Choosing the Place of Care for an Elderly Patient with a Long-Term Illness
Living and care facilities of a person with long-term illness
The OECD defines that the long-term care of a person should be organized at his/her home or in another facility, and it may be temporary or permanent in nature.
An elderly person with a long-term illness may receive the care related to his/her primary disease either at home or in an institution. National or regional legislation may steer the selection of the primary place of living and care.
The various care facilities have commonly, e.g. in Finland, been graded according to the care workload in such a manner that persons who need the least amount of care are assigned to care facilities with the smallest number of staff and those with highest care requirements are placed in care facilities with highest staff numbers.
The driving force behind this type of grading has been cost-efficiency and the ability to address various needs, but the downside of this approach has been the need to transfer elderly persons around during their last years of life. The personnel structure of different types of care facilities in Finland, however, has become increasingly similar over the years with regard to the skill level and number of staff, although the number of personnel available for those living at home is lower than for persons living in other types of living and care facilities.
Moving away from home is a major decision, which at worst affects the elderly person's autonomy and changes the content of the rest of his/her life.
Dementia syndrome is the most significant illness that leads to a change of treatment place.
Home
In all cases, the person him-/herself should be heard and the possibility of continuing with home-based care should be considered. A home visit gives the best picture of the patient's living conditions.
Aids and house alterations help some elderly patients to manage at home.
The burden of those family members, and other carers, who participate in the care and assist in daily living should be assessed. Their burden can be eased through provision of various services. The elderly patient may attend a day care centre to be cared for and to maintain social contacts, or he/she may receive medical or nursing care as well as rehabilitation services at a day hospital, where the patient may also stay overnight to let the caregivers rest and have an undisturbed night's sleep.
It may also be possible to offer hospital-level care at home for acutely ill elderly patients in the form of blood transfusions, intravenous antimicrobial drugs or chemotherapy.
In accordance with local policies, terminal care may be provided by the staff providing the home care services.
Family care
Family care entails organising care or other type of part-time or round-the-clock support at the private home of the care provider or at the elderly person's own home. The municipality or other organisation responsible for the care of the elderly contracts the family care provider (individual person or company providing such services) to deliver the family care service.
Family care has been found suitable for elderly persons who are lonely and feel insecure or who have mild memory disorders and for supporting informal caregiving by the person's own family.
Hospital-at-home
Hospital-at-home schemes provide medical care, which is delivered by health care professionals, at the patient's home thus avoiding an admission to a hospital ward.
Such care is administered to patients who live at home and, in some cases, to those living in some form of sheltered housing.
Various day hospitals and day care activities may be offered to care for the elderly population, and they vary in the amount of medical care offered. Patients participate for a set time period, and they attend the facility once or several times a week.
The care offered by day hospitals aims to promote the quality of life. The effectiveness of this care has been shown best for well equipped day hospitals with geriatric multi-disciplinary skills Medical Day Hospital Care for Older People Versus Alternative Forms of Care and also for less well equipped day hospitals that cater for patients with dementia.
Intermediate overnight care that lasts from 24 hours to several weeks may also be offered, and the venues include various nursing homes or residential care homes, depending on why the care is needed and the extent and nature of the patient's needs. Short-term stays in nursing homes are effective provided that the patient's functional capacity is maintained. Flexibility when matching the patient's needs has been found to be effective when providing individually tailored short-term care.
Assisted living schemes (sheltered housing, residential and care homes)
Various assisted living schemes cover a wide range of accommodation ranging from housing that closely resembles a private apartment to group home type facilities that are closer to institutionalized care. The terminology varies from country to country, and there may be great variation in the actual meaning of the different terms depending on the place of residence. Such schemes are distinct from nursing homes in that the tenants are usually able to lead a life that is not dissimilar to ordinary life at home. In advanced assisted living services help is available 24 hours a day, 7 days a week.
From the viewpoint of care workload, the population structure in assisted living schemes offering round-the-clock care is almost similar to that of nursing homes. As institutional care significantly reduces in the coming years, the majority of persons with long-term illnesses, who are no longer able to cope with daily routines alone at home, will in the future live in assisted living facilities.
In many cases the tenants have to contribute towards the cost. It may, for example, be the tenant's responsibility to pay for the medication, cleaning services, rent or food. In some countries, such payments may be covered by state subsidies.
The level of services offered varies greatly. When assisted living is considered as an alternative, it is essential to establish the staffing arrangements, the number and share of trained nurses per shift, the supervision of the tenants' movements and how the night time cover is arranged.
Nursing homes
Patients are usually admitted to nursing homes on a permanent basis and the payment arrangements are country specific. Decisions on long-term care can be cancelled if the resident no longer needs such service (e.g. moving back to home after rehabilitation).
Non-acute hospitals
Proper diagnosis, shorter stays and rehabilitation are the key issues that are currently being explored in non-acute hospitals that provide care for the elderly.
Choosing the place of care for a patient with a long-term illness
The choosing of a care facility for an elderly patient should take place within a care need evaluation process in cooperation with the patient him/herself. In this process, a multidisciplinary approach is employed to map the needs, by evaluating the following aspects: the patient's physical, psychological, cognitive and social functioning Assessment of Functional Capacity in the Elderly as well as on the nature of the existing illnesses, all of which need to be matched with local resources.
The person(s) responsible for choosing the care facility must be well versed in the available local resources and match those with the patient's care requirements.
Decisions regarding the choice of a care facility have both social and health policy implications, and such decisions must therefore be made locally using the aid of gerontological and geriatric expertise.
In some cases, the patient's financial situation may enable individual solutions.
The aims and principles of a geriatric assessment
The principal aim of a geriatric assessment is to diagnose, treat and provide rehabilitation for an illness that is reducing the functional capacity of the patient. If this is not possible, an attempt should be made to maintain the patient's functional capacity by compensating for any functional deficit. Should this also prove to be unsuccessful, providing assistance at home or - in the last resort - moving away from one's home should be considered.
There is plenty of evidence on the effectiveness of comprehensive multidisciplinary geriatric assessment and on the care and rehabilitation plan that is based on the assessment, concerning elderly persons living both at home and in institutional facilities Comprehensive Geriatric Assessment for Older Adults Admitted to Hospital.
The purpose of a geriatric assessment is to establish whether the patient
has any such illnesses or conditions that can be treated or corrected, and when corrected will improve the patient's functional independence
has any such illnesses or conditions the deterioration of which can be significantly slowed down
has enough physical and mental resources to carry out rehabilitation
has physical problems with the present accommodation or lack of appropriate aids which have led to reduced functional independence
lives in conditions that put his/her safety under threat, including an illness, physical problems with the present accommodation, travelling long distances or abuse
is actually seeking to be admitted to an institution due to loneliness, boredom or fear
has financial means
has resources related to mental or religious matters or social relationships
has personal preferences as regards the future care facility.
Carrying out a geriatric assessment
The aim is to form a better understanding of the medical reasons behind functional impairment and of the prognosis of the principal illnesses. ”Unable to cope at home” is not a diagnosis.
The assessment encompasses the cognitive, psychological and physical health of the patient as well as functional capacity and social life circumstances. Laboratory tests and imaging studies are used to complement the assessment.
Studying old records and interviewing the patient and/or his/her representative, as well as staff at previous care places, are part of the assessment.
The assessment takes into account the patient's need for medical care and rehabilitation as well as help needed with daily activities.
The extent and nature of services that can be delivered at the patient's home should be weighed against the various local residential care services. Local social and health policies determine how care facilities are allocated and to which patients.
Assessment team
The physician of the team should be a geriatrician or other specialist with expertise in the subject.
The improvement and maintenance of functional capacity, as well as an assessment regarding the need for home alterations or physical aids, is the domain of a physiotherapist, occupational therapist or other person with expertise in the subject.
A social worker assists in applying for appropriate financial aid (carer's allowance, aid with transport, attendance allowance etc.) and must be well versed in appropriate national legislation.
Whenever necessary the assessment team may consult other professionals, including an orthopaedic surgeon, neurologist, dentist, dietitian, ophthalmologist, chiropodist or clergyman.
The justness and conformity of the decisions is verified with the aid of effective and reliable evaluation tools that have been specially developed to assess the patient's functional capacity and help requirement. Mutually agreed decision-making criteria are also used.
An assessment and a decision should both be made promptly and in consensus with the patient. Depending on national legislation, the patient may have the right of appeal against the decision.
Choosing appropriate evaluation tools
It is worthwhile to use various evaluation tools to support a geriatric assessment; each domain to be assessed must have its own assessment tool (see also Assessment of Functional Capacity in the Elderly). Before choosing an evaluation tool for clinical practice, the following facts should be considered: the validity and reliability of the tool, its popularity nationally and internationally, the possibility to use the same tool at the different levels of care and its sensitivity and specificity as regards the qualities that need to be evaluated.
The user must be familiar with the scale and characteristics of the tool he/she is using, and all evaluation tools must only be used for the purpose for which they have been designed and tested.
