- Email: [email protected]
A methodology in surveying geriatric patients, facilities and services
Soc. Sci. & Med., Vol. 12. pp. 229 to 234. © Pergamon Press Ltd. 1978. Printed in Great Britain.
0037-7856/78/0701-0229502.(X~/0
A METHODOLOGY IN SURVEYING GERIATRIC PATIENTS, FACILITIES AND SERVICES* ROMUALD K. SCHICKE Medizinische Hochschule Hannover, 3 Hannover 61, Postfach 610 180, West Germany Abstract--This study focuses upon the methodology employed in surveying long-term patients, geriatric facilities and their services, with implications for planning endeavors in improving medical and social services for the aged. The research is characterized by a twofold inquiry; one directed to patient characteristics reflecting service needs and the other directed to the data relating to the services themselves. A comparison of the social and medical needs of the aged with the capabilities of services to meet these needs provides valuable information for planning purposes.
INTRODUCTION
Increased life expectancy and a correspondingly higher prevalence of chronic disabling diseases characterize modern and future trends in the health care delivery system. Average life expectancy (at birth) in the U.S.A. has increased at the turn of the century from 49.2 to 70.1 years in 1966 [1]. As an increasing proportion of the population needs care in the realm of degenerative diseases and disabling conditions (such as heart diseases, arthritis, respiratory conditions, high blood pressure, diabetes, visual and hearing impairments), increasing medical care other than that provided in acute, special or allied hospitals (Table 1) will be necessary. In 1970, the aged, representing nearly 10~ of the total population in the U.S.A., utilized between 26 and 33~o days of care in short-stay hospitals, with an average length of stay of 13.1 days for those aged 65 and over compared with 7.7 days for all age groups E2]. Furthermore, there is a considerably higher utilization of physician services by the aged (6.1-6.2 visits per person/year) than by the total average population (4.3) [3] and an approximately threefold consumption of drugs and medications [4], as reflected in Table 2. The risk of (various degrees of) disability and impairment has increased among the aged population. This is aggravated by decreasing family dependence with the trend towards smaller families and households, changing from three to two generation units. Thus, greater dependence upon institutional care (of varying degrees) (as seen in Table 3) inevitably impinges on the quality of social life remaining for the aged [5]. Consequently, the increased expectation of life has been qualitatively and quantitatively accompanied by the weakening social ties and aggravated by hard-core risk of bed disability and institutionalization, as reflected in Table 4 [6]. * Based upon a study conducted by the author while Director of Research, Health Facilities Planning Council for New Jersey. Princeton, N.J.
It seems, however, that success in reducing institutionalization, has been more evident in the area of mental disease than others as a result of chemo-therapeutical achievements. The need for health care services has varied more for the aged than for other groups. In 1972 16.7~o of those aged 65 and over underwent one or more hospital admissions and experienced, on average, 36.5 days annually of restricted activities, 14.1 days of bed disability [7] and were the main utilizers of long-term facilities including nursing homes. Owing to the varying health and nursing needs, especially among the aged, several studies indicate a "misplacement" factor with over or under-use of services or facilities [8, 9]. Thus, the proper level of services to be provided for the geriatric patient becomes of utmost importance in order to minimize the "institutionalization syndrome" and to allow for the best possible social functioning. The higher rate of disability and illness of the aged has resulted in increased costs of care (see Table 2) in stark contrast to the limited financial resources available; government funds contributed 68'ko of resources towards care of aged in 1971 [4]. It seems that the problems for the aged in health care are aggravated not only by the scarcity of appropriate services (rendered at the proper time in an appropriate facility), but also by financial considerations. In providing more appropriate services they could also be rendered more economically. The social, medical, and economic situation of (the needs of) the aged provides a framework within which nursing homes can be seen to play an important role in meeting the socio-medical needs of the aged. The traditional gap between the acute health care institutions and the patients' homes has been filled by profit motivated enterprises. This is due to the prevailing philosophy and public image of a nursing home, as a predominantly personal maintenance and custodial facility, in which health services are marginal or incidental as such, rather than central. However, the nursing homes' structure has been changing in recent years. With the introduction of the Title 19 (PL 89-98, Social Security Amendments of 1965) more certification in the long-term facility sector (e.g.
229
230
ROMUALD K. SCHICKE Table 1. Per cent of non-institutionalized persons 65 and over limited in activity due to chronic conditions, U.S., July, 1963-June, 1965 Per cent of old people who are limited as a result of that condition
Condition Heart conditions Arthritis and rheumatism Orthopedic Impairments (excluding paralysis or absence of arms, legs, back spine or hips) Visual impairments High blood pressure Mental and nervous condition Genito-urinary conditions; paralysis Diabetes; asthma and hay fever; hernia; hearing impairments Varicose veins; chronic sinusitis and bronchitis Neoplasms (cancersj; peptic ulcer Hemorrhoids; tuberculosis
22~o 2l~o
11~o 9~o 8~o 6'~/0 4~o each 3% each 2~o each 1~ each < 1~o each
Source: [I] Table 2. Per capita expenditure for personal health care for two age groups, fiscal year 1966 All ages
Under 65
65 and over
71.59 44.55 14.40
60.76 39.98 14.58
176.01 88.65 12.72
5.73 25.29
5.14 21.50
11.39 61.75
6.58 7.07 6.79
5.68 0.78 6.75
15.24 67.69 7.22
$182.02
$155.18
$440.68
Hospital care Physicians" services Dentists" services Other professional services Drugs and drug sundries Eye glasses and appliances Nursing home care Other health services Total Source: [4]
Table 3. Per cent distribution of residents in nursing and personal care homes, degree of patient care according to age; United States (May-June, 1964)
Age All ages Under 65 65-74 75-84 85 and over
Intensive
Other nursing
Personal
Neither nursing nor personal
31.0 25.3 28.3 30.3 36.5
28.7 24.2 30.1 29.4 28.5
26.9 31.4 26.3 27.2 24.8
13.5 19.1 15.4 13.2 10.1
Source: [5] Extended Care Facilities), has been accompanied by an increase of care standard requirements t h r o u g h b o t h licensing and accreditation (mechanisms). W h e n considering the general data available in long-term facilities, it is found that data on facilities' requirements are more readily available t h a n informa-
tion suitable to assess the actual services provided in different institutions to p a t i e n t s . w i t h various characteristics and needs (aside from cost factors or services rendered). The latter aspects constitute the main targets for the study which aims to provide pertinent informa-
Surveying geriatric patients, facilities and services
231
Table 4. Expectation of healthy life at age 65 (in years)
Fiscal year
Expectation of life*
Expected bed-disability and institutionalization
1958 1960 1962 1964 1966
14.2 14.5 14.6 14.3 14.6
1.1 1.1 1.1 1.1 1.1
Expectation of healthy life 13.1 13.4 13.5 13.2 13.5
* For calendar year Source: cited in [-6] tion on both patients and facilities, and by comparing services with patients' characteristics to determine to what extent they are or can be adequately met.
