By Amy R. Blosch, Senior Care Consultant and Case Manager for Companion Care of Albuquerque, NM.
90% of re-hospitalizations within 30 days are a result of clinical deterioration. Clients released to their homes often experience a lack of support, supervision, care and maintenance. The estimated cost of re-admissions reaches 12 billion dollars annually. MedPAC states that 74% of these re-admissions are preventable. 19% of Medicare discharges are followed by an adverse event of which, 2/3 are drug events which are judged preventable. (CareMinders Home Care)
According to a study conducted by United States Department of Health and Human Services (Kusserow, 1990) it was determined that the number one contributing factor in senior citizen re-admissions is noncompliance with medication schedules. Adults aged 65 and older comprise approximately 13% of the US population and consume over 30% of all prescription medication dispensed. By 2030 this population will reach over 23%. Over 60% of the elderly have at least one chronic disease that requires regular medication and maintenance. 95% of the elderly live outside institutions that are responsible for dispensing medications. Research indicates that 55% of the elderly fail to comply in some way with their medications.
Non-compliance can be (but is not limited to):
- Over dosing;
- Prematurely discontinuing medications;
- Taking a dose at the wrong time;
- Taking outdated medications (self diagnosing with leftover medications);
- Storing medications improperly;
- Taking a medication prescribed for someone else, usually a spouse;
- Taking a dose of medication with prohibited foods or liquid;
- Taking a dose medication without proper food and/or liquid.
The consequences of noncompliance are serious and costly.
Noncompliance with medications can result in the increased use of hospitals, physician visits, unnecessary treatment, misdiagnosis and placement in a nursing home earlier than “needed” due to complications from untreated or reoccurring illness.
There are many inter-related reasons for noncompliance.
Physiological Factors: Loss of vision or hearing can impede an elderly person’s ability to read important information about his prescriptions or to hear instructions about his regimen. Mobility limits, the presence of symptoms, memory loss, depression and cognitive decline or impairment can negatively affect compliance.
Behavioral Factors: This includes social isolation, social and health beliefs, and economic condition. Many elderly people live alone. Studies have shown that people who live alone or have little interaction with friends or family more often fail to comply with medication regimens.
Health Care Provider/Patient Interaction Factors: These include how well the physician, the pharmacist, and the patient communicate with each other. The quality and content of a physician’s instructions, the content of the pharmacist’s label, and the ability of a patient to ask questions can all affect compliance.
Education is the key to improving compliance.
Attempts to improve compliance through educational and other behavioral strategies do work, as long as they are matched to the individual patients needs. Evidence suggests that with proper home support the elderly can overcome compliance difficulties and thus, reduce re-admissions. Non-medical caregivers provide supervision and maintenance to prevent re-admissions.
Case Management and Consulting Services with Non-Medical Home Care
Case managers provide a comprehensive and holistic approach to caring for the elderly, thus increasing overall health and decreasing re-admissions.
Case management is a comprehensive approach which looks at the many facets of seniors’ needs and problems, then works with the clients and their family to set up a care plan to address the issues. After a hospital discharge, case managers work with the discharge nurse to ascertain recovery health goals, meet with the clients in the home to discuss their needs, desires and identify obstacles to maintaining health and recovery. Case managers then set up a plan of action. The case manager is able to assess the clients housing, in-home resources, support system and overall environment. The case manager works closely with the caregiver and family to monitor the progress of the client and reevaluates care needs as they present.
Many basic self care tasks such as shopping, meal preparation, laundry, housekeeping and bathing and grooming can become difficult to accomplish and become secondary or are completely abandoned. As they age, seniors may face challenges regarding proper nutrition. Medications they take may cause appetites to diminish or foods to taste differently. Some may lose interest in eating nutritious meals because they find it hard to cook for one and feel lonely when dining alone.In 1997, there were over 4.5 million (14.2%) elders who reported having difficulty carrying out activities of daily living (ADL’s) and 6.9 million (21.6%) who indicated difficulties with instrumental activities of daily living (IADLs). ADLs include bathing, dressing, toileting, transferring, continence, and feeding. IADLs include ability to use the telephone, shopping, food preparation, housekeeping, laundry, using transportation, responsibility for medications, using the telephone, doing housework, and responsibility for taking medications (Iowa, n.d.).
