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Continuing care retirement communities and the role of the wellness nurse
Continuing Care Retirement Communities and the Role of the Wellness Nurse The goal of the wellness nurse is to help apartment residents stay home. By
JEANNINE
MILLETTE
PETI T
ontinuing ca re ret irement communities (CCRCs ) offer nurses unique opportunities to practice autonomous, case-managed nur sing in settings that provide a continuum of care for the geriatric client. At CCRCs, nurses-often called "well ness nurses"-work with the most functional elderly. To perform their jobs effec tively, wellness nurses need an understanding of the entrance contract, the expectations of the clients, and the philosophy of the organization . The scope of practice for the wellness nurse is often defined by the services that are made avai lable within each setting and the cost of extra services. The goal of the wellness nurse is to maintain the health of the apartment residents by understanding relocation trauma, by providing continuity of care, and by taking part in educational programs, such as a wellness program, a forum designed to enhance the health care decision-making ability of the geriatric client.
C
quently there are gradations between independent and total care, a spectrum referred to as continuing care. CCRCs evolved from facilities that were either nursing homes or apartment complexes started by religious or fraternal organizations. More recently, hotel chains, such as the Marriot Corporation , have built retirrnent communities. In the past, to enter these complexes, services were given in return for all of the individual's financial assets. The more common arrangement today is an entrance or accommodation fee, in addition to a monthl y fee . All CCRCs have various health status, financial assets , and income requirements . Some CCRCs are custom-built, two-bedroom luxury high-rises with balconies; others a re small efficiencies. Most have communal dining rooms, some resembling restaurants, others more like cafeterias. CCRCs usually provide transportation, housekeeping serv ices, garden plots, libraries, beauty shops, and activities.
Background Types There are 800 CCRCs in the United States, and their number is expected to double by the year 2000. 1 A quarter of a million people , with an aver age age of 82, live in CCRCs ,2 The age distribution of the popula tion in one retirement community in the Midwest places the majority of the residents between 75 and 85 years old. Eight percent were over 90 years old (Figure I) . CCRCs offer different levels of living arrangements, from ind epend ent apartments to nurs ing home care. Fre-
JEANNINE MILLETTE PETIT, RN , MS, GNP , is a ge rontolog ical nur se prac titioner at the Veter an 's Adm inistr a tio n Med ical Center in M ilwaukee.Wiscons in. GaR 1/\TR
N URS 1994;15:28-31.
Copyright
@
1994 by Mos by-Year Book, Inc.
0197-4572/94/$3.00 + 0 34/1/48944
28
GE RIATRI C N URSI NG Janullr)'/ Februory 1994
All CCRCs have contracts with t h eir residents. Each CCRC's contract may va ry in terms of what is included but usually is intended to remain in effect for the life of the res ident. This financial agreement enables the owners of the community to obtain financing for new construction and remodeling. The American Association of Homes for the Aging separates CCRCs into three categories . In 1992 type A homes had a median entrance fee of $70,529 for a one-bedroom apartment plus $1,145 as a monthly fee .? This type of contract is considered " all inclusive" because it offers guaranteed nursing care in the nursing home section of the commun it y without a n increase in the monthly fee. The cost of nursing home care can be as much as $3,600 per month, or three times the monthly fee of a type A CCRC. Therefore the resident
Petit
40 ..,---- - - - - - -- - - - - -- - - -- -- - - ----,
c 0
..-
30
0 :l 0... 0 0...
'+-
0
20
Q)
OJ
0 ..-
cQ) U L Q)
CL
10
0-+,- - - -' 65 - 70
7 1- 7 5
76- 80
8 1-8 5 86 -9 0 9 1- 95 Age Range
96 +
FIGURE 1. Age distribution of apartment residents. (From Census Bureau Survey of 1990, "Survey of Economic and Program Participation.")
Regulatory Aspects entering into the contract knows that the cost of nursing home care will be reduced substantially. The fear of losing all of one's assets to pay for nursing home care is one of the main reasons that a person may desire a CCRC with a life care contract. The all-inclusive aspect, however, may not pertain to all of the services rendered. For apartment residents, emergency care may be included but medication assistance is at an extra cost. Although residents meet the financial requirements, they may be reluctant to spend their money for these extra services. Type B CCRCs do not guarantee unlimited nursing home care but have a contractual agreement to provide a specificnumber of days per year or lifetime in the nursing home. Many give priority placement or reduced rates for those who live in the community. The additional amenities may be similar to those of a type A home but come at extra cost. Type C homes are the "pay-as-you-go," or fee-forservice, type. The entrance fee is less. This arrangement appeals to those who are reluctant to initially invest large sums of money and feel less likely to need nursing home care. The cost of care is shifted to the time when the care is needed, assuming that resources remain. Type C homes usually do not have a financial obligation to those who have spent all their money. Consequently, the resident who cannot afford care will then need to relocate should nursing home care be needed.
Petit
Because CCRCs are a combination of housing, insurance, and health care, different governmental regulations may apply to various parts of the community. For example, a license is required for the nursing home section, while housing codes need to be met for the apartments. The Continuing Care Accreditation Commission attempts to regulate the industry by accrediting communities that meet standards in the following areas: resident life, finances, governance and administration, and health care.' Buying into a type A CCRC is, in essence, like obtaining a long-term care insurance policy. Similar to other insurance policies that utilize the principle of "risk pooling," CCRCs operate on the assumption that not every client will need expensive nursing homecare. For type A and type B homes, the entrance fee is paid by all but used to subsidize the care given in the nursing home for those who need it. Financial stability of type A and type B homes is dependent on high occupancy rates in the apartments (90%), entrance fees that cover subsidized care, and a realistic estimation of morbidity to accurately project future costs.' