Home Health Care Nursing Homes and Long Term Facilities for the Elderly

¶ … Care for a Family Member

When a family is searching for the best possible healthcare environment for an older person in the family, that family really has three choices. They can place the elderly person in a nursing home, or have a home care agency come into the home and provide services, or the family can turn to a long-term care solution. This paper reviews the positives, negatives, and other aspects of all three solutions. Using peer-reviewed sources, this paper looks at specific areas of interest in the three potential solutions for a family.

Nursing Homes - Suicide

According to the Centers for Medicare and Medicaid Services, more than 40% of Americans will need some care in a nursing facility (which is also seen as a "long-term" service) in their lifetime (Mullin, 2013). Moreover, the cost for a private room (on average in the United States) in a nursing home runs around $248 a day; a semi-private room averages$222 a day or around $81,000 annually (Mullin, p. 1). About 100 days is apparently all that Medicare will pay, so to begin a look at nursing home situations means checking out the finances.

Meanwhile, how safe are nursing homes when it comes to protecting an elderly family member? The issue that is presented in the American Journal of Public Health is suicide; this is pertinent because the rate of suicide among males age 65 or older is 30 suicides per 100,000 (Mezuk, et al., 2015). That is a fairly high rate compared with males under the age of 25 (7 per 100.000). The issue of suicide is raised in this piece because the typical risk factors for suicide are "social isolation, depression, and functional impairment," and these factors can often be found in nursing home patients (Mezuk, 1495).

It helps that the 1987 Nursing Home Reform Act mandates screening of all long-term care patients vis-a-vis psychiatric services, but there is no evidence that all nursing home patients have frequent screening to determine their mental and emotional health. While there are always the unknowns vis-a-vis patients, and some can fall through the cracks of any facility, there is concern in this regard because suicidal ideation (thinking about or contemplating killing one's self) is "common among long-term care patients" and between 5% and 33% of nursing home residents report having had suicidal ideation (Mezuk, 1495).

Other factors that may come into play when older people are going through even temporary or rare suicidal ideation include: a) there are nursing homes that house residents with "psychiatric disorders" -- which can be troubling for a new patient; b) facility characteristics can negatively impact patients, like the size of beds and the number of beds (a sense of being crowded or a lack of privacy contributes to this issue); c) some nursing homes go through high turnover in staff, which has been associated " ... with higher risk of suicidal behavior among residents"; and d) the simple fact of having an elderly person go from living with a family to having to transition into a nursing home " ... is a risk for suicide" (Mezuk, 1495).

Also, when an older man or woman is admitted into a nursing home, there is always a kind of " ... complex interplay of social and psychological factors," which can include a loss of social connectedness, autonomy, and personal identity, Mezuk explains. These transitional periods in the life of an older person can produce feelings of " ... anxiety, loneliness, and hopelessness" because going from being at home with family to suddenly sharing a facility with many people with many different issues can clearly be psychologically challenging (Mezuk, 1495).

The authors conducted research by gathering data from the "Virginia Violent Death Reporting System (2003-2011)," and they matched locations of suicides (3,453) against the available information about nursing homes (285) and assisted living facilities (548). What they came up with was a suicide rate of 14.16 per 100,000 in nursing homes and 15.66 per 100,000 in the community (Mezuk, 1500). In any event, it is clear that research needs to be conducted regarding nursing homes and the mental and emotional health of elderly residents.

Nursing Homes -- Quality of Care

In the Scandinavian Journal of Caring Science the authors conducted a study to determine the relationship between the work culture in a nursing home and the quality of care in a nursing home. In order to research this issue, they looked into databases for any articles that described the relationship between a particular work culture and the quality of care. They got 14,510 hits but 10,401 were "duplicates"; and of the rest of the articles (4,109) just 10 specifically focused on the specific aim of the research (Andre, et al., 2014). And of those 10, nine actually zeroed in on " ... the importance of leadership style and supportive management" vis-a-vis creating high quality in nursing home care (Andre, 449).

This may seem like a no-brainer (i.e., leadership is needed to create a strong work culture) but the authors have concluded that changes are needed in some nursing homes based on their research. Those changes include: making sure that healthcare workers have "job satisfaction, empowerment, autonomy and influence in nursing homes" (Andre, 449). If healthcare workers in nursing homes have "empowerment" and "influence" over their efforts, they will be "more committed and involved" in giving residents the highest quality care (Andre, 449).

In addition, the authors suggest some of the articles they uncovered referenced several kinds of management practice, and among the better practices -- which keep professional healthcare staff on the job and not unhappily seeking better positions -- are those in which management consistently gives positive "acknowledgement" to staff. Also when management builds a good communication relationship with staff older people are served in a way that helps them keep their dignity.

So, in terms of a family researching the best nursing home for an elderly family member, doing research of each potential nursing home (how happy are the nurses and how often to nurses leave; how competent is management; is the work culture professional and enthusiastic?) is a good way to avoid bad situations in nursing homes.

Elderly Transitioning from Nursing Homes to Long-Term Care

The article in the Journal of the American Geriatrics Society takes the position that low income older people are better off leaving nursing homes and instead getting services provided by Medicaid home and community-based services. Moreover, the authors asset that there is increasing enthusiasm in the field of elderly care for community-based long-term care (LTC), partly because costs are usually lower for home and community-based services (HCBS), and because there is a philosophical and moral movement to get people out of nursing homes (Wysocki, et al., 2014).

In fact several states have created what Wysocki calls " ... specific diversion programs," which work to identify older people who are "at risk" of being stuck long-term in nursing homes (71). Not that this article is totally advocating shutting down nursing homes, but there is definitely a movement to get the elderly into homes and into community-based long-term care. Obviously if an individual is moved out of a nursing home and into a private home, then the home healthcare services will be needed.