OBJECTIVES AND METHODOLOGY As indicated, the objectives of the study are to render a profile of patient population in the light of the characteristics of long-term facilities in the State of New Jersey. The studies' data reflecting various medical, social, financial and related information on all patients, may provide a generalization on the assessment of patients' needs in terms of their characteristics. Furthermore, against the background of patient information, the study aims to analyse patient characteristics in the light of services provided by the facilities. Among its core objectives, the study aims to provide indices, employing objective standards and definitions wherever possible, in order to reach conclusions about the given social, physical, and emotional needs of the aged or how they may be met by the facilities surveyed. Moreover, it is intended to isolate problems and problem areas of the long-term facilities concerning the kind and scope of care they provide and in the realms of personnel, physical, plant, financing, and patient services, that might hamper improvement of services. It is hoped that this study's approach which attempts to match patients' characteristics against the service that the homes provide, may contribute to the knowledge of needs and problems of patients and their institutions and stimulate further research.
Methodology A one-day census of long-term facilities' patients was comprised of 206 Licensed Nursing Homes, 25 Approved Medical Institutions, and 44 Incorporated Homes for the Aged (Infirmaries only) providing various social, medical, financial, and other pertinent information on 9918 patients and yielding an overall 77% response from the facilities surveyed. In total, 115,665 patient information data, averaging 12 types of information per patient, have been gathered and analyzed. Data on nearly 10,000 long-term facilities' patients were obtained by u s i n g a questionnaire-type format, condensed on an IBM PORT-A-PUNCH card for each individual patient during a one-day census [10-12]. More than 300 long-term facilities' staff
members provided the basic data on both patients and facilities surveyed. The card-questionnaire has been accompanied by an appropriate catalogue of instructions and definitions to ensure uniformity and compatibility. The IBM card provided for 11 categories of questions comprising information on the patient's admission date, placement and referral pattern, frequency of visits, patient's former address, home address of relative or sponsor, sex, age, marital status, main source of payment, type of accommodation occupied, and an array of various patient characteristics including mobility and health status, attitudes and behavioral pattern (see Fig. 13 The manually punched prescored card served as a direct input media for electronic data processing, prior to a desk review for accuracy. To isolate further errors or conflicting information, an EDP error analysis preceded the final tabulations. By using the questionnaire PORT-A-PUNCH card as an EDP input medium, transcription errors have been entirely eliminated and others owing to afore mentioned reviews appreciably minimized. Consequently, information from facilities has been solicited through a conventional questionnaire accompanied by instructions and definitions. Collected data have been processed manually, tabulated and appropriately analyzed. A post-coding method was elected in order to accommodate proper classification of answers to some open-end questions. The ctverall survey's data yielded a 77% response rate from all long-term facilities in the State of New Jersey. Because of limitations imposed by expense and time an in-depth analysis of data was confined to a representative 10% sample. The stratification of longterm facilities licensed nursing homes, approved medical institutions, and incorporated homes for the aged (infirmaries) was considered according to size and number of patients in order to obtain a representative cross-section stratified by both type of homes and patients. The stratified sample embracing 21 longterm facilities (15 licensed nursing homes, 2 approved medical institutions, 4 incorporated homes for the aged) when compared with the patients' survey revealed information on 991 patients. In addition to the quantitative verification, data in the sample's 991 patients have been tested for contents and their significance regarding various patients' characteristics. The correlation analysis carried out which focused on separate and distinct information elements, rendered an overall strong correlation (r = 0.98209) of the known universe.
232
ROMUALD K. SCHICKE
DIAGRAM HE At.TH
FACIL I
OF SURVEY'S DESIGN
~
LONG TERM PATIENT ORIGIN SURVEY
ONE DA't CENSUS MIDNIGHT,
S E P T E M B E R 15,196,5
[~
Long-Term
~I~ DATL PAIIFNI ACIdlTIED:
....
Long-Term
Patients
@
[',,~
P~A'En
X
FFI ATIVF%
X OIHFR
@ ~,~ x
~
HOSPITAL
wl F K L Y I
X EVER' FrW MONTItS
~1 w E~ LY
X ANNUaLlY
X MCNTHL
Facdities'
Pat0ent's
~ OT.FII IAGFNCY ORGbNli~ATInN)
Z~o'~T~,rs :
I
X NEVER
Comparison
---
rE
HUNORfDS
,
4
~
.. '[
Charactenstocs
Characteristics
~ATIr;.T'S ,,3'dE ,:.CDRE3S CG3E ;
I
-~
T ¢
RE@';RFIrr, BY:
--a~n--
FAM'Iy IIM~q[[IAI[}
~ _
Facihties
%
g
(
UNIT~ . . . . . . .
i
,
5
i
.
