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Nurse clinician in a multidisciplinary geriatric clinic
Nurse Clinician in a Multidisciplinary Geriatric Clinic If we develop more community-based clinics like this, more elders could live independently at home. MARY ANN MATTESON As the numbers of older people increase in our society, health care providers are exploring a variety of ways to meet their needs. After all, 95 percent of the 25 million persons over 65 live in the c o m m u n i t y ( I , 2 ) . This means that primary care, mobilization of resources, and coordination of services in the community have become focal points for nursing assessment and intervention. Illustrating this point is my role as clinical specialist in gerontological nursing in a community-based, university-affiliated, multidisciplinary clinic for older clients. Clinic and Clients
T h e Geriatric Evaluation and T r e a t m e n t ( G E T ) Clinic at the Duke University Center for the S t u d y of Aging and H u m a n DevelWhen she wrote this article, Mary Ann Matteson, RN, MSN, was an assistant professor at Duke University School of Nursing and clinical specialist at the Duke Geriatric Evaluation and Treatment Clinic, Durham, NC. She is now clinical assistant professor, University of North Carolina School of Nursing, Chapel Hill.
opment serves as a model evaluation and treatment facility for older adults and their families. The clinic is an outgrowth of Duke's Older Americans Resources and Services ( O A R S ) program of policy research on alternatives to institutionalization. T h e program was begun in 1972. Through research and testing, the O A R S program produced reliable, valid, easily applied procedures for multidimensional functional assessment, standardized ways to document the basic elements of care planning, and procedures for evaluating the Outcomes of geriatric care. All of these procedures are used regularly in the clinic today. Although the clinic was initially created for the research program, and funded by an Administration on Aging grant, it continues as a service and teaching unit of the Duke Center of Aging. The wide range of services includes functional evaluation; medical and nursing services; individual, family, and group psychotherapy; psychotropic drug services; relocation and placement services; and coordination of services(3). Based on an interdisciplinary concept of service, the clinic uses the expertise of a physician, psychiatrist, nurse clinician, psychologist, social worker, and physical therapist. T h e clients' care reflects a holistic approach related to the
five areas of functioning categorized in the 72-item O A R S Multidimensional Functional Assessment Questionnaire ( M F A Q ) : social resources, economic resources, mental health, physical health, and activities of daily living(4). T h e clients are persons over 55 years of age and living in the community who are at risk for institutionalization because they have many functional deficits. Clients may be referred to us because of problems that arise from chronic physical illness, limited social or economic resources, mental or emotional impairment, or inability to carry out activities of daily living independently. Referrals come from physicians, social workers, public health nurses, neighbors, friends, families, or the clients themselves. Families frequently seek counseling and instruction for coping with frail, multi-impaired older relatives. About 35 new clients are evaluated every month, and the clinic carries a continuing caseload of some 150 clients. Costs for clinic visits are covered on a sliding scale by Medicare, Medicaid, and Blue Cross/Blue Shield. H o m e visits are not covered by insurance, and clients usually are not charged. The Care Process
T h e evaluative process begins with a home assessment for clients who live within a 10- to 20-mile ra-
Geriatric Nursing November/December 1983 379
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/
S
ssessmeilt c,.tld Co, re
Ann Brown, 73 years old, was referred to the clinic by her daushter because of "depression," "confusion," and "memory loss." The daughter was concerned because her mother had become increasingly withdrawn, refusing to go to church or participate in her usual activities. Ms. B. lived alone in her own home; her husband had died one year ago. I made an initial assessment of Ms. B. in her home with her daughter present. The house was a small, one-story, brick structure in a lower middle class neighborhood. There were three steps leading up to the front door but no handrail. I was greeted by a small, frail, gray-haired woman and her attractive, well-dressed daughter, who appeared to be in her early 40s. She had taken time from her job as a bank teller in order to meet with~me. The house was relatively neat, though cluttered with memorabilia. There were two bedrooms, a small kitchen and bath, and living and dining rooms. The house was well heated and comfortable, the floors highly polished. The cupboards were well stocked with food, but the client had no appetite and refused to eat. The medicine chest contained only Bufferin for mild arthritic pain and occasional headaches, multivitamins, and milk of magnesia for occasional constipation. As Ms. B. walked to her chair, she used a cane and appeared to have difficulty seeing where she was going. When I inquired about her vision, she said cataracts were forming in both eyes but were not fully enough developed for surgical removal. Her unsteady gait was due to visual impairment rather than a problem with
dius of the clinic. T h e purpose is to d e t e r m i n e whether the older person can continue to live safely in his or her home, what environmental modifications m i g h t be necessary to promote independerit living, and whether health care r e c o m m e n d a tions can be carried out in the home. Following the h o m e visit (where this is possible), clients c o m e to the clinic for a thorough intake evaluation. T h e intake consists of a functional assessment, using the M F A Q , a complete history and mental status exam, physical exam, and psychiatric evaluation with psychological testing when indicated. Frequently, the family is ineluded in both h o m e and intake assessments in order to obtain a full picture of the older person's situation and potential resources for interdependent functioning.
