evolve.elsevier.com/Ebersole/gerontological
mobile, youth-oriented society may find it diffi- cult to fully comprehend the insecurity that el- ders feel when moving from one site to another in their later years. In addition to the stress of relocation and the initial anxiety of adapting to a new setting, elders typically move to ever more restrictive environments, often in times of crisis. This chapter discusses residential care options across the continuum and transitions between health care settings with related implications for nursing practice. Professional nursing roles in settings across the continuum where care is provided to older adults are dis- cussed in Chapter 2.
Elder-Friendly Communities
“Home” provides basic shelter, is a place to establish secu- rity, and is the place where one “belongs.” It should provide the highest possible level of independence, function, safety, and comfort. Most older people prefer to remain in their own homes and “age-in-place,” rather than relocate to more protected settings, especially institutional living. Future generations of older people will be much more likely to want to remain living independently and seek opportunities to adapt homes and communities to meet their needs. The ability to age-in-place depends on appropriate support for changing needs so the older person can stay where he or she wants. Developing elder-friendly communities and
increasing opportunities to age-in-place can enhance the health and well-being of older people. Enabling the com- munity to become the good neighbor to older citizens provides mutual benefits to all who are involved.
Components of an elder-friendly community include the following: (1) addresses basic needs; (2) optimizes physical health and well-being; (3) maximizes indepen- dence for the frail and disabled; and (4) provides social and civic engagement. Figure 3-1 presents elements of an elder-friendly community. Many state and local govern- ments are assessing the community and designing inter- ventions to enhance the ability of older people to remain in their homes and familiar environments. These inter- ventions range from adequate transportation systems to home modifications and universal design standards for barrier-free housing. Home design features such as 36-inch-wide doorways and hallways, a bathroom on the first floor, an entry with no steps, outlets at wheelchair level, and reinforced walls in bathrooms to support grab bars will become standard nationwide in the next 50 years (Robinson & Reinhard, 2009).
Advancements in all types of technology hold promise for improving quality of life, decreasing the need for per- sonal care, and enhancing the ability to live safely at home and age-in-place (Daniel et al., 2009). Some emerging technologies to enhance safety and independent living for older adults are discussed in Chapter 13.
Addresses Basic Needs Provides appropriate and affordable housing Promotes safety at home and in the neighborhood Ensures no one goes hungry Provides useful information about available services
Promotes healthy behaviors Supports community activities that enhance well-being Provides ready access to preventive health services Provides access to medical, social, and palliative services
Fosters meaningful connections with family, neighbors, and friends Promotes active engagement in community life
Provides opportunities for meaningful paid and voluntary work
Makes aging issues a community-wide priority
Mobilizes resources to facilitate “living at home”
Provides accessible transportation Supports family and other caregivers Maximizes Independence for
Frail and Disabled Promotes Social and Civic
Engagement
Optimizes Physical and Mental Health and Well-Being
An Elder-Friendly Community
FIGURE 3-1 Essentialelementsofanelder-friendlycommunity.(FromAdvantageInitiative,CenterforHomeCarePolicyandResearch,VisitingNurse
ServiceofNewYork.Availableatwww.vnsny.org/advantage/.)
A
Among Asians, South Americans, and African Americans, it is often an expectation. Growth of multigenerational households has accelerated during the economic downturn among all cultures and races and this trend is expected to continue (Hooyman & Kiyak, 2011). Relocating from one’s own home to the home of an adult child can have many benefits for both, but without adequate preparation it can also be stressful. Box 3-1 presents some factors to consider when planning to add an older person to the household.
A variation of multigenerational housing has long ex- isted in what has become known as “granny flats.” These may be apartments added to existing homes or the con- struction of small housing units on family property with privacy as well as sharing of time and resources. Such arrangements allow families to be close enough to be of assistance if needed but to remain separate. They are prac- tical and economical, and their production has continually expanded, particularly in Australia. In the United States, use of this model is minimal, but existing “mother-in-law”
cottages and apartments have served a similar purpose for many families for years.
Another model of shared housing is that of opening one’s personal home to others. Older people often live in houses that were purchased in their young adult years and find that, as they age, much of the space may be underused. Sharing a house can be easily implemented by locating, screening, and matching older people looking for houses to share with those who have them. The National Shared Housing Resource Center (NSHRC) (http://www.nationalsharedhousing.org/) has established subgroups to assist individuals interested in home sharing. Those who have done so report feeling safer and less lonely.