R
C3DE C7
::CMF ADDr'c?S
I
SPC:;COR ;~EL ~T;'*'E C,q FP;CND~:
I
--tENS
dNITS
Evaluation and Planning
4
7 ,~jSEX :
g
L@ ~/
I
|
,o
2O
30
,
2
Ill
I
9 - --
X
WlOOWE
lib
so
so
70
SO
so
4
5
S
?
e
s
,oo
~ i NL PAY ;FflEE]
o~N NESOUHCES X FAM,Ly C~R IEt ATIVI~S,
X PtBLIC AS31SrANCE
SLUL CROSS
~ PR;','~T[ CMARITASLE
OTHf~ ~ITALTH ~N~,URANCE
X O~HER
~-~ NUMBER ~
O~G~NI~TION
~Sl-N"
q';~,, PAT;ENTS C RA l X R~-YSCltN ~----
~
PATIENT HOUS'~D
$$~1C5
DET RMIN .~<~ Nt.RSE PUNCH ALL APPROPR+ATE
X iN~CNT, ~E~IT
PECULIAR C'R nlsruRBl~G HABITS
X PODR LIVING AN0 EAtinG '4ABITS
X a ~ U A;VRY
),~ P.ySlSAL
BI "T~R
[~
IiOTHER
PARTICIPATING
X PA,~,VE. w, :HCHANN
SEU'- AMBU AI U ~
X m(NIAL
-~-
I~clwz.
>~ BEU~Sr
FRIL,~AT,ON
It
ot TERIORAIdUN
COWVALE 9CENT R[ COVEHIN$
I ~ R E ~ E F T S INSTI"UTIONAL CAR~
RF ;~GI~EO
X NON~ OF THE!E
k SE PENCIL ONLY :
m
~i
C.O
i
Cq n
8F
~I)R~
PUNCHED
TABS
Feed-Back
Path
X SEPAFIATEO-OIVORCED
MARRIEI)
~h.~ HA, N SOUF~ or ~ A Y M ~ :
I
7
X SIId~LE
X ~EMALE
~'x
9
MAQ&TAL STATUS :
b~,~,lllll ~ t, k E
.~ ARE ENTIRELY
REMOVED
Fig. 1. PORT-A-PUNCH questionnaire card.
The dual approach, at first, a stratified sample for institutions and subsequently independently verifying the patients' characteristics against the known universe, adequately support the relevance/significance of the data used in the study. Non-responses generally constitute a problem area in research, also when dealing with a finite universe. In this study, the problem of non-responses has been approached by resorting to the correlation-coefficient method. From the distribution of non-responses in the finite universe, an expected sample was drawn and measured against the actual occurrence in the experience sample, rendering a value of r = 0.81569; thus, a relatively satisfactory correlation factor between both elements has been established. The methodological approach used in this study is reflected by the following diagram (Fig. 2):
Fig. 2. Diagram of survey's design. STUDY RESULTS
Characteristics of patients The majority of the homes' occupants were female (73%). The proportion of widowed patients predominated, comprising almost two thirds of all residents in the long-term facilities. The age group composition revealed that 30% of the patients were between the ages of 70 and 79; those between 80 and 89 years old represented the single highest age category, or 42% of all patients. The average age of the patient was 79.3 years. Reportedly, 29 patients were over 100 years old, among whom the oldest was 106 years of age. Parenthetically, the above study's findings are supported by two other surveys' data [-13, 14]. According to the determination made by nurses: (63% of cases), physicians (20% of cases), or both (11%), among 14 characteristics to be optionally selected for each of the patients, the following were most frequently named: physical deterioration, semiambulatory mobility status, and mental deterioration. A characterization by mobility status indicated that 15.9% of the patients were bedridden, 47.6% semiambulatory, and 36.5% ambulatory. Notably, less than 9% of patients were described as convalescent or recovering. A positive characteristic stating that 35.3% of the patients were active and participating within the scope of their physical and mental capabilities, was contrasted by the fact that 16% of the patients were passive and withdrawn, 17.6% displayed peculiar and disturbing habits, 7.3% were bitter and resigned, and 5,7% were resentful of institutional care. The study revealed that nearly 70% of the patients were placed in the institutions by family members. Physicians made arrangements for the patients' referrals in 49% of cases, hospitals assisted in 14% of the placements, and 37% of the patients were accommodated through arrangements by other agencies and organizations, the County Welfare Department among others.
Surveying geriatric patients, facilities and services More than half of the patients, or 52 out of 100, received social calls weekly, 31 had bi-weekly or monthly visitors, and 2 out of 100 were visited once a year. It was hypothesized that the frequency of social calls was, in part, dependent upon social ties connecting the patients with relatives and/or friends, related to the marital status, to the patients' sex, and the distance to the former place of residence. When related to the marital status, the findings reveal that 85.4~o of the married patients were visited most frequently (in weekly or bi-weekly intervals), followed by widowed (68.6~), single (42.5~) and lastly by separated/divorced (36.8~o). In addition, those patients characterized as active and participating received more social calls than those withdrawn or resentful of institutional care. The analysis of the variables conducted for each marital category by in- and out-of-county residents has revealed that the location of the patients' former permanent place of residence had no influence upon the frequency pattern of social calls. Hereby, the ~2 and contingency coefficient methods were employed. Moreover, with regard to in- and out-of-county residents, data were computed by each marital status, however, not revealing appreciable differences for visits by "in- versus out-of-county" residents. Such results provided guidelines for regional planning efforts in the area of long-term facilities with regard to location. Attributable, in part, to the size and structural character of some of the homes affording smaller size rooms, 49 out of 100 patients occupied private and 2-bedroom accommodations, 8 out of 100 stayed in rooms with four or more beds. Facilities and services
Based upon the study's findings, the overall average length of stay approximated 300 days. Patients in the homes for the aged stayed longer (581 days), followed by those in approved medical institutions with 572 days, and patients in licensed nursing homes staying for nearly 236 days computed by the formula: 2 x patient days admissions + discharges Considering the varying patient needs in terms of their physical handicaps, mental status, and social needs in the light of institutional programs, both formal and informal types, programs have shown considerable gaps and shortcomings. Reportedly, approximately one fourth of the facilities surveyed carried out formal rehabilitation programs, occupational therapy, social rehabilitation activities, and active recreational therapy, although such programs notably varied in degree and scope. It thus became evident that predominantly larger facilities can more adequately maintain such programs, while smaller facilities, partially owing to economic considerations, may limit their programs to mainly informal, "casual" occupational, social rehabilitation, and "passive" recreational programs. Combining all facilities in the sample (21), the average size of an institution was 56 beds. When relating the availability of active physical rehabilitation programs, it was found that they were more concentrated
233
