Improving Healthcare Delivery in Nursing Homes

Improving Healthcare Delivery in Nursing Homes: Focus on Broken Bones

The objective of this study is to focus on health care management issues, problems, and policies in a current organization and specifically that of a nursing home with a focus on broken bones.

Identification of Problem

Osteoporosis and fracture related to osteoporosis "are primary health concerns and sources of significant death and disability around the world." (Clinton, 2011) In 2006, it is stated that hip fractures along "cost Americans in excess of $20 billion." (Clinton, 2011) This is a huge problem since one in four patients with a hip fracture die "within one year of having the fracture." (Clinton, 2011) Osteoporosis is a bone disease that is stated to "decrease bone density" and to increase the "risk of fractures." (Clinton, 2011) These types of fractures are termed 'fragility fracture' and this occur with "minimal trauma and typically would not happen if the patient did not have weakened bone." (Clinton, 2011)

The body is stated to absorb more bone than it actually produces and this causes the bones to become dense and to become weaker. Affected is the spongy trabecular bones at the ends of the bones more so that the hard cortical bone that comprises the shaft of bones. (Clinton, 2011, paraphrased) Age is a primary risk factor for developing osteoporosis in both men and women. It is stated that breaking bone is serious, especially in older adults. It is reported that broken bones "can cause severe pain that may not be completely treatable. Almost all fragility fractures are associated with a decreased life expectancy when compared to patients who have not had a fracture. Twenty-five percent of seniors who break a hip die within one year from problems related to the broken bone itself or surgery to repair it. Many of those who survive need long-term nursing home care. A woman's lifetime risk of breaking a hip from osteoporosis is equal to her risk of breast, ovarian, and uterine cancer combined." (Clinton, 2011)

It is reported in one study that there have been few in the way of "major health promotion efforts…directed toward old people." (Kutner, et al., 1992) The reason stated for this is that there are "widely held myths" that serve to provide discouragement for inclusion of older adults in such efforts." (Kutner, et al., 1992) Myths include that "health promotion means the prevention of disease rather than improving health status" and that "older people are unable to tolerate health promotion interventions, as for example, exercise regimens as well as for the reasons that older adults are not able or willing to change their health attitudes, behaviors, or lifestyles and that older people are difficult to recruit into studies and hard to evaluate and finally that behavioral or lifestyle changes in late life will have only minimal impact on the health and functioning of old people and that intervention is not cost effective for the elderly." (Kutner, et al., 1992) Of primary importance is that since most older adults have at least one chronic disease or disability, health promotion efforts for them are important for maintain function." (Kutner, et al., 1992)

II. Analysis of Problem

The Multicenter Trials of Frailty and Injuries reports the Cooperative Studies of Intervention Techniques (FICSIT) that is a project supported under a cooperative agreement for 1990 through 1993 by the National Institute on Aging and the National Center for Nursing Research of the National Institutes of Health. FICSIT is reported as a "series of clinical trials of biomedical, behavioral, and environmental interventions designed to increase physical function capacity and reduce falls and fall-related injuries among the frail elderly." (Kutner, et al., 1992)

The difference between FICSIT and other interventions in the elderly is that it is a multi-institutional cooperative investigation." (Kutner, et al., 1992) Its interventions are reported as "randomized clinical trials with sample sizes ranging from 100 to 1,250." (Kutner, et al., 1992) It is reported that clinical center that participate conducted "their own proposed interventions and collect associated site-specific data, while simultaneously contributing to a large body of data collected from all sites." (Kutner, et al., 1992) The eight clinical sites are collaborative with a statistical coordinating center and a monitoring board. It is reported that participating sites as well as their populations and their proposed interventions and major outcomes are as follows:

(1) Kaiser Permanente, Northwest Region, Center for Health Research, Portland, OR -- This study compares a control group to a moderate exercise group. The objective of the study is to modify environmental risks for reduction of falls in the elderly. Groups of 25 individuals comprise the study with a total of 625 participants that received exercise interventions and 625 individuals control groups. Eligibility Criteria is stated at 65 years of age or older that lived in the community, ambulatory, at least 1 fall in the past year, a near fall in the last month, or that were 75 years of age or older. The outcome measures stated are falls and fall-related injuries.

(2) Yale University School of Medicine, Gerontology Research Group, New Haven, CT. Randomized block design. Usual health care plus social visits compared with usual health plus multidisciplinary program including behavioral and medication changes, education, and exercise. Sample size is stated at 150 persons in each of 2 groups. Eligibility criteria is stated at 70 years of age and older and living in the community, ambulatory, no severe cognitive impairment, no participation in vigorous exercise. Outcome measures reported are balance nd gait and fear of falling.

(3) University of Washington, Department of Health Sciences, Seattle, WA. Modified 2 X 2 factorial design using strength and endurance training. Reduced exercise time in group receiving both interventions. Randomization stratified by sex. The sample size was 25 persons in each of four groups. Eligibility criteria 69 -- 85 years old, living in community, unable to tandem walk perfectly, thigh strength index less than or 3 equal to 1.38 Newton-meters per kilogram for men, less than or equal to 0.95 Mn per kg for women. Strength, aerobic capacity, gait and balance.

(4) Emory University, Wesley Woods Geriatric Center, Atlanta, GA. -- This study is randomized into control, static exercise (balance platform) and dynamic exercise (Tai Chia, an ancient Chinese exercise form) groups. Control groups attend weekly health and wellness seminars. The sample size is stated at 67 individuals in static exercise groups and control groups and 81 in Tai Chi groups. The eligibility criterion stated at 70 years or older, living in community, ambulatory, no major debilitating illness. The outcome measure, balance, range of motion, ADLs and instrumental activities of daily living (IADL).