Functioning in everyday life is divided into instrumental activities of daily living (IADL) and activities of daily living (ADL).
IADLs include e.g. light housework, preparing meals, shopping, using the telephone, taking medications and managing money.
As frailty syndrome progresses, the patient will initially need help with IADLs and gradually also with ADLs, which include personal hygiene needs, bathing, dressing, moving and transferring, eating and changing position when in bed.
The commonly used evaluation tools to assess functional capacity include the e.g. Barthel Index, the Functional Independence Measure (FIM), the Katz Index and the many tools used to evaluate ADLs and IADLS in the Resident Assessment Instrument (RAI) system Assessment of Functional Capacity in the Elderly.
Other tools and tests, especially suitable for measuring the physical functional capacity of elderly persons include e.g. grip strength, the Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) test, as well as the chair stand test (chair rise sit to stand) 5 or 10 times.
Cognitive functioning
A geriatric assessment always includes an evaluation of the person's cognition, but the importance of such an evaluation is particularly important when choosing a care place.
Intellectual functioning is assessed through interviews and observing the patient as well as with the aid of specially designed tests.
The assessment tool packet for the diagnosis of memory impairment and early dementia developed by CERAD http://cerad.mc.duke.edu/Default.htm is recommended by various experts. MoCA (Montreal Cognitive Assessment) test is a sound alternative.
Several tools designed to assess the disease stage are available for the evaluation of specific diseases that impair intellectual functioning. The tools help to pinpoint the area of the brain involved and the degree of the impairment. The disease causing intellectual impairment must be diagnosed by a doctor.
Commonly used tools to assess cognition include the Clinical Dementia Rating (CDR), the Mini-Mental State Examination (MMSE) and the Cognitive Performance Scale (CPS) in the RAI assessment system.
Psychological functioning
Depression is the most common psychiatric illness among the elderly population. Depression may occur alone, it may be associated with other illnesses or it may be atypical. It is recommended that for the diagnosis and monitoring of the treatment response of depression the treating physician uses assessment tools designed specifically for the elderly. The patients should be asked direct questions regarding depression.
Delusional disorders (paranoia) are the second most common psychiatric illness among the elderly population and may occur independently or as one of the many symptoms of the emerging dementia.
Behavioural problems occur usually in association with other psychotic symptoms Psychosis in the Elderly or illnesses and/or with dementia-inducing conditions, and they manifest themselves as inappropriate or indiscreet behaviour. The patient fails to sense, perceive or interpret his/her surroundings and experiences correctly. Behavioural problems - particularly night time activity and aggression - may increase the burden of the carer and the patient's surroundings as well as compromise the safety of the patient and others.
Appropriate evaluation tools may be used to assess behavioural problems, such as the Cohen-Mansfield Agitation Inventory (CMAI) or the behavioural assessment scales in the RAI assessment system.
Care and nursing workload
At present the workload involved is assessed with the aid of various evaluation tools which measure the work input of the care staff. One of the most studied and used tools is the Resource Utilization Groups (RUG-III) in the RAI assessment system. This scale has been used for decades e.g. in the Unites States, as the payment basis in long-term care facilities. Resource needs may also be defined with the aid of activity-based measurements.
It is essential that the person seeking a care place and the care provider agree on the compatibility of the care requirements and the level of care offered. When choosing a care place, different resource utilisation scales are used to assess whether the staffing levels at the proposed care place match the patient's care and aid requirements.
Health status
Frequent use of out-of-hours and hospital services, as well as various health care providers, is indicative of an unstable state of health.
The availability of medical facilities and follow-up should be assessed before a care place is chosen. If no other tool is available, the assessment may involve looking at the percentage of trained nursing staff among the care staff and the accessibility to a doctor.
Nursing skills that are associated with maintaining the patient's health status include skills such as monitoring blood glucose readings, changing urinary catheters and stoma care. Basic care denotes assistance with activities of daily living.
The Changes in Health, End-Stage Disease and Signs and Symptoms (CHESS) Scale in the RAI assessment system may be used to assess the stability of a patient's health status.
Social functioning
Social functioning is a relative concept, which may be influenced both by external factors, such as a high-rise flat in a building with no lift or lack of outside lighting, and by internal factors, such as memory impairment, getting easily lost or unwillingness to socialise.
Social functioning diminishes as a result of impaired physical, psychological or cognitive functioning. Withdrawing from social functions and giving up previous interests may be a manifestation, or a first sign, of other underlying problems.
Mapping out the patient's social life may lead to the source of undiagnosed illnesses and /or other problems. Moreover, when choosing a care place the availability of social interaction may be a point to consider.