however, although rather unevenly distributed, amongst 33~o of facilities in homes averaging 87 beds, while the balance of facilities (67~) provided no formal programs. Nevertheless, the latter did offer some informal, part-time recreations stressing "passive" rather than "active" efforts. Some authors [15, 16] have viewed the potentiality of rehabilitating nursing home patients with some scepticism; however, especially when a strict selectivity of potential rehabilitation candidates is or cannot be observed. A further study [17], reflecting the views of 35 nursing home operators, takes a rather sceptical stand and a dim view as to the rehabilitation possibilities of their patients. More specifically, while 25~ of the respondents did not state any problems connected with rehabilitation programming, an equal percentage could be explained by the facilities' fiscal and physical inabilities to provide such services. 50y/oof the respondents placed the blame upon the general disinterest of patients to participate in such programs. Nevertheless, through concentrated selective efforts, and taking into account the prognosis for improvement, the lot of a number of aged persons could be grossly ameliorated, either medically, socially or both by adding "life" to age. Still another author, while taking a more positive attitude toward rehabilitative potentials for patients, poses the question as to what implications rehabilitation efforts may have for patients from 70 years of age and over. Such concern may, in part, be justified when one considers a patient population in such an advanced age group afflicted with a variety of physical and mental handicaps and ailments. Nonetheless, the rehabilitation could be conceived as a provision of "the whole spectrum of opportunity extending from the full restoration of a human being to normal affective function in an appropriate environment to the lowest level of success characterized by humane maintenance care under circumstances that may not even be perceptible to the patient but color and influence the life of others." [18]. As illuminated by the above definition, some students of nursing care take a more positive view of the merits of a therapeutic effort, stratified according to patients' capabilities and potentialities, and stressing the needs of greater patient self-reliance or return to greater self-sufficiency with the aid of appropriate occupational and other therapies. Motivating the patients to make optimum use of their remaining and latent physical and mental faculties, within the limitations imposed by their condition, seems to be the major philosophical theme of any rehabilitative endeavor. Admittedly, these efforts have, of course, to be seen within the given constraints as this study's findings indicate. Among the problems encountered by longterm facilities, those affecting the shortage of personnel were predominant. Out of 21 facilities reporting. 13 listed personnel, 4 financial and physical plant, 1 organizational, and 1 patient care as problem areas of their prime attention. The difficulties encountered by long-term facilities in the realm of fiscal and personnel situations are common to a large number of those institutions generally. It seems that long-term facilities are less
234
ROMUALDK. SCHICKE
attractive to nursing personnel when dealing with older people in terms of professional gratification and incentives. Regrettably, this attitude is the result of a society dominated by the glorification of youth. Despite the problems with which the surveyed facilities face, a number are concerned with improving and expanding their services. Of these, 6 facilities intend to extend their services in the realm of social and recreational activities to include occupational and physiotherapy.
SUMMARY The survey of patients and long-term facilities using a dual methodological approach may prove suitable in gaining appropriate information for an assessment of services' needs based upon characteristics of aged patients and facilities separately. Owing to the varying needs for social and medical services an intensified effort is needed to meet them at various levels of institutional and extra-institutional care emphasizing greater need for co-operation and coordination among facilities in order to cope with the demands of the increased proportion of the aged. It is hoped that this paper will stimulate further inquiries into a geriatric care sector, which is, regrettably, so rarely explored.
REFERENCES
1. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Chronic Conditions causing Activity Limitation, United States, July, 1963-June, 1965; Series 10, No. 51, February 1969. 2. Pettengill J. H. Trends in hospital use by the aged. Soc. Sec. Bull. 38, 3, 1972. 3. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Current Estimated from the Health Interview Survey, United States 1969, Series 10, No. 63, 1971.
4. Cooper B. S. and Worthington N. L. Medical care spending for three age groups. Soc. Sec. Bull. 35, 3, 1972. 5. U.S. Department of Health, Education and Welfare, National Center for Health Statistics, Series 12, No. 10. Nursing and Personal Care Services Received by Residents of Nursing and Personal Care Homes, United States, May-June 1964, Washington DC, 1968. 6. U.S. Department of Health, Education and Welfare. Toward a Social Report. Ann Arbor, University of Michigan Press, 1970, p. 4. 7. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Prevalence of Selected Chronic Respiratory Conditions, United States--1970, Series 10, No. 84, 1973. 8.--Shelton D. S. et al. Bed utilization--a community study. Hospital Mgmt 105, 47, 1968. 9. Berg R. L. et al. Assessing the health care needs of the aged. Hlth Serv. Res. $, 36, 1970. 10. Schicke R. K. Patient origin study tests new inquiry technique. Hospital Topics, April 1966, pp. 55-57. 11. Schicke R. K. Facts on 780,000 hospital patients uncovered in statewide study. Hospitals J.A.H.A. 41, 56, 1967. 12. Schicke R. K. Health services research and methodologies in planning for medical care facilities, some international comparisons. Meth. Inform. Med. 10, 163, 1971. 13. U.S. Department of Health, Education and Welfare, Public Health Service, Division of Hospital and Medical Facilities. A Comparative Study of 40 Nursing Homes, their Design and Use, Washington DC, 1965. 14. U.S. Department of Health, Education and Welfare, Public Health Service. Nursing Homes, their Patients and their Care, Public Health Monograph No. 46, Washington DC, 1957, 15. Muller J. et al. The rehabilitation potential of nursing home residents. Am. d. publ Hlth 53, 243, 1963. 16. Kelman H. R. An experiment in the rehabilitation of nursing home patients. Publ. Hlth Rept. 77, 356, 1962. 17. Mahaffey T. E. Proprietary nursing homes--a report on interviews with 350 nursing home operators in Detroit, Michigan. Health Information Research Series No. 18, New York, 1961, pp. 15-18, 22. 18. Rogers R. Rehabilitation in focus. Nurs. Home 16, 11, 1967.