Residential Options In Later Life Some older people, by choice or by need, move from one type of residence to another. A number of options exist, especially for those with the financial resources that allow them to have a choice. Residential options range along a continuum from remaining in one’s own home; to senior retirement communities; to shared housing with family members, friends, or others; to residential care communi- ties such as assisted living settings; to nursing facilities for those with the most needs (Figure 3-2). There are many different models of senior housing, and older peo- ple may seek assistance from nurses in choosing what kind of living situation will be best for them. It is impor- tant to be aware of the various options available in your local community as well as the advantages, disadvantages, cost, and services provided in each option. When dis- charging older people from the hospital or long-term care facility, knowledge of where they live or the type of setting to which they are being discharged will assist in providing appropriate resources and teaching so that outcomes can be enhanced for both the individual and his or her family.
Shared Housing
Shared housing among adult children and their older rela- tives has become a choice for many because of cultural preferences or need. The sharing may relieve the economic burdens of maintaining a home after widowhood or retire- ment on a fixed income. Historically, strong cultural influ- ences predict the frequency of multigenerational residences.
Independence Dependence
Home ownership
Single-room occupation (SRO) Condominium ownership Apartment dwelling Shared housing Congregate lifestyles
Retirement communities Public housing complexes Residence with family Foster homes Board and care Residential homes Continuing care retirement communities (CCRCs)
Nursing facilities Skilled nursing facilities Acute care facilities
Inpatient hospice care facilities Partial dependence
to complete dependence Independence to
partial dependence Independence
FIGURE 3-2 Continuumofresidentialoptionsbasedonlevelofassistanceneeded.
Population-Specific Communities
As the number of senior communities expands, older adults will have more options of moving somewhere that they find especially welcoming. These options include communities that emphasize a particular sport, like tennis or golf. Groups of people can also come together to form intentional communities, buying a cluster of home tracts and building in such a way to support their particular lifestyles or needs or personalities. Still others provide unique additional services, such as those in communities that specialize in providing residences for persons with, for example, a mental illness, alcoholism, or developmen- tal disabilities.
Lesbian, gay, bisexual, and transgender (LGBT) seniors face several problems in housing in their older years. They
may have little family support and may face discrimination in housing options. Many LGBT seniors say they do not feel welcome at traditional residential options. Those who want to live together are discouraged from doing so by some organizations. Residential facilities and communities designed specifically for LGBT seniors are increasing in number across the country. Nurses should be aware of this heretofore invisible group of older adults who need access to welcoming resources. Chapter 24 discusses issues spe- cific to LGBT seniors in more depth.
Senior Retirement Communities
Communities designed for elders are proliferating. Numerous combinations of single-family homes, apartments, activities, Questions You Should Ask:
• Whataretheneedsofthenewmemberandofthefamily?
• Wherewillspacebeallottedforthenewmember?
• Howwillthisnewmemberbeincludedinexisting
familypatterns?
• Howwillresponsibilitiesbeshared?
• Whatresourcesinthecommunitywillassistinthe
adjustmentphase?
• Istheenvironmentsafeforthisnewmember?
• Howwillfamilylifechangewiththeaddedmember,and
howdoesthefamilyfeelaboutit?
• Whatarethedifferencesinsocializationandsleeping
patterns?
• Whataretheolderperson’sstrongneedsandexpectations?
• Whataretheolderperson’sskillsandtalents?
Modifications You Have to Make:
• Arrangesemiprivatelivingquartersifpossible.
• Regularlyschedulevisitstootherrelativestogiveeach
familyrespiteandprivacy.
• Arrangeadultdayhealthprogramsandsenioractivities
fortheolderpersontohelpkeepcontactwithmembersof
hisorherowngeneration.Considerhowtheolderperson
willfeelaboutgivingupfamiliarsurroundingsandfriends.
Discuss Potential Areas of Conflict:
• Space:especiallyifsomeonehasgivenuphisorher
spacetotheolderrelative.
• Possessions:olderpeoplemaywanttomove
possessionsintothehouse;othersmaynotfindthem
attractiveormayinsistonreplacingthemwithnew
things.
• Entertaining:timeswhenoldandyoungfeeltheneedor
desiretoexcludetheotherfromsocialevents.