Case Managers supervise non-medical caregivers in assisting with many of these daily activities. Malnutrition among the elderly can be difficult to determine due to a large percentage of seniors living alone. After a medical discharge, clients are in a weakened state and require close monitoring. Non-medical caregivers are able to plan appropriate meals to ensure proper nutrition and then prepare meals for the client. The caregiver is also present to monitor food intake and assess subtle changes in the client’s appetite and ability to consume the amount of food necessary to attain or maintain optimum health. Caregivers also use this opportunity to supervise the client taking daily medications.
Home and Self Care Management Elevates Health and Living Conditions
Laundry and housekeeping is also an important daily task that often becomes secondary as senior citizens age. Washing and changing bed sheets is a regular task, especially if the client is incontinent. Stripping the bed and re-making the bed can be exhausting for the elderly. Without the help of a caregiver the client may choose to forgo changing the sheets regularly which can lead to unsanitary sleeping conditions which will increase the likelihood of bedsores & skin infections which may result in seeking treatment from doctors or urgent care medical facilities. The same is true for general cleaning of undergarments, clothes and towels. Clutter and general disarray creates areas in the home that present hazards for injury or re-injury. Non-medical caregivers provide a cleaner living environment for the client. This promotes safety, comfort and security and decreases re-admissions.
The elderly also struggle with general self care maintenance such as bathing or showering. Balance and gait disorders affect 10-15% of elderly patients who thus suffer an increased risk of falling. Costs related to the care of fall-related fractures cost nearly $10 billion each year. Older patients commonly show changes in their gait that result in imbalance, muscular weakness, and falls (Iowa, n.d.). Self care maintenance creates many opportunities for slip and fall accidents. Seniors, aware of their limitations and frailty will often omit bathing or showing to lower their risk of injury however the lack of self care contributes to an overall diminished state of health and wellbeing. Non-medical caregivers in the home are able to monitor, supervise and participate in proper self care which again, promotes safety, comfort and security as well as increases the overall health of the client and decreases re-admissions.
Non Medical Caregivers help to Alleviate Family Caregiving Stress and Burnout
95% percent of people over age 65 live at home, and many are cared for, to some extent, by a relative. Caregiver stress is a common problem among families and/or spouses of the elderly. The tension and stress of caring for an ill older adult can also negatively affect the quality of care provided and can increase the risk of physical and psychological abuse (Iowa, n.d.). Non medical caregivers become a functional part of the family support system and help to shoulder many of the care and household responsibilities that help to keep the family unit mentally and physically healthier. Many caregivers bring with them a vast knowledge of senior care and are able to approach care obstacles with a perspective that is not emotionally charged. Families can depend on a caregiver to follow up with day to day care summaries which include daily activities, care tasks such as medications taken, meals prepared and eaten, household duties accomplished, personal care incidents requiring special attention as well as being in the home to monitor and supervise the client in their general daily activities. Caregivers, along with the case manager, refer often to the goals of the hospital discharge plan and work to meet health goals which decrease re-admissions.
A Clinical Perspective
A consultation with the Director of Nursing for Sage Memorial Hospital in Ganado, Arizona (El Meligi, 2013) indicated that they are currently reformatting their community health programs to a more expansive role for their Community Health Representatives (CHR) which operates much like a case manager or case consultant for non medical home care service providers. CHR’s will be notified of a senior citizen hospital discharge , the referrals they were given and will make a home visit to determine the needs of the client and if the services referrals will be adequate to meet their needs. Further referrals will be comprised of medical and non medical care providers. The CHR will meet with the client monthly to follow up and evaluate the progress and continuing needs of the client. The Director of Nursing stated that the obstacles to reducing hospital re-admissions for the elderly are that their clients are noncompliant with their medications; suffer from poor nutrition and mobility. CHR’s will offer non medical care services to aid and assist senior citizens in their recovery, thus reducing re-admissions.
CareMinders Home Care, I. (n.d.). The Perfect Storm in Healthcare Reform.
El Meligi, C. (2013, May 26). Director of Nursing. (A. R. Blosch, Interviewer)
Iowa, U. o. (n.d.). Functional Assessment of the Elderly. Retrieved from Geriatric Medicine: http://casemed.case.edu/curricularaffairs/Y3BasicCoreNov07_Mar08/Y3Core2/readings/Functional%20Assessment%20of%20the%20Elderly.pdf
Kusserow, R. P. (1990, June). Department of Health and Human Services-Office of Inspector General. Retrieved from Medication Regimens: Causes of Noncompliance: http://oig.hhs.gov/oei/reports/oei-04-89-89121.pdf