The health of older citizens will become a critical national policy issue during this century. As a country, we Americans may have to rethink fundamental cultural values about the meaning of providing health care to older adults with chronic conditions. Simply treating disease is no longer sufficient. The growing number of older adults, and the families who care for them, will need emotional, educational, and financial resources that are not currently available. Planning to meet this challenge is important because an elderly population explosion is coming, beginning in 2010.Nursing Gerontology Essay Paper

By 2030, 70 million U.S. citizens will be over age 65, and 8.5 million Americans will be over age 85 (National Center for Health Statistics, 1999). The "oldest old" Americans—those aged 85 years or more—are the fastest growing group in the US. This trend is important to those planning health care needs for the future because the oldest old individuals are most likely to be disabled, use multiple medications, or need consistent caregiving. Many older adults will be from ethnically diverse cultures. For example, Hispanic elders, now 5.6% of the elderly population, will increase to 16.4% of the elderly population during the next 50 years. In some states such as California, where 25% of the population is foreign born, the proportion of older Americans from diverse cultures will be even higher (National Center for Health Statistics, 2002).Nursing Gerontology Essay PaperThis growing elderly population will have an increasing need for health care and related services, an effect that will ripple through society as we grapple with the implications of caring for our elders. The increased proportion of older adults in the population need not present major problems if we can provide appropriate resources for adequate quality of life for older adults, such as specialized health care that includes attention to the management of chronic illness, support for family caregivers, and the financial constraints of older adults. Even today, when the number of older adults is smaller, critical health and quality of life issues remain unresolved, issues that may grow worse as the population of older adults increases.Nursing Gerontology Essay Paper

The purpose of this article is to provide an overview of major issues that affect whether the growing number of older adults can expect to enjoy a healthy old age. Four critical areas will be discussed: providing resources to individuals to help manage chronic medical conditions, assuring a sufficient number of primary health care providers educated in geriatrics and gerontology, removing financial barriers to accessing health care and medications, and changing the cultural value system that emphasizes disease treatment over providing emotional, educational, and support resources. Reassessing current public policies that influence our ability to provide for the health and well-being of older citizens will influence our success in meeting these health challenges. The policy implications of these four major health issues will be briefly discussed in this article and addressed in more detail in the other articles in this topic of the journal, each of which focuses on a particular challenge related to health care and aging.

Because of their fragile health, elderly individuals often need special care, particularly since a minor health related issue can sometimes spin out of control quickly in the elderly.Nursing Gerontology Essay Paper

Working as a geriatric nurse is often very gratifying and rewarding personally. However, it takes a special type of person to work in this field, and the work can also be frustrating or disheartening at times as well. If you are looking to become a geriatric nurse, you must keep in mind that the aging process affects everyone differently. While some elderly patients are somewhat content or even happy-go-lucky, others may be sad, scared, or even angry that their health is failing.

Before becoming a geriatric nurse, you should evaluate your personality. Geriatric nurses should be generally upbeat and cheerful people. They should also be patient, understanding, empathetic, and compassionate, with a true desire to work with aging patients. If you choose this career, you should also be able to handle and bounce back from depressing events, such as the death of a patient.Nursing Gerontology Essay Paper

Negative stereotypes of older age and nursing homes persist in our society. Common misconceptions include the view that older adults are lonely, bored, or dissatisfied with life and that nursing homes are lifeless institutions (Gugliucci & Weiner, 2012). Suffice it to say that the later years of one's life may be challenging, and if one moves to a nursing home, residing there may not be the “home” of choice. However, as complex as nursing home environments may be, social and developmental opportunities abound, and operations are under constant scrutiny to create culture change. For this review each book (leg) offers components of life lived in nursing homes. The Learning by Livingproject is but one integration point. In short, Beaulieu's book provides the staff perspective and the details of what staff needs to be aware of in providing social work care in the nursing home environment; Gaffney's book represents one person's experience of nursing home living, in a variety of homes for the remainder of her life; and Doll's book offers specific insights into sexuality, a real issue that could enhance nursing home residents’ quality of life. My credentials for this essay include being a gerontologist, a member of a nursing home board of trustees, the principal investigator for the Learning by Living project, sharing countless experiences with students, and, maybe most importantly, having cared for a parent in a nursing home. I suggest each leg of this review represents important issues that need to be considered if we are to create a nursing home environment in which we undo the negative stereotypes of both older age and nursing homes.Nursing Gerontology Essay Paper