balance or musculoskeletal deficits. A brief physical assessment showed that her reflexes were normal and symmetrical. Her range of motion was slightly impaired in the weight-bearing joints. There was no evidence of postural hypotension. A brief history revealed that Ms. B.'s past few years had been characterized by loss, culminating with" the death of her husband. Loss of visual acuity had decreased her social" activities. An avid reader, she was unable to enjoy her favorite mystery novels or keep up with events in her newspaper. Mr. B. had provided much of the transportation and social networking for his wife. He drove her to church and other activities, read to her, and helped with household duties. The daughter was concerned but unable to provide day-to-day help due to responsibilities to her husband and three children plus a full-time job. She was worried about her mother's safety and ability to live alone; Ms. B. was adamant about staying in her own home. The home assessment led me to think that Ms. B. might be able to manage at home with environmental modifications and the help of community services. During the administration of the O A R S multidimensional functional assessment questionnaire [see text] at the clinic, Ms. B. was quiet, withdrawn, and tearful at times, especially when talking about her husband's death and her loss of vision. She was disturbed by her impaired memory but attributed that to "old age." She appeared thin, pale, and gaunt. Questionnaire results showed that her memory was somewhat impaired, with a total of five errors on the mental status exam. When questioned, she was uninterested in answering, preferring to say that she didn't know or could not remember. This is diagnostically significant, since persons with organic brain disease tend to confabulate or hide the fact that
W h e n assessment is complete, the p r i m a r y evaluating clinician presents the case, together with a plan of care, to the interdisciplina r y t e a m conference. T h e p r i m a r y evaluating clinician m a y be from a n y discipline and should have been present at the home visit and intake. During the t e a m conference, m e m b e r s of the various disciplines share their particular insights, a final care plan is approved, and a clinician f r o m the most a p p r o p r i a t e discipline is designated as the person to c a r r y it out. A t the s a m e time, a date is set for. follow-up evaluation. As nurse clinician I work as a m e m b e r of the team, primarily as caregiver, educator, and researcher. T h e s e roles require client assessment, intervention, and evaluation; collaboration with other professionals; role modeling for students of
380 Geriatric Nursing November/December 1983
nursing and other disciplines; carrying out clinic administrative tasks as designated by the clinic supervisor; and conducting independent or collaborative clinical research related to nursing and the aged client. T h e Nurse Clinician Role T h e appended case study illustrates m y role when acting as prim a r y evaluating clinician. Nursing interventions within the clinic inelude health teaching of clients and families; health monitoring, such as taking blood pressures or observing tolerance of drug t r e a t m e n t ; counseling clients and families; and coordinating care given by various service providers. I also act as a consultant to other professionals or nonprofessionals in institutional 9 and c o m m u n i t y settings. So the consultation usually focuses on spe-
they do not know the answers. The functional assessment revealed that Ms. B.'s social and economic resources and physical health were satisfactory or better but that her mental health was severely impaired. She had marked psychiatric symptoms that interfered with routine judgments and decisions in everyday life. As a result, she had moderate impairment in A D L capacity, due not only to her mental health status but also to her impaired vision. The medical exam revealed that Ms. B. was a relatively healthy woman with mild arthritis in her knees and hips, and early cataract formation. Lab studies, including a CBC, thyroid panel, urinalysis, folate, a n d BI2, were normal. The psychiatric exam helped to confirm earlier suspicions that the client was suffering from a reactive depression, resulting from an accumulation of losses associated with late life. The psychiatrist prescribed a low dose of imipramine (Tofranil) to help Ms. B. increase her activity. I presented the case to the multidisciplinary team with this proposed plan of action: 1. Weekly therapeutic counseling at the clinic with medication monitoring. 2. Mobilization of community resources to provide a home health aide and transportation services. 3. Environmental modifications, including color coding, handrails, and less polish on floors in order to reduce the glare. I would be the primary clinician, responsible for counseling, medication monitoring, coordination of services, and environmental modifications. The psychiatrist would act as consultant for medication management. The physical therapist would go on the next home visit with me to assess Ms. B.'s arthritis and the possible use of mild exercise. The team agreed to the