• Responsibilitiesandchores:theolderpersonmayfeel
uselessifheorshedoesnothingandmayfeelinthe
wayifheorshedoessomething;theyoungmayfeel
thattheirpositionisusurpedormaybeangryiftheyare
expectedtowaitontheparent.
• Expenses:increasedcostofhomemaintenance,food,
clothing,andrecreationmaynotbesharedappropriately.
• Vacations:whethertogotogetheroralone;theyoung
mayfeeluneasynottakingtheolderpersonoutand
resentfuliftheymust.
• Childrearing:disagreementoverchild-rearingpolicies.
• Childcare:grandparentalbabysittingmaybewelcomedby
familyandresentedbytheolderperson;orifnotallowed,
theolderpersonmayfeelalackoftrustincapability.
Decrease Areas of Conflict by the Following:
• Respectingprivacy.
• Discussingspaceallocations.
• Discussingtheelderperson’sfurnishingsbeforemove.
• Makingitclearinadvancewhensocialeventsinclude
everyoneorexcludesomeone.
• Clearingdecisionsabouthouseholdtasks—allshould
haveresponsibilitygearedtoability.
• Payingashareofexpensesandmaintainingaseparate
phonereducesstrainandincreasesfeelingsof
independence.
BOX
3-1
Planning to Add an Older Person to the Householdoptional services, meals in the home, cafeterias, restaurants, housekeeping, and security are available. In some cases, emer- gency services and health clinics are adjacent. These are all designed to make independent living feasible with the least effort on the part of the elder. Some senior communities are luxurious and have a wide range of physical and cultural ame- nities; others are simpler, providing only the basic necessities.
Prices are consistent with the level of luxury provided and the range of services available.
Although the costs of the majority of senior communi- ties are borne by the consumers, for elders with limited incomes, federally subsidized rental options are available in some areas of the country. Older adults benefiting from this option are assisted through rental housing subsidized by the U.S. Department of Housing and Urban Develop- ment (HUD). Although not all HUD housing is desig- nated for senior living, Section 202 of the Housing Act, U.S. Department of Housing and Urban Development, approved the construction of low-rent units especially for older people. These units may also have provisions for health care, recreation, and transportation.
Community and Home Care
Nurses will care for older adults in hospitals and long- term care, but the majority of older adults live in the com- munity. Community-based care settings include home care services, independent senior housing, retirement communities, residential care facilities, adult day health programs, primary care clinics, and public health depart- ments. The growth in home and community health care is expected to continue because older people prefer to age in place. Other factors influencing the growth of home- based care include rapidly escalating health care costs.
Chapter 2 discusses roles for nurses in home and com- munity care.
An innovative long standing community-based pro- gram is Program for All-Inclusive Care for the Elderly (PACE). PACE is an alternative to nursing home care for frail older people who want to live independently in the community with a high quality of life. It provides a com- prehensive continuum of primary care, acute care, home care, nursing home care, and specialty care by an interdis- ciplinary team. PACE is a capitated system in which the team is provided with a monthly sum to provide all care to the enrollees, including medications, eyeglasses, and trans- portation to care as well as urgent and preventive care.
Participants must meet the criteria for nursing home ad- mission, prefer to remain in the community, and be eligible for Medicare and Medicaid. Adult day services are also provided.
PACE is now recognized as a permanent provider un- der Medicare and a state option under Medicaid. PACE has been approved by the U.S. Department of Health and Human Services (USDHHS) as an evidence-based model of care. Models such as PACE are innovative care delivery models, and continued development of such models are important as the population ages. More information about PACE models and outcomes of care can be found at http://www.npaonline.org/website/article.asp?id512.
Adult Day Services
Adult day services (ADS) are community-based group programs designed to provide social and some health ser- vices to adults who need supervised care in a safe setting during the day. They also offer caregivers respite from the responsibilities of caregiving, and most provide educa- tional programs for caregivers and support groups. The most recent nationwide survey of adult day centers con- firmed that there are over 4600 adult day services centers in the United States providing care for 150,000 care re- cipients each day—a 35% increase since 2002. Adult day centers are serving populations with higher levels of physical disability and chronic disease, and the number of older people receiving adult day services has increased 63% over the last 8 years (National Adult Day Services Association, Ohio State University College of Social Work, MetLife Mature Market Institute, 2010).
Adult day services are an important part of the long- term care continuum and a cost-effective alternative or supplement to home care or institutional care. ADS are increasingly being utilized to provide community-based care for conditions like Alzheimer’s disease and for transitional care and short-term rehabilitation following hospitalization.
