Facilitating Self Care Practices in the Elderly

Barbara J Horn

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317739609
• Edition: 1
• Topic: Ciencias sociales
• Subtopic: Gerontología

This up-to-date book is a synthesis of current knowledge from published sources and expert consultants relating to three commonly occurring problems in home health care practice--self-administration of medications, family caregiving issues, and teaching the elderly. For each problem addressed, assessment guides and interventions are outlined, making this book an invaluable resource for professionals, researchers, and agencies concerned with providing top-quality care for the elderly. Home health care agencies can use the guide for orientation of new staff and inservice education for current staff. Home health care staff can use many of the assessment guides and resource lists in their work with clients. Facilitating Self Care Practices in the Elderly can also serve as a basis for standard development. Researchers interested in these clinical problems will find that the literature review and synthesis will facilitate the development of the theoretical underpinning for their research. Educators will find the book helpful in courses and as a basis for curriculum development.

Chapter I

Introduction

Barbara J. Horn, RN, PhD

Pricipal Author

Formal home health care services have been provided for clients and families since the late 19th century in this country. Although elderly persons have been a major group to receive such services, it was not until 1966 that government policy focused on facilitating home care of elderly persons. In 1966, home health care agencies became eligible for Medicare funds. In 1981, the Home Care Waiver allowed Medicare reimbursement for home health care which did not exceed the cost of institutional care.

During the period from 1966 to 1981, Medicare costs for health care of elderly persons more than doubled. In an attempt to control costs, prospective payment systems were instituted for institutional care. Hospitals and medical centers were strongly encouraged to limit the length of hospitalizations according to DRG classifications. As a result of the cost containment policies, elders have been leaving hospitals in an earlier stage of recuperation and have an increased need for formal home care. In addition, the care needs have become more complex; the use of sophisticated high tech equipment such as intravenous systems has become much more common and has contributed to problems of caregivers in the home. Not only do clients and caregivers need to be taught how to provide care in the home, but the interventions and equipment used in the hospital setting usually require modification for use in the home by the elderly.

The work presented in this book is a portion of the material developed by project staff of the three year, Elderly Homecare Project funded by Fred Meyer Charitable Trust (1986-1989).* Major goals of the project were: (1) to identify the impact of early hospital discharge on the provision of home health care by identifying the types of clinical problems home health care providers encountered in providing services to acutely ill, homebound elders, and (2) to develop approaches for managing critical clinical problems identified by home health care agencies. In this chapter, the project design and the findings will be presented. In the ensuing three chapters () a review of the “state-of-the-art” and assessment guides for three of the most critical clinical problems will be presented.

DESIGN

The project design was to obtain from home care providers the nine most critical clinical problems facing them as they provided care to elders recently discharged from the hospital setting. Following the generation of the nine problems (master problem list), the literature was reviewed and experts were consulted to determine the current knowledge base. Papers (state-of-the-art) were written for the three most critical problems. Care protocols and education materials were to accompany the papers.

Delphi Process

To identify the clinical problems, 178 Medicare certified home health agencies in Alaska, Idaho, Montana, Oregon, and Washington were asked to participate in the project. A modified Delphi process was used to collect the data. The Delphi process is a set of procedures for formulating a group judgment about a particular subject area. Three rounds of questionnaires were used.

Round I

The first questionnaire used open-ended questions. An agency contact person was asked to identify clinical problems (physiological, psychosocial, or technological) that providers of their home care agency were experiencing in relation to early hospital discharge of the elderly client. The problems identified by the agencies were categorized through a process of content analysis. Three revisions of the categories were necessary in order to achieve a category system that could accommodate the data. Two coders then used the category system to classify each problem documented in the responses. Agreement between the two coders was achieved through consensus. One limitation of the data is that clients and care givers were not asked for their perceptions of their needs. The five major categories which evolved from the data were:

1.Technologically sophisticated, complex or time-intensive nursing problem.

2.Problems involving psychosocial and client/family issues.

3.Problems related to client/family teaching.

4.Problems related to the health care delivery system.

5.Problems of miscellaneous nature.

The response rate for round I was 60% (118 out of 178 agencies responded).

Round II

The second round questionnaire was closed-ended. The top ranking 30 clinical problems within the first three categories, namely: (1) technologically sophisticated, complex, time-intensive nursing problems; (2) psychosocial problems; and (3) teaching problems, were submitted to the agencies. Agencies were instructed to indicate if each of the 30 problems listed was a current problem for their agency. If the agency indicated that it was a problem, the agency was instructed to rate (using a five-point rating scale) three dimensions. These dimensions were: (1) complexity of the problem, (2) degree of technology required, and (3) frequency of problem occurrence. The response rate for round II was 84% (99 out of 118 agencies responded).