0037-7856/78/0701-0229502.(X~/0
A METHODOLOGY IN SURVEYING GERIATRIC PATIENTS, FACILITIES AND SERVICES* ROMUALD K. SCHICKE Medizinische Hochschule Hannover, 3 Hannover 61, Postfach 610 180, West Germany Abstract--This study focuses upon the methodology employed in surveying long-term patients, geriatric facilities and their services, with implications for planning endeavors in improving medical and social services for the aged. The research is characterized by a twofold inquiry; one directed to patient characteristics reflecting service needs and the other directed to the data relating to the services themselves. A comparison of the social and medical needs of the aged with the capabilities of services to meet these needs provides valuable information for planning purposes.
INTRODUCTION
Increased life expectancy and a correspondingly higher prevalence of chronic disabling diseases characterize modern and future trends in the health care delivery system. Average life expectancy (at birth) in the U.S.A. has increased at the turn of the century from 49.2 to 70.1 years in 1966 [1]. As an increasing proportion of the population needs care in the realm of degenerative diseases and disabling conditions (such as heart diseases, arthritis, respiratory conditions, high blood pressure, diabetes, visual and hearing impairments), increasing medical care other than that provided in acute, special or allied hospitals (Table 1) will be necessary. In 1970, the aged, representing nearly 10~ of the total population in the U.S.A., utilized between 26 and 33~o days of care in short-stay hospitals, with an average length of stay of 13.1 days for those aged 65 and over compared with 7.7 days for all age groups E2]. Furthermore, there is a considerably higher utilization of physician services by the aged (6.1-6.2 visits per person/year) than by the total average population (4.3) [3] and an approximately threefold consumption of drugs and medications [4], as reflected in Table 2. The risk of (various degrees of) disability and impairment has increased among the aged population. This is aggravated by decreasing family dependence with the trend towards smaller families and households, changing from three to two generation units. Thus, greater dependence upon institutional care (of varying degrees) (as seen in Table 3) inevitably impinges on the quality of social life remaining for the aged [5]. Consequently, the increased expectation of life has been qualitatively and quantitatively accompanied by the weakening social ties and aggravated by hard-core risk of bed disability and institutionalization, as reflected in Table 4 [6]. * Based upon a study conducted by the author while Director of Research, Health Facilities Planning Council for New Jersey. Princeton, N.J.
It seems, however, that success in reducing institutionalization, has been more evident in the area of mental disease than others as a result of chemo-therapeutical achievements. The need for health care services has varied more for the aged than for other groups. In 1972 16.7~o of those aged 65 and over underwent one or more hospital admissions and experienced, on average, 36.5 days annually of restricted activities, 14.1 days of bed disability [7] and were the main utilizers of long-term facilities including nursing homes. Owing to the varying health and nursing needs, especially among the aged, several studies indicate a "misplacement" factor with over or under-use of services or facilities [8, 9]. Thus, the proper level of services to be provided for the geriatric patient becomes of utmost importance in order to minimize the "institutionalization syndrome" and to allow for the best possible social functioning. The higher rate of disability and illness of the aged has resulted in increased costs of care (see Table 2) in stark contrast to the limited financial resources available; government funds contributed 68'ko of resources towards care of aged in 1971 [4]. It seems that the problems for the aged in health care are aggravated not only by the scarcity of appropriate services (rendered at the proper time in an appropriate facility), but also by financial considerations. In providing more appropriate services they could also be rendered more economically. The social, medical, and economic situation of (the needs of) the aged provides a framework within which nursing homes can be seen to play an important role in meeting the socio-medical needs of the aged. The traditional gap between the acute health care institutions and the patients' homes has been filled by profit motivated enterprises. This is due to the prevailing philosophy and public image of a nursing home, as a predominantly personal maintenance and custodial facility, in which health services are marginal or incidental as such, rather than central. However, the nursing homes' structure has been changing in recent years. With the introduction of the Title 19 (PL 89-98, Social Security Amendments of 1965) more certification in the long-term facility sector (e.g.
229
230
ROMUALD K. SCHICKE Table 1. Per cent of non-institutionalized persons 65 and over limited in activity due to chronic conditions, U.S., July, 1963-June, 1965 Per cent of old people who are limited as a result of that condition
Condition Heart conditions Arthritis and rheumatism Orthopedic Impairments (excluding paralysis or absence of arms, legs, back spine or hips) Visual impairments High blood pressure Mental and nervous condition Genito-urinary conditions; paralysis Diabetes; asthma and hay fever; hernia; hearing impairments Varicose veins; chronic sinusitis and bronchitis Neoplasms (cancersj; peptic ulcer Hemorrhoids; tuberculosis
22~o 2l~o
11~o 9~o 8~o 6'~/0 4~o each 3% each 2~o each 1~ each < 1~o each
Source: [I] Table 2. Per capita expenditure for personal health care for two age groups, fiscal year 1966 All ages
Under 65
65 and over
71.59 44.55 14.40
60.76 39.98 14.58
176.01 88.65 12.72
5.73 25.29
5.14 21.50
11.39 61.75
6.58 7.07 6.79
5.68 0.78 6.75
15.24 67.69 7.22
$182.02
$155.18
$440.68
Hospital care Physicians" services Dentists" services Other professional services Drugs and drug sundries Eye glasses and appliances Nursing home care Other health services Total Source: [4]
Table 3. Per cent distribution of residents in nursing and personal care homes, degree of patient care according to age; United States (May-June, 1964)
Age All ages Under 65 65-74 75-84 85 and over
Intensive
Other nursing
Personal
Neither nursing nor personal
31.0 25.3 28.3 30.3 36.5
28.7 24.2 30.1 29.4 28.5
26.9 31.4 26.3 27.2 24.8
13.5 19.1 15.4 13.2 10.1
Source: [5] Extended Care Facilities), has been accompanied by an increase of care standard requirements t h r o u g h b o t h licensing and accreditation (mechanisms). W h e n considering the general data available in long-term facilities, it is found that data on facilities' requirements are more readily available t h a n informa-
tion suitable to assess the actual services provided in different institutions to p a t i e n t s . w i t h various characteristics and needs (aside from cost factors or services rendered). The latter aspects constitute the main targets for the study which aims to provide pertinent informa-
Surveying geriatric patients, facilities and services
231
Table 4. Expectation of healthy life at age 65 (in years)
Fiscal year
Expectation of life*
Expected bed-disability and institutionalization
1958 1960 1962 1964 1966
14.2 14.5 14.6 14.3 14.6
1.1 1.1 1.1 1.1 1.1
Expectation of healthy life 13.1 13.4 13.5 13.2 13.5
* For calendar year Source: cited in [-6] tion on both patients and facilities, and by comparing services with patients' characteristics to determine to what extent they are or can be adequately met.
