PRIMARY CARE PRACTICE

VIVIAN ROSS BRUCE E. ROBINSON KATHERINE H. ECHEVARRIA

Adult congregate living facilities (ACLFs) and foster home care are Florida's designations for licensed BHC, accommodating nearly 50,000 needy adults. Many deinstitutional- ized frail or indigent occupants are included in this population, of which an estimated 84 percent are elder- ly(1,2). One approach to delivering primary health care to these frail, semi-independent elderly in BHCs is through the geriatric nurse practi- tioner (GNP)/physician (MD) team.

To qualify for BHC placement, clients must remain independent in bathing, dressing, toileting, and feed- ing. However, most residents usually require supervision of medications and assistance with most home man- agement or instrumental activities of daily living, such as shopping, meal preparation, finances, and transpor- tation(3). In most states, Supplemen- tal Security Income with added state supplements provides about $500 per month for residential assistance. In contrast, Florida provides higher rates for nursing homes totaling $2,000 plus per month(4,5).

In 1982 through the combined ef- forts of several local ACLF operators and their ACLF Program Office agency administrators, a GNP/MD program was developed for four local boarding homes in the Tampa area whose clients receive public aid. The gerontological concepts of LTC and congregate housing provided the conceptual framework and guide-

Vivian Ross, RN, (2, FAD, is professor and chairperson of the Gerontological Nursing Master's Program, Bruce E. Robinson, MD, is assistant professor and director of the Geriat- ric Division, and Katherine H. Echevarria, RN, C, MS, is clinical instructor in gerontolog- ical nursing at the University of South Florida College of Nursing, Tampa, FL.

lines for the program. To meet resi- dents' needs in continued treatment of health care problems and promo- tion of well-being, mutual goal set- ting between the practice team, resi- dents, and operators became the pre- ferred clinical approach(6,7).

Subsequent meetings facilitated the development and actual imple- mentation of on-site continuing health care in regularly scheduled mobile nurse-operated clinics. Fol- lowing requests for on-site primary care, a study was conducted to inves- tigate the ability of the GNP/MD team to meet the primary care needs of 49 residents in 4 local homes.

Vulnerability-Self-Sufficiency Index

Cannot walk up and down stairs without help

Needsa walker, 4-pronged cane, or wheelchair sometimes

Cannot identify the current year Needs help preparing meals Needs help with garbage Not healthy enough to do ordinary

housework Needs help dressing" Needs help with medications Needs help bathing" Needs help with chairs* Has bladder accidents Goes out only one day per week or

less Health frequently prevents activity Source:. Adapted from MorrLs(16). • Residents were completely independent in these areas.

Prior to the initiation of this pro- gram, many obstacles existed in pro- viding adequate primary care to BHC residents in their community health care systems. The principal barrier was communication prob- lems between health care providers and BHC operators and residents. This barrier was created by residents' educational gaps (most had sixth- grade educations or less), years of so- cial isolation, and emotional illness in state hospitals, and providers" lack

of appropriate information and fail- ure to counteract these deterrents to plans for residents' compliance and follow-up.

Other barriers included lack of ad- vocacy of residents' preferences and rights by health care staff, critical fail- ure to engage boarding home opera- tors in plans of care, need for multi- disciplinary health care providers to assure holistic psychosocial/physio- logical well-being, and inadequate public-funded transportation(8).

H e a l t h Characteris t ics

The 49 elderly and middle-aged residents have a variety of diagnosed medical and psychiatric problems that have evolved over their life- times. They also have chronic mouth and foot problems due to years of poor hygiene and neglect.

Most have been discharged from state mental hospitals with chronic emotional problems that necessitate long-term stabilizing psychotropic drug treatment and counseling. Seri- ous social deficits following years of institutionalization also compound their health problems.

The team rated the residents' sev- erity of physical and mental health impairment by using summary rat- ing scales from the Functional As- sessment Inventory (1, excellent; 6, total impairment)(9). The resultant data demonstrate a low level (mean score, 3.3) of physical health impair- ment but a higher level (mean score, 4.7) of mental health impairment, for which more intensive service and medication needs are apparent.

Role of the N u r s e Practitioner

The GNP has a collaborative and independent practice role with the MD(I 0,11). Through nurse-operated clinics in the boarding homes, all ser- vices of LTC are provided for health maintenance and optimum indepen- dence of residents. The GNP serves

334 Geriatric Nursing November/December 1988

residents" long-term health care needs according to the five areas of responsibility of the primary health care provider(l 2,13).