Long-term care (LTC) and nursing home care are two terms that erroneously get used interchangeably. LTC is the umbrella term, describing the provision of care for people who have disabilities or chronic care needs, including dementia, over a long period of time. However, those needing LTC may or may not require 24-hr professional care or need to reside in a nursing home. The services may be provided in a variety of settings, such as the person's home, in the community, in assisted living facilities, or in nursing homes. Nursing home care is one form of LTC and usually is based on a medical model. It is the provision of 24-hr care with licensed professional nurses in a residential setting. Residents tend to have physical, cognitive, or mental health issues that keep them from performing at least one (usually more) of the activities of daily living (ADLs) (i.e., bathing, dressing, eating, walking, toileting, and grooming). Nursing home professional staff includes medical directors, nurses, geriatric social workers, activities directors, and registered dieticians, and sometimes physical, occupational and speech therapists. Certified nursing assistants assist with frontline resident care. It is important to note that short-term or rehabilitative care, even if provided in a nursing home, is not LTC. Instead the person may need assistance and/or rehabilitation after surgery, an illness, or an injury. This care can be provided in the person's home, in a rehabilitation hospital, or in a skilled or rehabilitation unit in a nursing home. When a person is admitted to a nursing home for LTC, she/he becomes a resident of the nursing home. It is preferable not to refer to the person in this situation as a patient. However, if a person is admitted into a nursing home for a short-term stay, skilled care, or rehabilitation, then the person is considered a patient.Nursing Gerontology Essay Paper

The University of New England College of Osteopathic Medicine Learning by Living Project (referred to as Learning by Living in this review) was piloted in 2006. It was designed and implemented as an experiential medical education learning model by the Director of Geriatrics Education and Research within the Medical School's Department of Geriatric Medicine. Since its inception, medical and other health professions students have been “admitted” into nursing homes to live the life of an elder nursing home resident for approximately 2 weeks—(24hr a day/7 days a week)—complete with a medical diagnosis and “standard” procedures of care. Thus far, 28 medical students, two social work students, one gerontology student, and one student of architecture have participated in the Learning by Living project in 14 nursing homes in four states.Nursing Gerontology Essay Paper

The Learning by Living Project utilizes qualitative ethnographic and autobiographic research designs, whereby a unique environment or “culture” (nursing home) is observed and life experiences of the medical student are reported by him/her while living within the environment. Medical students “admitted” into the nursing home as a resident are asked to answer these questions: What is it like for me to live in a nursing home; What does it mean to me to be a nursing home resident? The Learning by Livingethnographic immersion has three stages: (a) Pre-fieldwork—getting ready for the experience; (b) Fieldwork—living in the environment with a diagnosis, standard procedures of care including a “medication” regimen, toileting, bathing, transferring with assistance, eating pureed foods, and engaging in activities and relationship building; and (c) Post-fieldwork—reflection on what occurred during fieldwork (Denzin & Lincoln, 1994, 2005).Nursing Gerontology Essay Paper

In 2005, 12% of students in California social work programs were taking courses on aging compared with a national report of 7% by the Council on Social Work Education and an earlier 1993 national survey of 3%. Still, the number of social work students training in gerontology remains less than the needed numbers (Damron-Rodriguez, Ranney, Goodman, Min, & Takahashi et al., 2013, p. 235). Most students in social work programs say that they plan to work with children, but given the jobs available, many of these students end up working with older adults. It is inevitable in our society. Beaulieu's book, originally published in 2002, clearly articulates what on-the-ground nursing home social work practice involves. According to Beaulieu, social workers who work in nursing homes are faced with two key challenges (a) the health care system bias toward community care rather than nursing home/institutional care; and (b) the press of national regulations in shaping nursing home care. This book is divided into six parts: Social Work in Nursing Facilities; The Interdisciplinary Team; Nursing Facilities and Governing Oversights; Diagnosis, Treatment, and Care Issues; Ethics; and Community Liaisons. The appendix provides examples of standardized forms that are part of the social worker's responsibility, and the book includes online resources and a glossary of terms and abbreviations. These resources are useful as it is rare to be exposed to this type of information or detail during one's educational training. In the Basic Orientation chapter (Chapter 2), Beaulieu presents the landscape of responsibilities for social workers in the nursing home setting, which includes counseling, resource allocations, advocacy, planning and treatment, mediation, and of course psychosocial factors. The importance of these supportive roles is underscored by the experiences of the Learning by Living students, who reported that social workers often aided them in their adjustment to nursing home living Nursing Gerontology Essay Paper

Between 1900 and 2000, life expectancy in the United States increased from 51 to 80 years for women and from 48 to 74 years from men (Population Reference Bureau, 2002). As Americans have increased their years of life, the prevalence of chronic conditions associated with age has also increased. It is estimated that by 2040, almost 160 million people in the US, most of them elderly, will be living with chronic conditions (National Academy on an Aging Society, 1999). Chronic conditions can cause limitations in daily activities, hospitalization, transition to a nursing home, and poor quality of life. However, many people who have chronic conditions lead active, productive lives.

