Gerontological & Community Based Nursing

1. Gerontological & Community Based Nursing Care across the continuum Professor Adrianne Maltese

2. Housing Options for Older Adults • Elder friendly Communities • Shared Housing (adult & children share) • Cohabitation- Group homes(share home W/older adult/intergenerational) l

3. Benefits- Elder friendly communities • Address Basic needs • Optimize Physical & Mental Well being • Promote Social & Civic Engagement • Maximize independence for frail/disabled

4. New Models of Community Care • PACE (All inclusive care for elders) • Capitated system • Cost - monthly for all inclusive care • Must meet requirements for nursing home admission • Paid for by Medicare/Medical/Medicaid

5. Adult day Care Services • Community based programs • Provides social & health services • Caregiver respite • Dementia care

6. Senior Retirement Communities • Various economic levels /cost to consumer • Need for low-income public housing complex for older adults. Other types: Foster care, Residential Care Facilities Assisted living

7. Other housing choices/costs • Foster care • Residential Care facilities • Assisted living • Continuity car Residence Communities • Population specific Communities • Nursing Homes

8. Coalition of Nursing Home Reform Issues to be dealt with: • Public - negative views • Lack of support & respect • Inadequate caregiver salaries • Poorly staffed ->unrealistic workload • Frail -very sick elders • Creating home environments

9. Principles of Culture Change in Nursing homes • Empower staff • Involve residents in their care/decision making • Provide individualized care • Built relationships • Provide sense of community & belonging • Engage resident in meaningful activities • Create a homelike environment • Respect for all staff and the value of caring

10. Omnibus Reconciliation Act 1987 (OBRA) • OBRA - mandated • MDS -Minimum Data Set • Increased training requirements • Elimination of use of meds/restraints • Bill of Rights for Long Term Care residents

11. Loss & Grief Loss ->grief->process of bereavement “Grief is the individual’s response to a loss and mourning is an active and evolving process that includes those behaviors used to incorporate the loss experience into one’s life after the loss.”

12. Loss, Grief & End of Life Care • Worden’s Model 2003- “grieving process series of evolving tasks” • Acceptance stage -person accepts of reality of loss • Working stage - person works through physical & emotional pain • Adjustment stage - person adjusts to a change in environment • Relocation of loss - person is able to emotionally move on with life

13. Loss , Grief & End of life • Jett’s Loss Response Model - incorporates a systems approach • Loss-> stage of disequilibrium • Search for meaning of loss • Story of loss is told repeatedly (this helps in the grieving process) • Adaptation & accommodation of new roles

14. Types of Grief • Anticipatory grief ->premature detachment = sociological death; premature withdrawal of a person =psychological death • Acute grief - a crisis. - person feels physically sick & is emotionally distressed - preoccupied with the loss->functional disruption - intense for first 3 months • Chronic grief - may temporarily inhibit activities; intermittent pain of grief -exacerbated on anniversary dates. • Pathological chronic grief - c/b excessive & irrational anger, insomnia, major depression

15. Implications for nursing care • Assessment “tell me about recent events in your life” Look for concurrent stressors “what spiritual beliefs do you hold in relation to death?”

16. Implications for nursing care • Goal- to attain healthy adjustment to the loss ; to reestablish equilibrium • Interventions - • Gently establish rapport • Offer reasonable hope /emotional support • Offer support for functional disruption • Provide information about the disease that may help person to process the loss. • Allow/encourage grievers to inform others • Facilitate elder to reorganize their life • Guide & encourage the reframing of memories

17. Conceptual Models -Death & Dying • Living-Dying Interval - (Pattion 1977) -the time between first learning about the impending death “crisis knowledge until the time of the actual “physiological”death.

18. Needs of the Dying & their Families • The “6 C’s Approach to caring for the dying & their families - • Care - best possible care • Control - active participant in own care • Composure -within the realm of one’s culture • Communication- 4 types of communication identified (Closed awareness,suspected awareness,mutual pretense;open awareness • Continuity - establish legacies • Closure - corresponds with reconciliation & transcendence

20. No hospitalization Focus on comfort vs. cure No invasive procedures Hospice org’s. provide medical,nursing,nurse assistants,chaplain, social worker 24 hr support pt & family Bereavement services Palliative VS. Hospice Care(ANA-ELNEC)

21. Nursing Interventions

22. Nursing Interventions • Encourage discussion of “end- of-life “ • Decisions re: type of care • Advance directives • Euthanasia - Active vs. passive.