OBJECTIVES AND METHODOLOGY As indicated, the objectives of the study are to render a profile of patient population in the light of the characteristics of long-term facilities in the State of New Jersey. The studies' data reflecting various medical, social, financial and related information on all patients, may provide a generalization on the assessment of patients' needs in terms of their characteristics. Furthermore, against the background of patient information, the study aims to analyse patient characteristics in the light of services provided by the facilities. Among its core objectives, the study aims to provide indices, employing objective standards and definitions wherever possible, in order to reach conclusions about the given social, physical, and emotional needs of the aged or how they may be met by the facilities surveyed. Moreover, it is intended to isolate problems and problem areas of the long-term facilities concerning the kind and scope of care they provide and in the realms of personnel, physical, plant, financing, and patient services, that might hamper improvement of services. It is hoped that this study's approach which attempts to match patients' characteristics against the service that the homes provide, may contribute to the knowledge of needs and problems of patients and their institutions and stimulate further research.
Methodology A one-day census of long-term facilities' patients was comprised of 206 Licensed Nursing Homes, 25 Approved Medical Institutions, and 44 Incorporated Homes for the Aged (Infirmaries only) providing various social, medical, financial, and other pertinent information on 9918 patients and yielding an overall 77% response from the facilities surveyed. In total, 115,665 patient information data, averaging 12 types of information per patient, have been gathered and analyzed. Data on nearly 10,000 long-term facilities' patients were obtained by u s i n g a questionnaire-type format, condensed on an IBM PORT-A-PUNCH card for each individual patient during a one-day census [10-12]. More than 300 long-term facilities' staff
members provided the basic data on both patients and facilities surveyed. The card-questionnaire has been accompanied by an appropriate catalogue of instructions and definitions to ensure uniformity and compatibility. The IBM card provided for 11 categories of questions comprising information on the patient's admission date, placement and referral pattern, frequency of visits, patient's former address, home address of relative or sponsor, sex, age, marital status, main source of payment, type of accommodation occupied, and an array of various patient characteristics including mobility and health status, attitudes and behavioral pattern (see Fig. 13 The manually punched prescored card served as a direct input media for electronic data processing, prior to a desk review for accuracy. To isolate further errors or conflicting information, an EDP error analysis preceded the final tabulations. By using the questionnaire PORT-A-PUNCH card as an EDP input medium, transcription errors have been entirely eliminated and others owing to afore mentioned reviews appreciably minimized. Consequently, information from facilities has been solicited through a conventional questionnaire accompanied by instructions and definitions. Collected data have been processed manually, tabulated and appropriately analyzed. A post-coding method was elected in order to accommodate proper classification of answers to some open-end questions. The ctverall survey's data yielded a 77% response rate from all long-term facilities in the State of New Jersey. Because of limitations imposed by expense and time an in-depth analysis of data was confined to a representative 10% sample. The stratification of longterm facilities licensed nursing homes, approved medical institutions, and incorporated homes for the aged (infirmaries) was considered according to size and number of patients in order to obtain a representative cross-section stratified by both type of homes and patients. The stratified sample embracing 21 longterm facilities (15 licensed nursing homes, 2 approved medical institutions, 4 incorporated homes for the aged) when compared with the patients' survey revealed information on 991 patients. In addition to the quantitative verification, data in the sample's 991 patients have been tested for contents and their significance regarding various patients' characteristics. The correlation analysis carried out which focused on separate and distinct information elements, rendered an overall strong correlation (r = 0.98209) of the known universe.
232
ROMUALD K. SCHICKE
DIAGRAM HE At.TH
FACIL I
OF SURVEY'S DESIGN
~
LONG TERM PATIENT ORIGIN SURVEY
ONE DA't CENSUS MIDNIGHT,
S E P T E M B E R 15,196,5
[~
Long-Term
~I~ DATL PAIIFNI ACIdlTIED:
....
Long-Term
Patients
@
[',,~
P~A'En
X
FFI ATIVF%
X OIHFR
@ ~,~ x
~
HOSPITAL
wl F K L Y I
X EVER' FrW MONTItS
~1 w E~ LY
X ANNUaLlY
X MCNTHL
Facdities'
Pat0ent's
~ OT.FII IAGFNCY ORGbNli~ATInN)
Z~o'~T~,rs :
I
X NEVER
Comparison
---
rE
HUNORfDS
,
4
~
.. '[
Charactenstocs
Characteristics
~ATIr;.T'S ,,3'dE ,:.CDRE3S CG3E ;
I
-~
T ¢
RE@';RFIrr, BY:
--a~n--
FAM'Iy IIM~q[[IAI[}
~ _
Facihties
%
g
(
UNIT~ . . . . . . .
i
,
5
i
.