There are several reasons why some older adults with chronic conditions remain independent and active, while others decline into frailty and dependence. First, some chronic conditions, such as chronic obstructive pulmonary disease, may be more disabling or more severe than other conditions. Second, some chronic conditions, such as hypertension, may be controllable with medications. Third, some older adults have the resources to self-manage their chronic conditions so that symptoms are controlled. Thus, in cases where the chronic condition is not itself disabling (if managed) and medications are available (and affordable), the provision of support in self-management of symptoms may allow many older adults to remain in their homes and lead lives that include normal activities.Nursing Gerontology Essay Paper

Older adults need a variety of resources to help them manage chronic conditions, especially when several chronic conditions are present, a common occurrence. Medical help for treatment of chronic disease conditions is available to most older adults through Medicare and Medicaid. In contrast, the care resources needed to manage chronic conditions in day-to-day life are not as readily available. In order to balance behavioral changes, medications, and symptom relief strategies, older adults need knowledge about what to do, the belief that they can achieve success, and family to help. When elders do not have family members close by, additional financial resources may be needed to acquire assistance. Providing emotional support and education to elders and families will require a fundamental change in the American value system, which currently promotes the logical medical treatment of chronic conditions, and ignores the emotional needs of patients and family caregivers who cope with multiple chronic conditions.Nursing Gerontology Essay Paper

Issue 2: Too Few Primary Health Care Providers are Educated to Provide Geriatric-Focused Care

The current shortage of nurses is expected to accelerate in coming years, and the impending lack of nurses to care for the nation’s older adults will be a critical health care issue. To prevent, or at least mitigate, the expected shortage of gerontological nurses in the US, increased recruitment of nurses to gerontological specialties must be initiated now.

Between 2010 and 2030, the number of registered nurses in the US is expected to steadily decline, as older nurses retire and fewer students enter baccalaureate nursing programs (American Association of Colleges of Nursing, 2002; University of Illinois at Chicago: College of Nursing-Nursing Institute, 2001). By 2020, the registered nurse (RN) workforce is expected to be 20% below projected requirements (Buerhaus, Staiger, & Auerbach, 2000; Reinhard, Barber, Mezey, Mitty, & Peed, 2002). The decline in the supply of nurses during the next 20 years will occur just as 78 million baby boomers retire and enroll in Medicare. From 2010 to 2030, the number of people aged 85 and older—the age group most likely to need nursing care—will increase by more than 4 million (U.S. Census Bureau, 2002).Nursing Gerontology Essay Paper

Unfortunately, most RNs have little or no preparation in gerontological nursing as part of their education. A recent survey disclosed that fewer than 25% of baccalaureate nursing programs include a course in gerontological nursing (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). The shortage of nurses who specialize in care of older adults is even more acute in advanced practice nursing. Though 63 nursing programs in the US currently prepare advanced practice gerontological nurses, most graduate only a few students each year, not nearly enough to meet even today’s need for nurses in long-term care settings, where many advanced practice gerontological nurses practice (Mezey & Fulmer, 2002).

Currently, only 12.3% of RNs are from ethnically diverse groups, a figure that does not mirror the 33% of the general population that is ethnically diverse (American Association of Colleges of Nursing, 2001). Elderly Americans, already a heterogeneous group, will include more culturally diverse individuals as the population ages. In 2000, 16% of older adults in the US were members of ethnic groups, but by 2050, the proportion is expected to increase to 36% (Himes, 2002). The current number of advanced practice gerontological nurses from diverse ethnic groups is not known, but there is little doubt that the number should be increased so the nursing workforce is more representative of the populations being served.Nursing Gerontology Essay Paper

Other disciplines have a similar shortage of geriatrics-educated professionals. Only 14 of the nation’s 145 medical schools require a course in geriatrics for medical students, and less than 0.5% of medical school faculty are geriatric specialists. In pharmacy today, only 720 of 200,000 pharmacists have geriatric certification. Though at least 5,000 geriatric psychiatrists are needed to meet today’s mental health care needs of older adults, about 2,400 geriatric psychiatrists are practicing in the US (Merck Institute, 2002).