cific needs of older clients and the ways that their needs m i g h t best be met under the prevailing circumstances. On a multidiseiplinary t e a m , responsibilities of the various clinicians often overlap and boundaries m a y b e c o m e unclear. It is frequently 9evident, however, that through counseling, monitoring of health t r e a t m e n t , or using social resources, the nurse is in an excellent position to carry out health teaching and preventive care that prom o t e the older c l i e n t ' s independence for as long as possible. Students of m a n y health-related disciplines (social work, nursing, psychology, medicine, or pastoral counseling) continually rotate through the clinic. M y chief educational responsibility is to serve as preceptor to four or five u n d e r g r a d uate and one or two g r a d u a t e - n u t s -
plan, which was implemented immediately. With the help of the local Council on Aging, a home health aide was provided three hours a day. The aide prepared meals, did light cleaning and shopping, and provided socialization by reading to Ms. B. and discussing daily events. I put red-colored markers on chairs, doorways, and counters to prevent bumps and falls; sheer curtains were added to reduce glare. A handrail was attached to the front steps, and red strips on the step edges to prevent tripping. The physical therapist prescribed exercises, which, although reluctantly carried out initially, were most useful and enthusiastically performed later on. I saw Ms. B. weekly for supportive counseling. She responded beautifully to the combined medication, counseling, and social support. Gradually she ate better, became more outgoing, and displayed greater interest in social activities: She eventually regained interest in church affairs and began participating in senior center activities twice a week. 9 It has been one year since Ms. B. first came to the clinic. Her functional ratings on the M F A Q have improved: from 5 (severely impaired) to 2 (good) on the Mental Health Scale, and 4 (moderately impaired) to 3 (mildly impaired) on the Activities of Daily Living Performance Scale. Her mental status improved and she had only one error on the mental status exam. She has adjusted to her impaired vision with the help of the environmental modifications. Her home health aide has become her friend and Companion, and life seems brighter and happier. Ms. B. continues to take a mild dose of imipramine and occasionally comes to the clinic on anniversary d a t e s - - h e r husband's death, for instance--or when she wants to talk over her problems. She was a joy to work with and her progrcss constituted a very satisfying success s t o r y . - - M A M
ing students. A b o u t 30 percent of m y time in the clinic (where I spend 70 percent of m y total time) is devoted to precepting. O f the 30 percent of time at the school of nursing, a b o u t 5 percent involves precepting. T h e learning focus is holistic nursing care of the geriatric client in the comtnunity, health maintenance, prevention of illness, and the nurse's role as a multidisciplinary t e a m m e m b e r . T e a c h i n g methods include videotaped and written lectures to provide theory base; individual discussion of values, attitudes, and specific needs of the "elderly; and clinical experience with clients. Acting as role model for nursing students is, perhaps, the clinician's most vital function. M y research has focused on depression in the elderly, the relationship of life circumstances to depres-
sion, and the use of group reminiscing as a m o d e of treatment. This research has been carried out both independently and collaboratively. Clearly, the nurse clinician role is multifaceted; so are the services that the O A R S - G E T clinic provides for its clients. Therein, I believe, lies the source of m y satisfaction in the work and the clients' satisfaction in the care received. References I. Harris. C. S, Fact Book on Aging: +4 Profile o f America's Older Population. Washington. D. C.. The National Council on the Aging. 1979. p. 3. 2. U. S. Census Bureau. Statistical Abstract o f the United States. 1981. Washington, D.C.. U.S. Government Printing Office. 1981. 3. Matteson. M. A. The Geriatric Care Process: The Duke O A R S Core Curriculum. Durham. N.C.. Duke University Medical Center. 1981. 4. Duke Center for the Study of Aging and tluman Development. Multidimensional Functional Assessment: The O A R S Methodology. 2nd ed. Durham. N.C.. The Center. 1978.