R
C3DE C7
::CMF ADDr'c?S
I
SPC:;COR ;~EL ~T;'*'E C,q FP;CND~:
I
--tENS
dNITS
Evaluation and Planning
4
7 ,~jSEX :
g
L@ ~/
I
|
,o
2O
30
,
2
Ill
I
9 - --
X
WlOOWE
lib
so
so
70
SO
so
4
5
S
?
e
s
,oo
~ i NL PAY ;FflEE]
o~N NESOUHCES X FAM,Ly C~R IEt ATIVI~S,
X PtBLIC AS31SrANCE
SLUL CROSS
~ PR;','~T[ CMARITASLE
OTHf~ ~ITALTH ~N~,URANCE
X O~HER
~-~ NUMBER ~
O~G~NI~TION
~Sl-N"
q';~,, PAT;ENTS C RA l X R~-YSCltN ~----
~
PATIENT HOUS'~D
$$~1C5
DET RMIN .~<~ Nt.RSE PUNCH ALL APPROPR+ATE
X iN~CNT, ~E~IT
PECULIAR C'R nlsruRBl~G HABITS
X PODR LIVING AN0 EAtinG '4ABITS
X a ~ U A;VRY
),~ P.ySlSAL
BI "T~R
[~
IiOTHER
PARTICIPATING
X PA,~,VE. w, :HCHANN
SEU'- AMBU AI U ~
X m(NIAL
-~-
I~clwz.
>~ BEU~Sr
FRIL,~AT,ON
It
ot TERIORAIdUN
COWVALE 9CENT R[ COVEHIN$
I ~ R E ~ E F T S INSTI"UTIONAL CAR~
RF ;~GI~EO
X NON~ OF THE!E
k SE PENCIL ONLY :
m
~i
C.O
i
Cq n
8F
~I)R~
PUNCHED
TABS
Feed-Back
Path
X SEPAFIATEO-OIVORCED
MARRIEI)
~h.~ HA, N SOUF~ or ~ A Y M ~ :
I
7
X SIId~LE
X ~EMALE
~'x
9
MAQ&TAL STATUS :
b~,~,lllll ~ t, k E
.~ ARE ENTIRELY
REMOVED
Fig. 1. PORT-A-PUNCH questionnaire card.
The dual approach, at first, a stratified sample for institutions and subsequently independently verifying the patients' characteristics against the known universe, adequately support the relevance/significance of the data used in the study. Non-responses generally constitute a problem area in research, also when dealing with a finite universe. In this study, the problem of non-responses has been approached by resorting to the correlation-coefficient method. From the distribution of non-responses in the finite universe, an expected sample was drawn and measured against the actual occurrence in the experience sample, rendering a value of r = 0.81569; thus, a relatively satisfactory correlation factor between both elements has been established. The methodological approach used in this study is reflected by the following diagram (Fig. 2):
Fig. 2. Diagram of survey's design. STUDY RESULTS
Characteristics of patients The majority of the homes' occupants were female (73%). The proportion of widowed patients predominated, comprising almost two thirds of all residents in the long-term facilities. The age group composition revealed that 30% of the patients were between the ages of 70 and 79; those between 80 and 89 years old represented the single highest age category, or 42% of all patients. The average age of the patient was 79.3 years. Reportedly, 29 patients were over 100 years old, among whom the oldest was 106 years of age. Parenthetically, the above study's findings are supported by two other surveys' data [-13, 14]. According to the determination made by nurses: (63% of cases), physicians (20% of cases), or both (11%), among 14 characteristics to be optionally selected for each of the patients, the following were most frequently named: physical deterioration, semiambulatory mobility status, and mental deterioration. A characterization by mobility status indicated that 15.9% of the patients were bedridden, 47.6% semiambulatory, and 36.5% ambulatory. Notably, less than 9% of patients were described as convalescent or recovering. A positive characteristic stating that 35.3% of the patients were active and participating within the scope of their physical and mental capabilities, was contrasted by the fact that 16% of the patients were passive and withdrawn, 17.6% displayed peculiar and disturbing habits, 7.3% were bitter and resigned, and 5,7% were resentful of institutional care. The study revealed that nearly 70% of the patients were placed in the institutions by family members. Physicians made arrangements for the patients' referrals in 49% of cases, hospitals assisted in 14% of the placements, and 37% of the patients were accommodated through arrangements by other agencies and organizations, the County Welfare Department among others.
Surveying geriatric patients, facilities and services More than half of the patients, or 52 out of 100, received social calls weekly, 31 had bi-weekly or monthly visitors, and 2 out of 100 were visited once a year. It was hypothesized that the frequency of social calls was, in part, dependent upon social ties connecting the patients with relatives and/or friends, related to the marital status, to the patients' sex, and the distance to the former place of residence. When related to the marital status, the findings reveal that 85.4~o of the married patients were visited most frequently (in weekly or bi-weekly intervals), followed by widowed (68.6~), single (42.5~) and lastly by separated/divorced (36.8~o). In addition, those patients characterized as active and participating received more social calls than those withdrawn or resentful of institutional care. The analysis of the variables conducted for each marital category by in- and out-of-county residents has revealed that the location of the patients' former permanent place of residence had no influence upon the frequency pattern of social calls. Hereby, the ~2 and contingency coefficient methods were employed. Moreover, with regard to in- and out-of-county residents, data were computed by each marital status, however, not revealing appreciable differences for visits by "in- versus out-of-county" residents. Such results provided guidelines for regional planning efforts in the area of long-term facilities with regard to location. Attributable, in part, to the size and structural character of some of the homes affording smaller size rooms, 49 out of 100 patients occupied private and 2-bedroom accommodations, 8 out of 100 stayed in rooms with four or more beds. Facilities and services
Based upon the study's findings, the overall average length of stay approximated 300 days. Patients in the homes for the aged stayed longer (581 days), followed by those in approved medical institutions with 572 days, and patients in licensed nursing homes staying for nearly 236 days computed by the formula: 2 x patient days admissions + discharges Considering the varying patient needs in terms of their physical handicaps, mental status, and social needs in the light of institutional programs, both formal and informal types, programs have shown considerable gaps and shortcomings. Reportedly, approximately one fourth of the facilities surveyed carried out formal rehabilitation programs, occupational therapy, social rehabilitation activities, and active recreational therapy, although such programs notably varied in degree and scope. It thus became evident that predominantly larger facilities can more adequately maintain such programs, while smaller facilities, partially owing to economic considerations, may limit their programs to mainly informal, "casual" occupational, social rehabilitation, and "passive" recreational programs. Combining all facilities in the sample (21), the average size of an institution was 56 beds. When relating the availability of active physical rehabilitation programs, it was found that they were more concentrated
233