These critical shortages in the number of health care providers who are educated in the unique health needs of older adults will continue to worsen as the demand increases in future years. Changes in policy, if implemented soon, may help meet this challenge. New policies that could improve the geriatric knowledge of the health care workforce include mandating a specified number of credits in geriatrics as a condition for license renewal, initiating new continuing education programs in academic institutions to attract professionals without geriatric training, and working with state licensing boards to implement requirements for geriatric course content in nursing, medical, and pharmacy education curricula (Merck Institute, 2002).Nursing Gerontology Essay Paper

Issue 3: Financial Issues Drive Health Care Choices for Many Older Adults

Older adults and their families face many financial issues in acquiring treatments and resources to support health. Financial resources can be quickly drained by paying for multiple prescriptions for chronic conditions (Center on an Aging Society, 2002; Merck Institute, 2002), inadequate reimbursement for mental health services (Merck Institute), and the lost work time and productivity of unpaid family caregivers (Kassner & Bectel, 1998; U.S. Bureau of the Census, 1996).Nursing Gerontology Essay Paper

The expense of paying for multiple prescriptions, which are not reimbursed by Medicare, is a well-known political health issue that is regularly addressed, with great publicity, by Congress, and, with less publicity, dropped from the legislative agenda. For elderly individuals, the cost of medications is a critical financial problem that never goes away. Many older adults have several chronic conditions that require costly prescription drugs to manage symptoms. For example, the average annual drug expenditure for diabetes is $1379, for heart disease, $1187, and for hypertension, $1021. The average annual out-of-pocket prescription drug expenditure for Medicare beneficiaries is $581, because many individuals buy supplementary insurance to help pay for drugs. Low income older adults who qualify for Medicaid may be more fortunate because Medicaid programs cover 60% of drug costs, though many states are planning to reduce or restrict their Medicaid drug benefits in 2003. Not surprisingly, nearly 20% of adults over age 65 report that they have taken less medication than prescribed in the past two years. Others have reported that they sometimes do not fill prescriptions, skip doses to make medication last longer, or spend less on food and heat so they can afford medicine (Center on an Aging Society, 2002).Nursing Gerontology Essay Paper

Older adults visit physicians more often than younger adults do, averaging 15 physician visits per year for adults aged 85 and older compared to 7.2 visits for adults aged 45 to 64 (Merck Institute, 2002). Most office visits for health care require only a small co-payment for Medicare beneficiaries. In contrast, older adults are not frequent users of mental health services, accounting for only 7% to 9% of mental health utilization in hospital, community, and private practice settings. This underuse of mental health services may be due to lack of education among primary care health care providers in geriatric mental health assessment. However, another likely cause is the lower reimbursement by Medicare for mental health conditions, compared to reimbursement for physical conditions. Thus, the high rates of untreated mental health problems among older adults (only 50% of older adults with acknowledged mental problems receive treatment from any provider and only 3% of those see a specialty mental health provider) may be due to the inability to pay Medicare’s 50% co-payment for mental health outpatient services (compared to 20% for general medical services) (Merck Institute).Nursing Gerontology Essay Paper

As adults age, some need help only with daily activities, such as cleaning, cooking, or personal care, in order to remain in their own homes. Unfortunately, Medicare does not reimburse for this type of care, so older individuals who need this "custodial" help must pay for it out-of-pocket or rely on unpaid caregivers, often family members or other support persons. Though some older adults may qualify for subsidized community programs, 70% of people over age 65 who need help with daily activities are cared for by unpaid caregivers, primarily spouses (24%) or daughters (20%) (Kassner & Bectel, 1998). This does not include the many families that are actively engaged in remote family caregiving through phone, visit and email supports. The number of family caregivers available to care for older adults is steadily decreasing in the US. In 1950, the "parent-support ratio" (the number of persons 85 years or older per 100 persons aged 50 to 64) was three. By 1993 this ratio had tripled to 10. By 2050 it is projected to triple again to 29 (U.S. Bureau of the Census, 1996).Nursing Gerontology Essay Paper