Accessibility is provided by the GNPs being present for regular monthly, on-site, scheduled visits and on-call phone consultations with the operators concerning changes in clients' status or emergencies. The GNP's willingness to understand, serve, and be in the boarding home assures residents of accessibility.

Comprehensiveness of care occurs with the defined commitment of the GNP/MD team to identify, assess, and resolve problems that influence maintenance of health. These in- clude social, cultural, economic, emotional, environmental, and func- tional concerns, as well as those prob- lems that are pathophysiological and more directly related to the tradition- al domain of the MD(14,15).

Coordination o£ services by both the GNP, who serves as case manager and coordinates clients' primary health care, and the MD, who is med- ical consultant and backup for prob- lems, is essential to this team ap- proach. The GNP plays a major role in providing preventive measures, coordinating multidisciplinary ser- vices in the community, and making referrals to continue congregate liv- ing versus institutionalization.

Continuity of care encompasses care "over the long haul," accommo- dating for changes, losses, and in- creased health risks of this vulnera- ble population who move through a variety of services, hospitalizations, and levels of health services.

Accountability is achieved with consistent and thorough recording and reporting of activities. These in- clude subjective and objective data and functional assessments with measurable outcomes. Prioritized health teaching and counseling are appropriate to the education, learn- ing levels, and emotional needs of the residents and operators.

Vulnerability Index

Rapid, easily administered, and interpreted multidimensional func- tional assessment is a challenge in identifying community-based elder- ly residents with impaired functional

Blood pressure screening gives residents an opportunity to discuss concerns.

capacity(9,14). One constant con- cern and need has been brief, valid, and reliable screening that can be done by one provider in the practice setting.

The Vulnerability-Self-Sufficiency Index is a valid and reliable assess- ment tool used for determining changes, progress, and levels of vul- nerability and for targeting addition- al service needs(l 6). It consists of 13 brief self-report items which pin- point key areas of mobility, menta- tion, instrumental activities of daily living, and personal care. In this way, clients can be identified according to defined levels of self-sufficiency.

Functional Assessment in On-Site Clinics

The data base record, updated an- nually, was designed to provide client profile information at a glance, with a brief functional assessment. The history data base includes family and other social support available to the client. Educational background, past employment, and environmen- tal resources provide information that influences assessments and plans for care.

During the interview/examina- tion, the GNP/MD team screens for functional impairments attributable to multiple factors of age, depriva- tion, abuses, disease or disability, and iatrogenesis. The assessment is recorded with a collaborative plan of care including psychosocial thera- pies, teaching modalities, medical treatments, referrals, and follow-up.

Information about maintenance of functional status is provided by the client and/or operator in response to queries about a typical day, usual health habits, and interim changes. Environmental and interpersonal in- teractions and observations of surro- gate family members are an essential part of the data base.

The Portable Clinic

A nurse managed, on-site clinic is held monthly within each boarding home. Portable equipment enables staff to perform routine physical as- sessments, simple disease sci'eening tests, physical maintenance activi- ties, and basic first aid.

The physical examination is con- ducted with a focus on function. Mental status exam, height, weight, gait, foot hygiene, hearing and visual acuity, earwax buildup, cardiopul- monary reserve, mobility, and mus-

• cle strength are assessed. Screening measures are performed

using simple equipment to do finger- stick blood glucose and stool he- mocculi tests, urinalyses by dipstick, and peak expiratory flow rates meas- ured with a portable handheld de- vice. And, as necessary, Pap smears and other laboratory specimens are obtained.

Preventive measures include yearly influenza vaccine and tuberculin tests. Breast and prostate exams and health teaching of both clients and operators, focusing on self-care, are regular functions of the clinic. Nutri- tion, exercise, and posture counsel-

Geriatric Nursing November/December i 988 335

ing are ongoing teaching measures. The GNP/MD team considers

functional and disease diagnoses when setting treatment goals in the long-term plan ofclient care. Nursing and medical interventions, referrals, follow-up visits, expected outcomes, and contingency plans for revision of treatment are part of the collabora- tive plan of care. The following out- comes of the team approach in the 4 boarding homes studied include po- sitive results and areas for further refinement.

