nurses, communication satisfaction with patients and families also was important.     

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.     

Evaluation of an intensive case management program for short-term nursing home residents

This study examines the impact of intensive case management services on nursing home length of stay and use of community-based resources for short-term nursing home residents. The findings did not reveal statistically significant effects, indicating that the outcomes of the services provided by the nursing home social workers and the intensive case managers were essentially the same. Discussion focuses on additional variables, such as rural/urban location and social service/nursing home staff relationships that may impact on the effects of case management on the discharge process.     

Patients' perceptions of their quality of life 11 years after discharge from a state hospital

OBJECTIVE: Fifty-three state hospital patients discharged to group homes in the community in 1978-79 were followed up at three and 11 years to assess their quality of life and several other dimensions of their community experience. METHODS: A structured interview was used to obtain data on patients' perceptions of and degree of satisfaction with aspects of their lives one month before hospital discharge and at three and 11 years after. Group home staff rated patients' functioning at follow-up. Data on rehospitalizations over the 11-year period were collected. RESULTS: At 11-year follow-up, 30 of the surviving 40 patients were living in noninstitutional settings: nine in independent or semi-independent settings and 21 in group homes. The 30 patients perceived that their quality of life outside the hospital had improved in several ways, including the extent of their social networks, the quality of their living environment, and their capacity to meet basic needs. When data were averaged over the 11 years and corrected for the shorter time in the study of subjects who died, patients spent only 2.6 percent of the follow-up period in the hospital. Only one patient at 11 years wanted to return to the hospital. CONCLUSIONS: The finding that even the small minority of patients who required multiple rehospitalizations preferred community life may have important clinical and policy implications for setting the threshold of hospital discharge.     

Differentiated levels of nursing work force demand

In addition to reviewing the literature about the extent to which basic nursing education is related to actual nursing practice, this article investigates the extent to which the relationship between nursing practice, education, and experience varies across specific health care settings. The literature presented no consistent or systematic association between type and amount of previous nursing experience and current nursing practice. However, the literature generally provided evidence of a consistent and systematic association between baccalaureate preparation and level of registered nurse (RN) practice. The review of practice and organizational differences across the hospital, nursing home, and ambulatory care sectors suggests that baccalaureate-prepared RNs in hospitals may have a more strongly differentiated role relative to those in nursing homes and ambulatory settings. If baccalaureate-prepared nurses continue to be perceived as capable of more complex and independent practice, and if employers believe that they can increase revenues by increasing the quality of nursing care or can save money by shifting to RNs some responsibilities now held by more costly personnel (such as physicians), then demand for baccalaureate-prepared nurses may increase.     

Immunisation against bovine vibriosis due to Campylobacter fetus subsp. fetus biotype intermedius

At Norristown State Hospital a mobile Team of workers was organized to give personalized and preventive psychiatric, medical and social attention to distressed elderly people within the communities served by this large psychiatric institution. The Team's mobility permitted flexible approaches to problem-solving at the person's own home or other places of residence. Over its 8.5 years of existence the Team evaluated 1,438 elderly persons and acted in a consultant capacity to 77 nursing or retirement homes. Most of these clients were treated successfully within the community; only 222 required admission to the parent hospital during that time. Those treated in their own homes usually were able to maintain or improve the quality of their lives. The timely psychiatric, medical and social help often uncovered physical and social factors that previously had been overlooked.     

Evaluation of problem solving and communication skills of persons with schizophrenia

This study examined gender differences in 162 female and 65 male patients with cancer referred to home care. Data were collected before hospital discharge using the Multidimensional Functional Assessment Questionnaire, the Karnofsky Performance Status, and the Quality of Life-Cancer Scale. Controlling for age and stage of disease, the results showed that men reported significantly more cancer-related impairments, more limitations in activity of daily living, and poorer social resources than women. No gender differences were found in quality of life, perceived emotional health, perceived physical health, performance status, and comorbidity. Significant predictors of self-care activities were: for women perceived physical health, Karnofsky Performance Status, and stage of disease (58% variance explained); for men Karnofsky Performance Status and medication taken (67% variance explained). Gender differences should be considered in discharge planning to provide appropriate home care services for male and female patients with cancer.     

