Promoting The Health Of Elderly And Disabled

AMY BRAUER, LCSWVISITING PHYSICIANS ASSOCIATION

Promoting the Health of Your Elderly Clients and Those with a Chronic

Disabling Condition: A Home-Based Medical Approach

Outline

Understanding the Homebound PatientRisks Unique to the Elderly and Disabled Health Promotion versus Health PreventionStrategies to Promote Health and Prevent

Health Risks in Homebound PatientsInterventions that Promote Health in the

elderly and disabledSummary

Understanding the Homebound Patient

Definition of “homebound”To be considered homebound, the patient does not have to be bedridden, but must have an illness or injury that makes is difficult to leave home without supportive devices or another person’s help.

This means, but is not limited to, the patient’s inability to effectively access appropriate medical care due to a “taxing effort”.


Undiagnosed Diseases and Silent PathologyFrail patients have multiple diseases and functional impairments, many of which may be undiagnosed.For example, atherosclerotic or cardiac conduction disease may not be apparent in a patient who rarely gets out of bed.


“Old Age” ComplaintsNew complaints should never be ignored or attributed to “old age”. Elderly patients respond to medical problems by reducing their functional status. Health care providers should have a high index of suspicion when a patient reports that he or she is eating less, in bed more, walking less, more forgetful, etc.


Polypharmacy Effects Polypharmacy can have highly unusual effects in the elderly such as

delirium or incontinence. Compliance with a drug regimen can be compromised due to

environmental factors and can lead to overdosing or under dosing. Over-the-counter medications can induce major problems which may

lead to the prescription of other medications.

Risks Unique to the Elderly and Disabled

Frequency of acute decompensation

Patients with multiple chronic illnesses are likely to exhibit an increased frequency of acute illnesses as their condition progresses, often resulting in increased hospitalizations and visits to the Emergency Department.

Hospitalization places seniors at risk for outcomes such as delirium, functional decline, pressure sores, and other adverse effects


Frequency of acute decompensationLoss of quality of life due to illness

More than 1.7 million Americans die of a chronic disease each year, accounting for 70% of all deaths in the United States. Americans lose an average of 15 years of life from chronic diseases—valuable time with family or friends gone forever (1).


Frequency of acute decompensationLoss of quality of life due to illnessIncreased healthcare costs

The National Medical Expenditure Survey data shows that older people with severe disabilities spend, on average, a greater percentage of family income on health care than do people without disabilities--12% versus 3%. Not only do they have high expenditures, but they have average lower family incomes (2).


Frequency of acute decompensationLoss of quality of life due to illnessIncreased healthcare costsLearned helplessness

Learned helplessness is the perceived lack of control over the events in one's life, which may result from prior exposure to (actually or apparently) uncontrollable negative events, such as illness. Learned helplessness effects self-efficacy and self-confidence.

Health Prevention vs. Health Promotion

Health Prevention is participation in specific activities that prevent illness or disease from occurring

Health Promotion is an approach geared toward improving well-being and optimization of health potential

Strategies to Promote Health and Prevent Health Risks

Evaluation and Screening Biopsychosocial Model Patient-Centered Model

The assessment approach in home-based medicine is based on the culmination of a biopsychosocial model and a patient-centered model of care.


Evaluation and Screening Biopsychosocial Model: biological, psychological,

social Patient-Centered Model: focus on the patient in their

network

Focus on Function: a patient’s ability to function within his/her home setting has a profound impact on his/her overall health status because of its effect on ADLs, nutrition, quality of life and ability to access community medical and social support services.


Ongoing Management Medical- regular and consistent visits by a

clinician to monitor illness and changes in condition Trends which represent decline can be identified and

treated as soon as possible in the interest of avoiding dramatic acute decompensations

Frail seniors living at home are at risk of nursing home placement when they lose self-care abilities

Patients with 4 or more chronic conditions are 99 times more likely to be hospitalized for a condition that could have been prevented with appropriate ambulatory care or home-based health services (3).


Ongoing Management Medical Pharmaceutical- ensuring patient knowledge of

appropriate medication use and dosing, set up and ability to swallow the pills Patients with multiple chronic conditions are typically

taking multiple medications simultaneously, placing them at a higher risk of adverse drug interactions

Regular monitoring of pharmaceutical issues assists in medication adherence


Ongoing Management Medical Pharmaceutical Psychological- frequent visits to the patient’s

home allows the clinician to follow a patient-centered approach, and monitor well-being and mental health A Patient’s overall mental health effects health outcomes

due to depression, sleep patterns, nutrition and level of self-care.


Ensure Proper Resource and Referral Home Health Services Personal Attendant Services Specialist Services Meals on Wheels Durable Medical Equipment Mental Health Ancillary Aging Resources: Case Management,

Social Activity and Networking, Mail order pharmacy, etc.