Round III

The third questionnaire was developed from the responses from round II and contained the 15 highest ranked clinical problems. The 15 problems were selected as follows: the problem had to be mentioned by at least 50% of the agencies responding to Round II. Agencies were again asked to indicate if the problem was currently a problem for their agency and if it was a problem, to rate the problems for the three dimensions—complexity, technology, and frequency. On Round III, the agencies were given information on how their agency and other agencies had rated the problem on the second round. Thus, agencies had information about other agencies’ views in relation to the problem. The response rate for Round III was 89% (88 out of 99 agencies responded).

Nine problems were selected from responses of the agencies to Round III. Criteria used for the selection for these problems were:

1.That the problem was rated at “3” or above on the 5 point rating scale for two of the three dimensions—complexity, technology, and frequency.

2.That the problem ranked among the top ten of the fifteen problems.

Utilizing the modified Delphi process we gained consensus from experts about their perception of the most pressing clinical problems in providing home care to elders.

FINDINGS

Sample Characteristics

The sample characteristics are based on 118 responses of Round I. The response rate was representative of all five states in the region. The sample agencies were providing care to the elderly as evidenced by the data which indicated that 84% of the clients served were 65 years of age or older.

The type of agency in the sample represented was that 60% were community based of which 30% were for profit, and 40% were hospital based of which 88% were not for profit. Forty-nine percent were rural while 51% were urban.

An analysis of the representativeness of the sample in relation to major demographic variables was conducted using cross tabulation and the Chi-Square statistic as well as the Kruskal-Wallis One-Way ANOVA and the Mann-Whitney U Test for group differences. The use of these tests over parametric counterparts was mandated by failure to meet the assumptions of normality and heterogeneous of variances. Major findings were generally consistent across all three rounds.

Statistical testing revealed no significant differences across states in regard to community based, hospital based or for profit or not for profit agencies. There were significant differences in the number of rural versus urban agencies by state, with proportionately more rural agencies than expected by chance in Idaho, Montana, and Oregon and proportionately more urban agencies than expected by chance in Washington. Significant differences were found in the number of for profit/not for profit agencies by community versus hospital based. More for profit agencies were community based while more not-for-profit were hospital based.

Master Problem List

At the completion of the third round of questionnaires the following nine clinical problems emerged as the most critical:

1.Teaching elders and families medication regimens

2.Nursing management of elder coping problems

3.Nursing management of family coping problems

4.Nursing management of intravenous therapies

5.Teaching elder/family management of intravenous therapies

6.Nursing management of symptoms for clients with cancer

7.Nursing management of wounds

8.Teaching elders/family care of wounds

9.Teaching elders/family management of diabetes

DISCUSSION

In the following three chapters, three of the top problems will be discussed.** Medication self-administration will be discussed in Chapter II. Medication regimens constitute a major treatment modality for most patients served by home care agencies. While medication regimens may be beneficial for treating disease processes, the problem for the patient, family, and health providers associated with maintaining an adequate medication program are complex and varied. Two major concerns were expressed by the sample regarding medication regimens. These concerns were: (1) medication noncompliance of the client and/or family members who were not supportive to the client in adhering to the medication regimen, and (2) the health providers— lack of knowledge of intervention strategies and/or lack of education materials for assisting patients and families with medication management. The content includes a synthesis of the literature related to medication-taking behavior of the elders and factors related to medication compliance. An assessment guide is presented followed by suggested intervention strategies and sources for education materials.

Because teaching was a component of three out of the nine major problems listed, the project team decided that a special state-of-the- art paper was needed on teaching the elderly. Therefore, Chapter III was written to assist home care providers in developing better and more effective teaching strategies. The literature was reviewed on special teaching techniques and adaptations for elderly in general and for elders with sensory, mobility or cognitive difficulties. Important guidelines for teaching are summarized. The appendix of Chapter III provides sample teaching plans, examples of how to assess and develop educational materials for reading level and lists teaching resources for clinicians and clients.

Family coping when providing care to older members is the focus of Chapter IV. Management of family coping problems when providing care to elderly members was identified as a major problem for home care staff. Staff identified families as being stressed, fearful, apprehensive, anxious, burned out, fatigued, and feeling overwhelmed. These feelings were attributed to: (1) the families’ lack of understanding or knowledge of needed care and (2) the lack of community or family resources that could help family members cope or have time away from caregiving. Therefore, Chapter IV focuses on the magnitude and significance of family caregiving problems and theoretical frameworks that provide explanations of family coping problems. An assessment guide was developed to assist th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Chapter I Introduction
• Chapter II Medication Regimens and the Home Care Client: A Challenge for Health Care Providers
• Chapter III Tailoring Teaching to the Elderly in Home Care
• Chapter IV Family Coping: Caring for the Elderly in Home Care