Community of Caring Pulling neighborhood services together opened the door to health care for elders.

GALE ROBINSON SMITH

G ood health care doesn't have to mean going to a clinic or physician's office. Home or

neighborhood care can give elders a networkl of family, friends, and health providers to improve general well-being, avoid the isolation and loneliness often felt by elders, and, in some cases, reduce costs and the need for nursing home placement.

Neighborhood Care

The Bronx branch ofthe YMCA of Greater New York was already something of a gathering place for elders. It housed a Senior Nutrition program that served 1500 senior citi- zens two meals a day, and also of- fered recreation and exercise. Then in 1984, Community Action United in Service to the Elderly--CAUSE for shtwt--a joint program of the YMCA, Our Lady of Mercy Medical Center, and the College of Mount Saint Vincent Nursing Program, be- gan to provide primary care services to elders who would not otherwise have access to nonemergency care.

A nurse, physician, and nutrition- ist comprise the health care team at the center. Seniors are examined thoroughly every three or four months on a regular basis. If needed, more frequent monitoring is avail- able.

Gale Robinson Smith, RN, PhD, is an assistant professor at Rutgers-The State University of New Jersey, College of Nursing, Newark, NJ. The author was a teacher at the College of Mount Saint Vincent when this article was written. She thanks Dorothy Chafkin.

The nurse and physician also ex- tend care to the homebound who live in the apartment house in which the center is located. A podiatrist visits the center once a month. A dental clinic is available at the medical cen- ter. Mental health services are pro- vided through the outpatient depart- ment of Our Lady of Mercy Medical Center.

Physical fitness is a vital part of the CAUSE health program. At each vis- it the nurse or physician assess mus- cle tone and strength and ask the eld- er about daily exercise.

Some clients use exercise bicycles at home, while others walk about a

mile a day or take advantage of phys- ical-activity classes at the center. One of the most popular is the Friday- morning dance class. An 86-year-old woman takes two buses and walks to the center so she can join in.

Using drugs and alcohol to ease the stresses of age can lead to abuse, so alternative coping skills are taught by the nurse. A weekly T'ai Chi class has proved to be a popular way of dealing with stress.

I fa senior needs special tests or an exam by a specialist, the center pro- vides transportation. But seniors are encouraged to develop their own out- side resources.

Seniors are thoroughly examined every three to four months.

248 Geriatric Nursing September/October 1989

For example, a woman who was treated for a nonmalignant bowel mass was visited at home by a stu- dent. Her closest relative was a cous- in 90 miles away. But in her apart- ment house were several active, re- tired former co-workers who checked up on each other regularly. They ad- ded the lady to their support group and performed vital services for her while she was hospitalized and after discharge.

Student Visits

The College of Mount Saint Vin- cent nursing students at the center are juniors enrolled in their first clin- ical nursing course, which empha- sizes assessment, including the nor- mal aging process. Initially, students observe the physician, who checks clients on a ~veekly, appointment ba- sis, and the nurse, who teaches clients about diet and medications. When a client gives permission, the student does the physical assessment, shar- ing it with the nurse and physician.

Family strengths and coping mechanisms are also assessed. An elderly mother may want a good rela- tionship with her son, yet she criti- cizes his wife frequently. Coaching by the student in this case involves helping the client keep in contact with her son while avoiding overcrit- icism of her daughter-in-law.

One woman, over 80 years old, in- spired staffby making frequent visits to her middle-aged, retarded son who lived in upstate New York. The son, in turn, visited his mother for brief periods, and he would participate in routine activities at the center. The center acknowledged this mother's strength in maintaining contact with her son and helped her cope with his visits.

As part of the total assessment, stu- dents also make home visits. These visits let the students check cleanli- ness, safety, and other physical con- ditions. Home visits also allow the personal relationship between the student and senior to deepen.

One student made several visits to an elderly man who lived alone. The man was isolated, with few friends and only one niece, who lived in New Jersey. To encourage him to meet new people, the student set up a con-

tract with him to come to the center once a week for two hours. When he came to the center, the student spent extra time with him to positively reinforce his socialization with oth- ers.

In the community assessment, the students gather information about how the elder shops and where other health care agencies, such as hospi- tals and nursing homes, are located.

The student-elder relationship benefits both groups. The seniors get to talk to young people who'll listen to their problems and try to find solu- tions for them, and the students meet lively older people who may contrast with a past image of helpless old

The higher number of diagnosed problems among elders in the program reflected

better monitoring, not poorer health,

clients. Seeing firsthand how well older people function on their own will help students to encourage inde- pendence in the elderly hospital pa- tients they will meet later in their nursing Careers.

CAUSE Works

To determine whether the pro- gram was worthwhile, an evaluation was completed of 55 seniors who ac- tively use CAUSE, and 48 seniors from another center with similar ser- vices except for CAUSE (1). A struc- tured questionnaire was used, with questions taken from the National Health Interview Survey (2).

Using national demographics, we predicted that equal occurrences of hypertension, diabetes, heart dis- ease, bronchitis, and arthritis would be found in both groups. However, the control group reported fewer in- stances of these conditions.

But they weren't necessarily healthier. In fact, many in the control group probably had one or more of these conditions but they were not aware of it. They were not under

treatment because they hadn't had a physical exam as the CAUSE group had.

The elders were asked about the ef- fects of smoking, stress, family his- tory, diabetes, obesity, caffeine, and diet on hypertension. The CAUSE group knew more about hyperten- sion than the control group and showed more awareness than the na- tional level; they also smoked less and drank less alcohol than the con- trol group.

Those in CAUSE made more fre- quent contacts with physicians and the health team: 94 percent of the CAUSE members ages 65 to 74 and 96 percent ages 75 years and older had been seen for health care in the last year. In comparison, 77 percent of the control group ages 65 to 74 years and 80 percent of those 75 years or older reported physician contact in the last year. Ninety-two percent of the study group reported having had a physical exam within the last year, in contrast to 66 percent of the control group.

The routine health care received by the CAUSE group allowed greater opportunity for disease to be .de- tected and created a more health- conscious population. Community screening studies have shown a high prevalence of undetected diseases in adults not subject to regular health care (3). The CAUSE program health education classes do seem to have had a major impact on the health awareness of the elders. In addition, the combination of screening and education caused changes in lifestyle that improved the general health and quality of life of elders who might not otherwise have received adequate health care.

References 1. Department of Community and Preventive Medi-

cine, New York Medical College. Evaluation of the CAUSE Program at Our Lady of Mercy Medical Center. To be published.

2. U.S. National Center for Health Statistics. ltealth Promotion Data for the 1990 objectives: Estimates from the National ltealth Interview Survey of Health Promotion and Disease Prevention: United States, 1985, ed. by O. T. Thornberry and others. Hyattsville, MD, U.S. Department of Health and Human Services, 1986. (NCHS advance data No. 136) (DHHS Publ. No. (PHS) 86-1250.

3. Rubenstein, L. Z., and others. Comprehensive health screening of well elderly adults: an analysis of a community program. J.GerontoL 41:342-352, May 1986.

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