1. Gerontological & Community Based Nursing Care across the continuum Professor Adrianne Maltese 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  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  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  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  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  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  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 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  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  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.” 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  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  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  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?”  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  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  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. Palliative VS. Hospice Care (ANA-ELNEC)  No hospitalization  Focus on comfort vs. cure  No invasive procedures  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  Hospice org’s. provide medical,nursing,nurse assistants,chaplain, social worker 24 hr support pt & family Bereavement services

21. Nursing Interventions

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