Geriatric Nursing November/December 1983 381
T h e Geriatric Evaluation and T r e a t m e n t ( G E T ) Clinic at the Duke University Center for the S t u d y of Aging and H u m a n DevelWhen she wrote this article, Mary Ann Matteson, RN, MSN, was an assistant professor at Duke University School of Nursing and clinical specialist at the Duke Geriatric Evaluation and Treatment Clinic, Durham, NC. She is now clinical assistant professor, University of North Carolina School of Nursing, Chapel Hill.
opment serves as a model evaluation and treatment facility for older adults and their families. The clinic is an outgrowth of Duke's Older Americans Resources and Services ( O A R S ) program of policy research on alternatives to institutionalization. T h e program was begun in 1972. Through research and testing, the O A R S program produced reliable, valid, easily applied procedures for multidimensional functional assessment, standardized ways to document the basic elements of care planning, and procedures for evaluating the Outcomes of geriatric care. All of these procedures are used regularly in the clinic today. Although the clinic was initially created for the research program, and funded by an Administration on Aging grant, it continues as a service and teaching unit of the Duke Center of Aging. The wide range of services includes functional evaluation; medical and nursing services; individual, family, and group psychotherapy; psychotropic drug services; relocation and placement services; and coordination of services(3). Based on an interdisciplinary concept of service, the clinic uses the expertise of a physician, psychiatrist, nurse clinician, psychologist, social worker, and physical therapist. T h e clients' care reflects a holistic approach related to the
five areas of functioning categorized in the 72-item O A R S Multidimensional Functional Assessment Questionnaire ( M F A Q ) : social resources, economic resources, mental health, physical health, and activities of daily living(4). T h e clients are persons over 55 years of age and living in the community who are at risk for institutionalization because they have many functional deficits. Clients may be referred to us because of problems that arise from chronic physical illness, limited social or economic resources, mental or emotional impairment, or inability to carry out activities of daily living independently. Referrals come from physicians, social workers, public health nurses, neighbors, friends, families, or the clients themselves. Families frequently seek counseling and instruction for coping with frail, multi-impaired older relatives. About 35 new clients are evaluated every month, and the clinic carries a continuing caseload of some 150 clients. Costs for clinic visits are covered on a sliding scale by Medicare, Medicaid, and Blue Cross/Blue Shield. H o m e visits are not covered by insurance, and clients usually are not charged. The Care Process
T h e evaluative process begins with a home assessment for clients who live within a 10- to 20-mile ra-
Geriatric Nursing November/December 1983 379
.U,t O W r l
/
S
ssessmeilt c,.tld Co, re
Ann Brown, 73 years old, was referred to the clinic by her daushter because of "depression," "confusion," and "memory loss." The daughter was concerned because her mother had become increasingly withdrawn, refusing to go to church or participate in her usual activities. Ms. B. lived alone in her own home; her husband had died one year ago. I made an initial assessment of Ms. B. in her home with her daughter present. The house was a small, one-story, brick structure in a lower middle class neighborhood. There were three steps leading up to the front door but no handrail. I was greeted by a small, frail, gray-haired woman and her attractive, well-dressed daughter, who appeared to be in her early 40s. She had taken time from her job as a bank teller in order to meet with~me. The house was relatively neat, though cluttered with memorabilia. There were two bedrooms, a small kitchen and bath, and living and dining rooms. The house was well heated and comfortable, the floors highly polished. The cupboards were well stocked with food, but the client had no appetite and refused to eat. The medicine chest contained only Bufferin for mild arthritic pain and occasional headaches, multivitamins, and milk of magnesia for occasional constipation. As Ms. B. walked to her chair, she used a cane and appeared to have difficulty seeing where she was going. When I inquired about her vision, she said cataracts were forming in both eyes but were not fully enough developed for surgical removal. Her unsteady gait was due to visual impairment rather than a problem with
dius of the clinic. T h e purpose is to d e t e r m i n e whether the older person can continue to live safely in his or her home, what environmental modifications m i g h t be necessary to promote independerit living, and whether health care r e c o m m e n d a tions can be carried out in the home. Following the h o m e visit (where this is possible), clients c o m e to the clinic for a thorough intake evaluation. T h e intake consists of a functional assessment, using the M F A Q , a complete history and mental status exam, physical exam, and psychiatric evaluation with psychological testing when indicated. Frequently, the family is ineluded in both h o m e and intake assessments in order to obtain a full picture of the older person's situation and potential resources for interdependent functioning.