however, although rather unevenly distributed, amongst 33~o of facilities in homes averaging 87 beds, while the balance of facilities (67~) provided no formal programs. Nevertheless, the latter did offer some informal, part-time recreations stressing "passive" rather than "active" efforts. Some authors [15, 16] have viewed the potentiality of rehabilitating nursing home patients with some scepticism; however, especially when a strict selectivity of potential rehabilitation candidates is or cannot be observed. A further study [17], reflecting the views of 35 nursing home operators, takes a rather sceptical stand and a dim view as to the rehabilitation possibilities of their patients. More specifically, while 25~ of the respondents did not state any problems connected with rehabilitation programming, an equal percentage could be explained by the facilities' fiscal and physical inabilities to provide such services. 50y/oof the respondents placed the blame upon the general disinterest of patients to participate in such programs. Nevertheless, through concentrated selective efforts, and taking into account the prognosis for improvement, the lot of a number of aged persons could be grossly ameliorated, either medically, socially or both by adding "life" to age. Still another author, while taking a more positive attitude toward rehabilitative potentials for patients, poses the question as to what implications rehabilitation efforts may have for patients from 70 years of age and over. Such concern may, in part, be justified when one considers a patient population in such an advanced age group afflicted with a variety of physical and mental handicaps and ailments. Nonetheless, the rehabilitation could be conceived as a provision of "the whole spectrum of opportunity extending from the full restoration of a human being to normal affective function in an appropriate environment to the lowest level of success characterized by humane maintenance care under circumstances that may not even be perceptible to the patient but color and influence the life of others." [18]. As illuminated by the above definition, some students of nursing care take a more positive view of the merits of a therapeutic effort, stratified according to patients' capabilities and potentialities, and stressing the needs of greater patient self-reliance or return to greater self-sufficiency with the aid of appropriate occupational and other therapies. Motivating the patients to make optimum use of their remaining and latent physical and mental faculties, within the limitations imposed by their condition, seems to be the major philosophical theme of any rehabilitative endeavor. Admittedly, these efforts have, of course, to be seen within the given constraints as this study's findings indicate. Among the problems encountered by longterm facilities, those affecting the shortage of personnel were predominant. Out of 21 facilities reporting. 13 listed personnel, 4 financial and physical plant, 1 organizational, and 1 patient care as problem areas of their prime attention. The difficulties encountered by long-term facilities in the realm of fiscal and personnel situations are common to a large number of those institutions generally. It seems that long-term facilities are less
234
ROMUALDK. SCHICKE
attractive to nursing personnel when dealing with older people in terms of professional gratification and incentives. Regrettably, this attitude is the result of a society dominated by the glorification of youth. Despite the problems with which the surveyed facilities face, a number are concerned with improving and expanding their services. Of these, 6 facilities intend to extend their services in the realm of social and recreational activities to include occupational and physiotherapy.
SUMMARY The survey of patients and long-term facilities using a dual methodological approach may prove suitable in gaining appropriate information for an assessment of services' needs based upon characteristics of aged patients and facilities separately. Owing to the varying needs for social and medical services an intensified effort is needed to meet them at various levels of institutional and extra-institutional care emphasizing greater need for co-operation and coordination among facilities in order to cope with the demands of the increased proportion of the aged. It is hoped that this paper will stimulate further inquiries into a geriatric care sector, which is, regrettably, so rarely explored.
REFERENCES
1. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Chronic Conditions causing Activity Limitation, United States, July, 1963-June, 1965; Series 10, No. 51, February 1969. 2. Pettengill J. H. Trends in hospital use by the aged. Soc. Sec. Bull. 38, 3, 1972. 3. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Current Estimated from the Health Interview Survey, United States 1969, Series 10, No. 63, 1971.
4. Cooper B. S. and Worthington N. L. Medical care spending for three age groups. Soc. Sec. Bull. 35, 3, 1972. 5. U.S. Department of Health, Education and Welfare, National Center for Health Statistics, Series 12, No. 10. Nursing and Personal Care Services Received by Residents of Nursing and Personal Care Homes, United States, May-June 1964, Washington DC, 1968. 6. U.S. Department of Health, Education and Welfare. Toward a Social Report. Ann Arbor, University of Michigan Press, 1970, p. 4. 7. U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Prevalence of Selected Chronic Respiratory Conditions, United States--1970, Series 10, No. 84, 1973. 8.--Shelton D. S. et al. Bed utilization--a community study. Hospital Mgmt 105, 47, 1968. 9. Berg R. L. et al. Assessing the health care needs of the aged. Hlth Serv. Res. $, 36, 1970. 10. Schicke R. K. Patient origin study tests new inquiry technique. Hospital Topics, April 1966, pp. 55-57. 11. Schicke R. K. Facts on 780,000 hospital patients uncovered in statewide study. Hospitals J.A.H.A. 41, 56, 1967. 12. Schicke R. K. Health services research and methodologies in planning for medical care facilities, some international comparisons. Meth. Inform. Med. 10, 163, 1971. 13. U.S. Department of Health, Education and Welfare, Public Health Service, Division of Hospital and Medical Facilities. A Comparative Study of 40 Nursing Homes, their Design and Use, Washington DC, 1965. 14. U.S. Department of Health, Education and Welfare, Public Health Service. Nursing Homes, their Patients and their Care, Public Health Monograph No. 46, Washington DC, 1957, 15. Muller J. et al. The rehabilitation potential of nursing home residents. Am. d. publ Hlth 53, 243, 1963. 16. Kelman H. R. An experiment in the rehabilitation of nursing home patients. Publ. Hlth Rept. 77, 356, 1962. 17. Mahaffey T. E. Proprietary nursing homes--a report on interviews with 350 nursing home operators in Detroit, Michigan. Health Information Research Series No. 18, New York, 1961, pp. 15-18, 22. 18. Rogers R. Rehabilitation in focus. Nurs. Home 16, 11, 1967.