Local Area Agencies on Aging are good sources of informa- tion about adult day services and other community-based options.
Residential Care Facilities
Residential care facility (RCF) is the broad term for a range of nonmedical, community-based residential settings that house two or more unrelated adults and provide services such as meals, medication supervision or reminders, activi- ties, transportation, or assistance with activities of daily living (ADLs). RCFs are known by more than 30 different names across the country, including adult congregate facilities, foster care homes, personal care homes, homes for the elderly, domiciliary care homes, board and care homes, rest homes, family care homes, retirement homes, and assisted living facilities.
RCFs are the fastest growing housing option available for older adults in the United States. This kind of facility is viewed as more cost effective than nursing homes while providing more privacy and a homelike environment.
Medicare does not cover the cost of care in these types of facilities. In some states, costs may be covered by private and long-term care insurance and some other types of as- sistance programs. Residential care payment is primarily private pay, although 41 states currently have a Medicaid Waiver/Medicaid State Plan for a limited amount of eligible individuals. The use of Medicaid financing for services in RCFs has gradually increased in recent years.
The rates charged and what services those rates include vary considerably, as do regulations and licensing.
Assisted Living
A popular type of residential care can be found in assisted living facilities (ALFs), also called board and care homes or adult congregate living facilities (ACLFs). Assisted living is a residential long-term care choice for older adults who need more than an independent living environment but do not need the 24 hours/day skilled nursing care and the constant monitoring of a skilled nursing facility. The typi- cal ALF resident is an 86-year-old woman who is mobile but needs assistance with two ADLs (Box 3-2). Assisted living settings may be a shared room or a single-occupancy unit with a private bath, kitchenette, and communal meals.
They all provide some support services.
Assisted living is more expensive than independent living and less costly than skilled nursing home care, but it is not inexpensive. There are 31,110 ALFs in the United States and most are private, for-profit facilities.
Costs vary by geographical region, size of the unit, and relative luxury. The national average base rate for an
ALF (single room and board and limited other services) is $3300 monthly (AssistedLivingFacilities.org, 2012).
Most ALFs offer two or three meals per day, light weekly housekeeping, and laundry services, as well as optional social activities. Each added service increases the cost of the setting but allows for individuals with resources to remain in the setting longer, as functional abilities decline.
Many seniors and their families prefer ALFs to nurs- ing homes because they cost less, are more homelike, and offer more opportunities for control, independence, and privacy. However, many residents of ALFs have chronic care needs and over time may require more care than the facility is able to provide. Services (e.g., home health, hospice, homemakers) can be brought into the facility, but some question whether this adequately substitutes for 24-hour supervision by registered nurses (RNs). Not every ALF has an RN or licensed practical–vocational nurse (LPN/LVN), and, in most states, any skilled nursing pro- vided by the staff other than nurse-delegated assistance with self-administered medication is prohibited. In the ALF, there is no organized team of providers such as that found in nursing homes (i.e., nurses, social workers, reha- bilitation therapists, pharmacists).
With the growing number of older adults with demen- tia residing in ALFs, many are establishing dementia- specific units. It is important to investigate services avail- able as well as staff training when making decisions as to the most appropriate placement for older adults with dementia. Continued research is needed on best care practices as well as outcomes of care for people with de- mentia in both ALFs and nursing homes. The Alzheimer’s Association has issued a set of dementia care practices for ALFs and nursing homes (Alzheimer’s Association, 2009)
• 86.9yearsold
• Female(74%)
• 70%movedtotheALFfromaprivatehomeorapartment
• Needshelpwithatleasttwoactivitiesofdailyliving
(ADLs)
• Bathing:64%
• Dressing:39%
• Toileting:26%
• Transferring:19%
• Eating:12%
• Needshelpwithinstrumentalactivitiesofdailyliving
(IADLs)
• Mealpreparation:87%
• Medications:81%
• 42%haveAlzheimer’sdiseaseorotherdementiatypes
ofdiagnosis
• Lengthofstay:28.3months
• 59%movetoanursingfacility
• 33%diewhilearesident BOX
3-2
Profile of a Resident in an Assisted Living FacilityDatafromNationalCenterforAssistedLiving:Resident profile(2010).Availableathttp://www.ahcancal.org/ncal/resources/Pages/ResidentProfile.aspx.