Applications of laser scanning confocal microscopy to the observation of human oocytes and embryos

Continuity of care beyond the walls of the acute hospital setting has always been a major emphasis in nursing. There is concern that the care needs of older adults at the time of discharge have been increased by shortened hospital stays. Yet little is known about the specific and changing health care needs of older adults during the early days at home following discharge from acute care, particularly those who are discharged without community referrals. To learn more about the experiences of this population, the College of Nursing at the University of Southern Maine, in collaboration with the Nursing Service Department at Maine Medical Center, conducted a demonstration project. This project involved follow-up home visits to older adults who were discharged to their homes from an acute care setting.     

The physician decision-making process in transferring nursing home patients to the hospital

BACKGROUND: Each year more than 25% of nursing home patients are transferred to the emergency department or hospital for evaluation and treatment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assessment and management of acute infections in the nursing home. METHODS: A cross-sectional study was conducted of all acute urinary tract infections and lower respiratory tract infections occurring from February through June 1991 in eight randomly selected urban nursing homes. The numbers of transfers to the emergency department of hospital were recorded along with identification of the clinical, psychosocial, and institutional factors that influenced the physician's decision to transfer. RESULTS: Three hundred fifty-nine patients had 258 urinary tract infections and 219 respiratory tract infections. Eighty-one (17%) of these events resulted in transfer to a hospital for evaluation (16/81) and/or admission (65/81). Less than one third (30.4%) of the events caused the patient to be examined in the nursing home by a physician before the decision to transfer to the hospital. The mean time between the staff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P < or = .05), a transfer to the hospital during the previous 6 months (P < or = .01), and fewer nursing home laboratory tests and treatments (P < or = .01) were all associated with hospital transfer. CONCLUSIONS: In this sample of acutely ill nursing home patients, physicians collected limited clinical data before the decision to transfer. Although some transfers may be appropriate, a reduction in the transfer rate may reduce health care costs and limit the risk of iatrogenesis, thus improving the outcome of acute illnesses occurring in the nursing home.     

Preparing for the "silver age of dentistry"

Providing oral health care to older adults will be a challenging and rewarding part of dental practice in the years ahead. It will include understanding normal aging, appreciation of the pathophysiology of chronic diseases experienced by many elderly, and application of key principles of pharmacology in care of patients receiving medications for treatment of these diseases. It will involve an understanding of the interaction of systemic conditions with oral health status, adequate diagnosis of oral disease, and appropriate rational treatment planning with a strong emphasis on preventive dentistry. It will include care provided in nursing homes or during housecalls for the homebound. Dentist-geriatricians will be working with teams of healthcare professionals that include physicians, dentists, podiatrists, ophthalmologists, nurses, social workers, nutritionists, pharmacists, and occupational and physical therapists. Above all, the team will provide skilled compassionate care, which is always good business!     

Can a clinical classification of stroke predict complications and treatments during hospitalization?

Former patients in a rehabilitation unit at a large Midwestern hospital continued to actively seek services provided by the inpatient nursing staff, primarily through telephone contact, long after their discharge. A proactive formal follow-up program managed by an advanced practice nurse in rehabilitation was proposed as a better means of providing continuing care for rehabilitation patients after discharge. To examine the efficacy of the nurse-managed follow-up program, a randomized clinical trial was conducted. One hundred patients were randomly assigned to either the intervention group or the control group. Comparisons were made between the two groups on several outcome measures at 4 months after discharge. Outcomes included Functional Independence Measure (FIM) instrument scores, complication rates, rehospitalizations, and anxiety levels. The organizational outcomes included number and types of calls to staff, as well as time spent by staff nurses and social workers. The results indicated significant differences between the intervention and control groups in terms of anxiety levels, the number of calls made to the unit, and the amount of time spent by staff nurses and social workers.     