balance or musculoskeletal deficits. A brief physical assessment showed that her reflexes were normal and symmetrical. Her range of motion was slightly impaired in the weight-bearing joints. There was no evidence of postural hypotension. A brief history revealed that Ms. B.'s past few years had been characterized by loss, culminating with" the death of her husband. Loss of visual acuity had decreased her social" activities. An avid reader, she was unable to enjoy her favorite mystery novels or keep up with events in her newspaper. Mr. B. had provided much of the transportation and social networking for his wife. He drove her to church and other activities, read to her, and helped with household duties. The daughter was concerned but unable to provide day-to-day help due to responsibilities to her husband and three children plus a full-time job. She was worried about her mother's safety and ability to live alone; Ms. B. was adamant about staying in her own home. The home assessment led me to think that Ms. B. might be able to manage at home with environmental modifications and the help of community services. During the administration of the O A R S multidimensional functional assessment questionnaire [see text] at the clinic, Ms. B. was quiet, withdrawn, and tearful at times, especially when talking about her husband's death and her loss of vision. She was disturbed by her impaired memory but attributed that to "old age." She appeared thin, pale, and gaunt. Questionnaire results showed that her memory was somewhat impaired, with a total of five errors on the mental status exam. When questioned, she was uninterested in answering, preferring to say that she didn't know or could not remember. This is diagnostically significant, since persons with organic brain disease tend to confabulate or hide the fact that
W h e n assessment is complete, the p r i m a r y evaluating clinician presents the case, together with a plan of care, to the interdisciplina r y t e a m conference. T h e p r i m a r y evaluating clinician m a y be from a n y discipline and should have been present at the home visit and intake. During the t e a m conference, m e m b e r s of the various disciplines share their particular insights, a final care plan is approved, and a clinician f r o m the most a p p r o p r i a t e discipline is designated as the person to c a r r y it out. A t the s a m e time, a date is set for. follow-up evaluation. As nurse clinician I work as a m e m b e r of the team, primarily as caregiver, educator, and researcher. T h e s e roles require client assessment, intervention, and evaluation; collaboration with other professionals; role modeling for students of
380 Geriatric Nursing November/December 1983
nursing and other disciplines; carrying out clinic administrative tasks as designated by the clinic supervisor; and conducting independent or collaborative clinical research related to nursing and the aged client. T h e Nurse Clinician Role T h e appended case study illustrates m y role when acting as prim a r y evaluating clinician. Nursing interventions within the clinic inelude health teaching of clients and families; health monitoring, such as taking blood pressures or observing tolerance of drug t r e a t m e n t ; counseling clients and families; and coordinating care given by various service providers. I also act as a consultant to other professionals or nonprofessionals in institutional 9 and c o m m u n i t y settings. So the consultation usually focuses on spe-
they do not know the answers. The functional assessment revealed that Ms. B.'s social and economic resources and physical health were satisfactory or better but that her mental health was severely impaired. She had marked psychiatric symptoms that interfered with routine judgments and decisions in everyday life. As a result, she had moderate impairment in A D L capacity, due not only to her mental health status but also to her impaired vision. The medical exam revealed that Ms. B. was a relatively healthy woman with mild arthritis in her knees and hips, and early cataract formation. Lab studies, including a CBC, thyroid panel, urinalysis, folate, a n d BI2, were normal. The psychiatric exam helped to confirm earlier suspicions that the client was suffering from a reactive depression, resulting from an accumulation of losses associated with late life. The psychiatrist prescribed a low dose of imipramine (Tofranil) to help Ms. B. increase her activity. I presented the case to the multidisciplinary team with this proposed plan of action: 1. Weekly therapeutic counseling at the clinic with medication monitoring. 2. Mobilization of community resources to provide a home health aide and transportation services. 3. Environmental modifications, including color coding, handrails, and less polish on floors in order to reduce the glare. I would be the primary clinician, responsible for counseling, medication monitoring, coordination of services, and environmental modifications. The psychiatrist would act as consultant for medication management. The physical therapist would go on the next home visit with me to assess Ms. B.'s arthritis and the possible use of mild exercise. The team agreed to the