The health care system must demonstrate far more focused interest in the family and "like family" (non-kin caregivers) as health care clients, because these caregivers provide the primary social, financial, and physical support for older Americans. As such, the family and "like family" caregivers are a major resource for American society, saving the health care system many dollars, perhaps as much as $196 billion per year (Rosalynn Carter Institute, 2002). On the other hand, this reliance on unpaid caregivers incurs costs to American society in lost productivity when caregivers cannot work. One study estimated that the lost productivity due to caregiving costs U.S. businesses $11 to $29 billion annually (Metlife Institute, 1999). If home and community-based long-term care of older adults continues to be primarily delivered by informal caregivers, they deserve to be the focus of attention for researchers so support systems can be designed that meet their needs, and their lost productivity can be recognized and, perhaps, mitigated.Nursing Gerontology Essay Paper

Issue 4: Cultural Values Do Not Give Priority to Providing Services and Support for Older Adults

Despite improvements in health care that have increased the life expectancy of persons throughout the world, aging is still viewed by many Americans with fear and trepidation.

Two of the most beautiful words in the English language--"nursing" and "home"--when put together in the term "nursing home" have become a symbol of fear, isolation, and suffering in the minds of many middle-aged and older persons. Life course planning in America is common in the financial planning arena, but has not been applied in the same way to lifelong improvement of self-care competency, and planning for learning the skills of relationships, care receiving, and caregiving. This lack of planning may be due to the dominant American cultural fear of aging. Unfortunately, this lack of motivation to make personal health-conscious decisions in early and mid-life may result in inadequate planning for lifelong meaningful activity, social support and living arrangements for later life. Thus, many older adults are not prepared for the natural occurrences of physical decline, loss, and grief.The presence of strong elder bias in the American culture prevents the application of new scientific knowledge and ways of thinking to clinical practice in the care of older persons. Older adults may have a variety of risk profiles for poor health, from the robust to the frail elderly. Yet, most of the stereotypes of aging picture the frail and disabled. Thus, many health care providers do not think interventions to teach techniques for self-management of symptoms are worthwhile in older adults because they will not live long enough to justify the effort.Nursing Gerontology Essay Paper

Wagner, Austin, and Von Korff (1996) have identified the conditions of the health care system necessary for the care of older adults with chronic disease and their families. These conditions in large part focus on "delivery by design" and include such features as having formal interest in the client’s feelings of self-efficacy, the presence of well-oiled outreach and monitoring activities, the capacity to provide personal, individual, and group coaching in behavior change, and overt attention to customization of standards of care to fit expressed preferences and family abilities. Unfortunately, these performance attributes have rarely been designed into health delivery systems. The primary model driving both formal care design and financing is care in urgent and emergent conditions, rather than preventive services or support for management of chronic conditions (Institute of Medicine, 2001).

Almost all financing schemes, including Medicare, are derived from methodologies directed at paying for acute care and procedure-oriented visits or hospitalizations. During the last fifteen years, significant reductions in hospital length of stay have produced a complex cascade of unintended consequences and burden for families caring for acutely and chronically ill elders.Nursing Gerontology Essay Paper

Often, multiple transitions mandated by payment systems funding various levels of care (skilled care, intermediate, assisted living, and foster care) have produced extreme complexity, lack of coordination, and lack of assessment of the true needs of families for safe care in the home. Unfortunately this focus on "setting-specific" strategies rather than family-centered care planning that is coordinated through time, place, and person, has produced chaos, redundant costs, and unmet needs. Assisting families to uncover values and personal goals as they learn to interpret complex care regimens, self-care directions, and treatment orders is often not a part of routine care in formal health care organizations. Funding for basic group educational classes to coach families in growing self-care skills and competencies is not provided for in current billing provisions. The best practices for improving self-care skill that have been learned in patient education centers and large funded studies in managed care organizations have seldom been translated into Medicare, Medicaid or commercial business payment systems.In the American culture and value system, emotional and cognitive understanding of illness and health often are not congruent.Nursing Gerontology Essay Paper

While elders and families are intimately involved in the emotional aspects of illness and disability, health care providers are likely to disregard emotional experiences and concentrate on logical solutions to treat or manage chronic disease conditions. Though medical anthropologists have described health and illness in terms of culture, health providers in clinical practice pay little attention to the "experience" of illness (Kleinman & Seeman, 2000). In the care of older persons, this lack of attention to the lived experience of chronic illness results in insufficient adjustment of care plans to fit with practical and financial realities of patients and families.Nursing Gerontology Essay Paper