Reduce Non-Adherence/Non-Compliance Regular community physician visits may be difficult

to achieve by patients who have limited access due to transportation issues, health or self-efficacy

Often patients do not choose to be maliciously non-compliant with a medical regime; they have most likely faced barriers that have placed their health in low prioritization.

It is important to implement strategies and interventions which limit or eliminate barriers to accessing healthcare, such as home-based health services.

Interventions to Promote Health and Prevent Health Risks

Home-based Medicine allows homecare professionals to better understand the obstacles that the elderly and disabled face daily

Housing and Handicap Accessibility: Although handicap accessibility is available in most affordable housing, many still face challenges to daily operations such as bathing and cooking within their own apartments or homes.

Handicap Accessibility may only mean entrance accessibility such as ramps or elevators, but may not mean that the patient has wide doors, lowered countertops or a walk-in shower.


Home-based Medicine allows homecare professionals better understand the obstacles that the elderly and disabled face daily

Economic and Financial Resources: The average family expenditures are greater when the patient has a deficit or 2 or more activities of daily living (2). Copays, medications and deductibles are direct costs and transportation and/or specialized living may be indirect costs faced on a fixed income.



Social Network: It is helpful to know whether a patient has friends or family nearby who may be helpful resources for a variety of needs. Gaining insight into the quality of the relationships between the patient and caregivers or family can be invaluable.



Patient Beliefs and Treatment Goals: Patients and their families may have very strong opinions as to their own expected diagnostic and treatment options. These may be influenced by a variety of sources such as belief systems, financial resources, social support, caregiver strain, transportation availability and end-of-life trajectories.


Education The British Medical Journal published an article in 1999

on improving the health behaviors of elderly people. A general practice educational program was studied using

a group of general practitioners and their patients. Intervention variable was the effect of educational

practices by physicians on health promotion for the elderly. The study showed that the intervention group had

increased preventative behaviors, greater frequency of social activity and an increase in the patient’s perception of overall health.

Although no significant change was seen in functional status or psychological well-being, the educational facet of health care had a positive effect on health outcomes (4).


Education Frequency

Studies on compliance in elderly women illustrate that about 25% of information is remembered during a one-time educational session (5).

Increased frequency and ongoing health education is crucial in promotion of health in the elderly. Additionally, it is important to involve caregivers in the education process in order to build confidence of care within the family system.

Home-based medicine allows the educational process to be tailored to the patient and his/her family in order to help diminish additional barriers and obstacles to health.


Education Frequency Self-Efficacy

Self-Efficacy is the perception or belief that you are able to accomplish or achieve a specific behavior

For patients and their families, education enhances their own self-efficacy. When a patient believes that they are able to achieve better health this empowers them and promotes healthier behaviors.

Summary

In a study done at the University of Nottingham (2001), mortality, hospitalizations, LTC placement, functional status and health status were measured to evaluate the effectiveness of home visiting programs that offer health promotion and preventative care to older people

(6).Results of this study demonstrated a significant

reduction in mortality and LTC placement. The results stated that hospitalizations may not have

been significant due to the clinicians finding a need for hospital care that might otherwise have been neglected.

Summary

Overall, studies have shown that home-based health services including physicians, nursing, personal attendants and case management have a positive effect on health-promotive behaviors.

For these services to be effective; however, it is important to understand the unique risks to the homebound elderly and disabled patient and implement strategies and interventions that promote health and prevent these risks.

References

1. Center for Disease Control. (retrieved online: March 6, 2008) http://www.cdc.gov/nccdphp/publications/brochure/brochure.htm

2. ASPE Research Notes. (retrieved online: March 6, 2008) http://aspe.hhs.gov/daltcp/reports/rn08.htm

3. Wolf, Starfield and Anderson. (2002). “Prevalence, Expenditures and Complications of Multiple Chronic Conditions in the Elderly”. Archives of Internal Medicine (162, November 11).

4. Kerse, N., Flicker, L., Jolley, D., Arroll, B. and Young, D. (1999). “Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme.” BMJ(319, September 11): 683-687.

5. Hannan, M., Cheng, D., Green, E., Swift, C., Rubin, C. and Kiel, D. (2004). “Establishing the compliance in elderly women for use of a low level mechanical stress device in a clinical study.” Osteoporosis International(15): 918-926.

6. Elkan, R., Kendrick, D., Dewey, M., Hewitt, M., Robinson, J., Blair, M., Williams, D. and Brummell, K. (2001). “Effectiveness of home based support for older people: systematic review and meta-analysis.” BMJ(323, September 29): 1-7.

Health & Medicine

Promoting The Health Of Elderly And Disabled