Wysocki explains that most elderly people who enter nursing homes are "discharged within 90 days," and those that are not discharged have a " ... low likelihood of being discharged" and in fact many of those individuals end up being in nursing homes for years (Wysocki, 71).

There is a dramatic difference between care in nursing homes and community-based, home-based settings. Nurses are on site 24 hours a day in nursing homes (which explains in part why nursing homes are so expensive), but in HCBS settings providers generally use "direct-care workers or paraprofessional staff," and very often those staff members are aided by "informal caregivers," providing mostly support and backup (Wysocki, 72). And while there are federally mandated standard requirements for nursing homes, no such standards are in place for home and community-based services.

In other words, Medicaid patients that leave nursing homes and instead go with HCBS programs, " ... must become familiar with a new set of providers in the community" (Wysocki, 72). One of the main points of this article is to compare and contrast what happens when older people leave nursing homes and enter into the home and community-based service sector of healthcare.

The results of this research examined the results for 1,169 people who stayed in nursing homes, and the 1,169 individuals that transitioned out of nursing homes and into home and community-based services. On page 73 the authors show that there were 113 "potentially preventable hospitalizations" among those who stayed in nursing homes; and there were 133 "potentially preventable hospitalizations" among those who transitioned into home and community-based services.

Also there were more hospitalizations for chronic obstructive pulmonary diseases (COPD) and for CHF (congestive heart failure), and for dehydration with those transitioning out of nursing homes than there were for those who stay in nursing homes (Wysocki, 74). The factors that indicate fewer medical emergencies and serious conditions in nursing homes may be accounted for because there are full-time nurses on hand.

What this all means is that yes, patients do like to get out of nursing homes for all the reasons mentioned in the first part of this paper. But, more investment should be made in transition programs; more comprehensive healthcare needs to be provided for patients that choose HCBS. The data that Wysocki and colleagues gathered and presented shows that even though the transition out of dreaded nursing homes is appealing, caution is advised. To wit, the families of those considering transition for their loved ones should recognize that their family member could be "at greater risk for hospitalization after returning to the community"(Wysocki, 71).

Hence, extensive planning for the medical and other needs of a family member transitioning out of a nursing home is crucial, because it could prevent negative health outcomes.

Depressive Issues in Long-Term Care

In the peer-reviewed journal PLOS the authors conducted a cross-sectional study and recruited outpatient care services for "long-term preventive care" at an outpatient clinic in Japan (Arataka Outpatient Services) (Ogata, 2015). 545 men and women over 65 years of age were recruited (who did not have dementia) and given questionnaires. The data from this research was then compared with existing studies from France, Finland, England, Czech Republic, Italy, and Israel.

The reason for the research is that depressive state has been "significantly associated with higher-level functional capacity" among older people in long-term community facilities (not nursing homes) (Ogata, p. 2). The results of individual facilities in different countries can be "quite different" (which one would suspect at the outset of a research project like this), albeit what was determined from all the data gathered was that "much larger samples of facilities per country need to be included" (Ogata, p. 8).

As to the results of this research the authors question the assessments that were used by researchers in the countries mentioned; in some of those countries more than one assessment was conducted into long-term facilities, and it is possible that "... the second and third assessments have largely been copied from printouts of the baseline assessment" (Ogata, p. 8). What does it all mean? For one thing, setting out on a research project to determine if individuals in long-term facilities are becoming depressed should set more realistic goals. Do patients in Israel receive more rehabilitation than those in the Czech Republic, for example? And if they do, sincere, in-depth research should be done in each country used, instead of going with existing assessment protocols.

Finally, Ogata explains: "Prevention of depressive state may contribute to not only depressive state but also to higher-level functional capacity." Prevention of depressive states for individuals involved in long-term care (not in nursing homes) is of vital concern for families looking for the right place to send their elderly loved ones.

Training Home Healthcare Workers

Older adults in most instances want to stay at home if at all possible. So it is important that when home healthcare is playing a role in an older person's life, that those nurses and other caregivers attending to that elderly person receive proper training. That is certainly what families want to be assured of: is the person coming into our house fully qualified and fully conversant with key medical and healthcare issues, and is that person compatible with our loved one?

This brings the authors of a BMC Health Services Research article to the salient point of this article: there is not a great deal of evidence in the literature as to how effective training programs are developed. The physical activity of elderly people that are being cared for at home, and the nutritional quality of the food has to be taken into account (Walters, et al., 2015).

This article shows how "Intervention Mapping" (IM) was used in the UK to develop a good training program for home healthcare nurses. This is a highly important topic because families who agree to have their elderly members cared for at home, will not themselves always be at home (there is work, school, activities that are outside the home), and moreover the family always has high expectations for the quality of the healthcare services when it comes to their kin (Walters, 289).

In order to enhance the health of the person remaining at home in a home healthcare situation, the " ... promotion of physical activity and fruit and vegetable intake" is vitally important. Many older European adults do not have someone pushing them, encouraging them, to get outside and go for walks. Older people with chronic illnesses, or with a disability of some sort, require competent care by nurses that are well trained for these needs.

A strong relationship of trust must be developed between the home healthcare worker (HHC) and the client; and once this relationship has been formed, the patient / client is more likely to accept lifestyle changes set in motion by the HHC worker. That having been pointed out, in the UK (and no doubt in the U.S. as well). But according to Walters, the HHC worker must have received adequate training in order to provide interventions in the lifestyle of the patient at home.