• Incorporating natural, social, and physical environments in assess- ment and treatment ofresidents(l 6)

• Natural social support network reinforcement

• Reduction of medical transpor- tation costs

• Teaching and counseling to resi- dents and owner/operators for health promotion and supervision of pre- ventive measures, including nutri- tion and exercise and mental health

• Scheduled, systematic health care that provides continuity of care and early detection of problems

• Consistency of health providers • Increased satisfaction expressed

by residents, operators, and the pri- mary health care team

• Linkages to referral agencies • Medicaid reimbursements to all

members of the joint practice team, Medicare reimbursement only to the MD

References 1. Benjamin, A., and Newcomer, J. Board and care

housing. Res.Aging8:388-407, Sept. 1986. 2. Florida (State o0. The State Long Term Care

Ombudsman Council Annual Report. Tallahas- see, State of Florida, 1986.

3. Florida (State) Health and Rehabilitation Ser- vice. ACLF Guide Tampa, FL, The Service, 1988.

4. Ruchlin, H. S., and Morris, J. N. The congregate housing services program: an analysis of service utilization and cost. Gerontologist 27:87-91, Feb. 1987.

5. Brain, K. L., and Rose, C. L. Geriatric patient outcomes and costs in three settings: nursing home, foster family, and own home. J.Am.Ger- iatr.Soc. 35:387-397, May 1987.

6. Avant, K. S., and Walker, L. O. The practicing nurse and conceptual frameworks. MCN 9:87- 90, Mar. 1984.

7. King, 1. A Theory for Nursing. New York, John Wiley and Sons, 198 I, pp. 163-177.

8. Brody, E. Service options in congregate housing. I.~ Congregate llousingfor Older People: A solu- tion for the 1980s. ed. by R. S. Chellis and others. Lexington, MA, Lexington Books, 1982, pp. 161- 176.

9. Pfeiffer, E., and others. Functional assessment of elderly subjects in four service settings. J.Am.Geriatr.Soc. 22:433437, Oct. 198 I.

10. American Nurses' Association. The Role of Ge- rontological Nursing. Kansas City, MO, The As- sociation, 1974.

I 1. Anderson, E., and others. Epigenesis of the nurse practitioner role. A mJ.Nurs. 74:1812-1816, Oct. 1974.

12. Nutting, P. A., and others. Community-oriented primary care in the United States. JAMA 253:1763-1766, Mar. 22-29, 1985.

13. Ham, R. J., and others. Primary Care Geriatrics. A Care-Based Learning Program. Kansas City, MO, Society of Teachers of Family Medicine, 1983.

14. Besdine, R. The educational utility of compre- hensive functional assessment of the elderly. J.Am.Geriatr.Soe. 31:651-656, Nov. 1983.

15. Hayter, J. Modifying the environment to help older persons. Nurs.tleahh Care4:265-269, May 1983.

16. Morris, J. N., and others. An assessment tool for use in identifying functionally vulnerable per- sons in the community. Gerontologist 24:373- 379, Aug. 1984.

SOCIAL SUPPORT KATHERINE C. TURNER

As people age, social support net- works break down because of death of family or friends, relocation, re- tirement, or as an indirect result of chronic illness(I-3). While nursing has recognized this breakdown and the importance of the environment and support as factors in healing and optimal functioning, there is a need for scientific knowledge to support interventions and guide clinical ap-

Katherine C. Turner, RN, MS, is a nursing consultant in gerontology at Newfoundland Depar tment o f Health, St. John 's , Newfound- land, Canada.

This article is adapted from a presentation given at the Gerontological Society of America in November 1987, Washington, D.C.

Comparisons of Total Functional Scores by Item Nursing Home Board and Home

Mean Care Mean Item (N = 26) (N = 26) t p Affect ( l ) 10.7 36.2 5.9 < .001 Affect (2) 10.9 36.1 6.0 < .001

Affirmation (3) 10.5 32.3 5.9 < .001 Affirmation (4) 10.61 32.5 5.6 < .001

Aid (5) 8.1 31.7 5.7 < .001 Aid (6) 6.6 26.6 5.2 < .001

Comparisons of Mean Scores for Total Network by Network Item Nursing Home Board and Home

Mean Care Mean Item (N ~ 26) (N = 26) t p N u m b e r in network 2.7 8.2 5.8 < .00l Durat ion o f

relat ionship 12.1 39.8 6.0 < .001 Frequency o f

contact 9.1 32.8 5.7 < .001 !

336 Geriatric Nursing November/December 1988