How access to long-term care affects home health transfers

This study examines the determinants of home health use after hospitalization for acute illness for eleven diagnosis-related groups (DRGs) in 1985, drawing on data from four primary sources: Medicare hospital bills, Medicare home health bills, the Medicare and Medicaid Automated Certification System files, and the American Hospital Association Survey. Separate Tobit models are estimated for each DRG. The analysis shows that transfers to home health care are heavily influenced by the hospital's long-term care arrangement and by conditions in local nursing home and home health care markets. Especially important is whether a hospital has its own long-term care unit, swing beds, or both, and whether nursing home beds are available in the local area. Patients discharged from hospitals are more likely to use home health care in areas with a low supply of nursing home beds and low Medicaid reimbursement levels for skilled nursing facilities. The results of this study have implications for proposals to extend Medicare's Prospective Payment System for hospital services to include postacute care. Proponents of a "bundled payment" that encompasses both acute and postacute services argue that the current system leads to inefficiencies and inequities. This analysis points to systematic relationships between home health and nursing home services, which should be factored into the development of a bundled payment policy.     

Perceptions of urban versus rural hospital patients about return to their communities

During a two-month period in 1976, male patients scheduled to be discharged from two Veterans Administration Hospitals, who were aged 55 or older, chronically ill, able to communicate rationally, and had been hospitalized at least a week for the current illness, were interviewed prior to discharge. Information was sought regarding their feelings about admission and discharge, the availability of and their need for 13 related health-related services at home, and the informal support systems available to them in their local communities. Comparisons were made between patients from distinctly rural settings (communities with less than 5,000 population) and those from larger towns or cities. Both urban and rural patients were modest in assessment of their own health-related needs, especially their need for social and ancillary health services. In almost all instances, the perceived availability exceeded perceived needs. Rural dwellers reported somewhat less apprehension about entering the hospital; they also reported more social contact in their home communities despite the fact that in this sample the rural dwellers were more likely to be older, widowed, and living alone. Rural dwellers were slightly more likely to have their own family doctor.     

A conceptual model for the mobility patterns of nursing home admissions

This article draws from the literature in long-term care, demography, and geography to develop an initial conceptual framework to explain variations in the patterns of nursing home moves. The conceptual framework is bolstered by preliminary data from state censuses of nursing homes that asked about the origins of current nursing home residents. The data suggest that a relatively high proportion of nursing home residents move to a different county in the process of admission to a nursing home. The research and applied implications of the framework are discussed.     

The relationships among nursing diagnoses in discharge planning for patients with lung cancer

An explanatory study was designed to investigate whether nursing diagnoses present at discharge from the hospital accurately describe the complexity of care required in the community. A sample of 196 patients with lung cancer referred to community agencies at discharge was described by types of nursing diagnoses; types of agencies needed and services required; and by age, gender, race, economic status, and hospital length of stay. Using multiple logistic regression, a model for home care referral resulted in four significant predictor diagnoses: altered nutrition: less than body requirements, bathing/hygiene self-care deficit, high risk for infection, and high risk for injury. The model for hospice referral resulted in four significant predictor diagnoses: anticipatory grieving, impaired skin integrity, high risk for impaired skin integrity, and pain. The data suggest that the nursing diagnoses described the discharge planning needs, which predicted the type of agency referral needed.     

Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease

The purpose of this study was to describe the impact of asthma and chronic obstructive pulmonary disease (COPD) in the elderly on health care utilization. The Health Care Financing Administration (HCFA) file for the year 1984 through 1991 involving beneficiaries < or = 65 yr were searched for the diagnoses of asthma and COPD by ICD-9 codes. The study groups were created by determining the first admission for an exacerbation of either disease during each year from 1984 through 1991. Patients were identified by their social security number. The 1984 cohort consisted of 56,692 patients with asthma exacerbation and 162,899 with COPD exacerbation. The 1991 cohort consisted of 67,758 patients with asthma exacerbation and 131,974 patients with COPD exacerbation. In addition, the 1984 cohort was tracked by social security number for evidence of rehospitalization for either asthma or COPD through 1991. Length of hospitalization increased as patients grew older. The discharge rate to an independent living facility diminished as age increased. The use of convalescent and nursing homes or home health care after discharge more than doubled from 1984 through 1991. The utilization of health care resources by elderly patients with asthma and COPD is immense, both during hospitalization and after discharge.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.