cific needs of older clients and the ways that their needs m i g h t best be met under the prevailing circumstances. On a multidiseiplinary t e a m , responsibilities of the various clinicians often overlap and boundaries m a y b e c o m e unclear. It is frequently 9evident, however, that through counseling, monitoring of health t r e a t m e n t , or using social resources, the nurse is in an excellent position to carry out health teaching and preventive care that prom o t e the older c l i e n t ' s independence for as long as possible. Students of m a n y health-related disciplines (social work, nursing, psychology, medicine, or pastoral counseling) continually rotate through the clinic. M y chief educational responsibility is to serve as preceptor to four or five u n d e r g r a d uate and one or two g r a d u a t e - n u t s -
plan, which was implemented immediately. With the help of the local Council on Aging, a home health aide was provided three hours a day. The aide prepared meals, did light cleaning and shopping, and provided socialization by reading to Ms. B. and discussing daily events. I put red-colored markers on chairs, doorways, and counters to prevent bumps and falls; sheer curtains were added to reduce glare. A handrail was attached to the front steps, and red strips on the step edges to prevent tripping. The physical therapist prescribed exercises, which, although reluctantly carried out initially, were most useful and enthusiastically performed later on. I saw Ms. B. weekly for supportive counseling. She responded beautifully to the combined medication, counseling, and social support. Gradually she ate better, became more outgoing, and displayed greater interest in social activities: She eventually regained interest in church affairs and began participating in senior center activities twice a week. 9 It has been one year since Ms. B. first came to the clinic. Her functional ratings on the M F A Q have improved: from 5 (severely impaired) to 2 (good) on the Mental Health Scale, and 4 (moderately impaired) to 3 (mildly impaired) on the Activities of Daily Living Performance Scale. Her mental status improved and she had only one error on the mental status exam. She has adjusted to her impaired vision with the help of the environmental modifications. Her home health aide has become her friend and Companion, and life seems brighter and happier. Ms. B. continues to take a mild dose of imipramine and occasionally comes to the clinic on anniversary d a t e s - - h e r husband's death, for instance--or when she wants to talk over her problems. She was a joy to work with and her progrcss constituted a very satisfying success s t o r y . - - M A M
ing students. A b o u t 30 percent of m y time in the clinic (where I spend 70 percent of m y total time) is devoted to precepting. O f the 30 percent of time at the school of nursing, a b o u t 5 percent involves precepting. T h e learning focus is holistic nursing care of the geriatric client in the comtnunity, health maintenance, prevention of illness, and the nurse's role as a multidisciplinary t e a m m e m b e r . T e a c h i n g methods include videotaped and written lectures to provide theory base; individual discussion of values, attitudes, and specific needs of the "elderly; and clinical experience with clients. Acting as role model for nursing students is, perhaps, the clinician's most vital function. M y research has focused on depression in the elderly, the relationship of life circumstances to depres-
sion, and the use of group reminiscing as a m o d e of treatment. This research has been carried out both independently and collaboratively. Clearly, the nurse clinician role is multifaceted; so are the services that the O A R S - G E T clinic provides for its clients. Therein, I believe, lies the source of m y satisfaction in the work and the clients' satisfaction in the care received. References I. Harris. C. S, Fact Book on Aging: +4 Profile o f America's Older Population. Washington. D. C.. The National Council on the Aging. 1979. p. 3. 2. U. S. Census Bureau. Statistical Abstract o f the United States. 1981. Washington, D.C.. U.S. Government Printing Office. 1981. 3. Matteson. M. A. The Geriatric Care Process: The Duke O A R S Core Curriculum. Durham. N.C.. Duke University Medical Center. 1981. 4. Duke Center for the Study of Aging and tluman Development. Multidimensional Functional Assessment: The O A R S Methodology. 2nd ed. Durham. N.C.. The Center. 1978.
Geriatric Nursing November/December 1983 381