(5) Audie L. Murphy Veterans Hospital, Ambulatory Care Department, San Antonio, TX. Usual care compared with physical therapy. Intervention is focused on general conditioning and functional activity training. The sample size is stated at105 persons in the intervention group and 105 in a usual care group. Eligibility is stated at 60 years or older, nursing home resident, functionally dependent for 2 or more activities of daily living (ADL), Mini-Mental State Examination score 50% or more. The outcome measures stated are functional status, physical status, health care utilization cost.

(6) Harvard University Medical School, Hebrew Rehabilitation Center for Aged and the U.S. Department of Agriculture's Human Nutrition Research Center on Aging. Cambridge, MA. -- This study is a 2 X 2 factorial design using strength training and nutritional supplements. The sample size is stated at 25 persons in each of 4 groups. Eligibility criteria is stated at 80 -- 99 years old, nursing home resident, ambulatory, 1 or more falls or high risk for fall, no acute or terminal illness, no severe dementia. Outcome measures are stated to include improved muscle strength and association between nutritional status and muscle mass.

(7) University of Iowa, College of Medicine, Iowa City, together with Iowa State University -- This study is on the compliance study of subjects in three groups, Parkinson's disease, post-hip fracture and nursing home resident. Compliance to the use of hip pads is measured. The ultimate goal of this project is stated to be the reduction of fall-related injuries. The sample size is stated at 30 persons in each of six groups. Groups are those living in the community, nursing home residents, those in rehabilitation, primarily for stroke, Parkinson's disease patients and those with previous hip fractures and residents of senior care facilities. Eligibility criteria is stated as 65 years of age and older and risk assessment for falls score is 12 or more and lives within 50 miles and no evidence of terminal illness and no history of psychotic behavior as well as being able to wear hip pads.

(8) University of Connecticut, Department of Neurology, Farmington, CT. - 2 X 2 factorial designs with balance and strength training as the intervention. Simple size is four groups with 30 persons each. Eligibility criteria is stated to include being 75 years and older, living in community, ambulatory, no cognitive impairment and no terminal illness. The outcome measures stated are functional status, balance on the balance platform, gait and functional mobility. (Kutner, et al., 1992)

There are physical deficits in the elderly that contribute to their frailty in terms of skeletal muscle strength, gait and speed, range of motion in the joints and musculoskeletal flexibility, postural stability, including balance, coordination nd reaction time as well as cardiovascular responsivity." (Kutner, et al., 1992) These conditions are reported to contribute to "significant functional limitations." (Kutner, et al., 1992) These conditions are reported to be such that contribute to significant functional limitations. (Kutner, et al., 1992)

The most prevalent type of injury among older adults is falls and it is stated that 30% of older adults 65 years of age or older fall each year. The number is highest for the oldest in this group and 5% of falls result in fractures with five percent of falls resulting in serious injuries that require medical care. Over 200,000 older adults suffer hip fractures every year as a result of osteoporosis and an increased risk of falls. Falls and other mobility-related issues are stated to be a serious health threat to the functioning of elderly adults. It is stated specifically that falls "are likely to be associated with loss of confidence in the ability to function independently, restriction of physical and social activities and eventual increased dependence." (Kutner, et al., 1992)

Some physical deficits in older adults have been shown to be preventable to some extent. Exercise programs are stated to "retard the rate of age-related bone loss and increase cardiac fitness." (Kutner, et al., 1992) It is reported that one large-scale study of fall prevention showed that "modification of home environment risks and participation in group health education sessions increased appropriate health practices and reduced the risk of falling for elderly persons." (Kutner, et al., 1992)

A clinical trial is an appropriate method for determination of the extent to which physical frailty, functional impairment nd risk of injury among elderly adults could be reduced by appropriate interventions. Such interventions would be designed for the purpose of improvement of physical functioning, such as skeletal muscle strength, mobility, flexibility, and balance, decrease of environmental hazard, and alter risky health behaviors and lifestyles." (Kutner, et al., 1992)

It is stated that a critical element in the evaluation of the effectiveness of the interventions "is being able to consistently assess the quality of life of the subjects." (Kutner, et al., 1992) Quality of life assessments are stated to be based "on a person's own opinion of his or her physical, emotional, and social well-being." (Kutner, et al., 1992) Quality of life is stated to have become a "major criterion for evaluating health and medical interventions." (Kutner, et al., 1992)

Determination of the optimal method of measuring quality of life in clinical trials is a complex issue." (Kutner, et al., 1992) Assessment of life quality among older individual is reported to be difficult and specifically among older adults who are subjects in health promotion intervention studies. (Kutner, et al., 1992) Quality of life is reported to have been viewed "from the outset of trails as an important mediator of compliance and intervention effectiveness as well as an important outcome variable." (Kutner, et al., 1992)

Masud and Morris (2001) state in their study that the most likely causes of falls in elderly persons include those stated in the following table labeled figure 1 in this study

Figure 1

Reasons for falls in elderly

Accident/Environment Related

31%

Gait or balance disorders

17%

Dizziness

13%

Drop Attacks

9%

Confusion

5%

Postural hypotension

3%

Visual Disorder

2%

Syncope

0.3%

Other specified causes

15%

Unknown

5%

Source: Masud and Morris (2001)

It is reported that primary risk factors include the following risks factors as stated in the following table labeled figure 2 in this study.

Figure 2

Primary risk factors for falls in elderly adults

Weakness

Balance Deficit

Mobility Limitation

Gait Deficit

Cognitive Impairment

Impaired ADL

Postural Hypotension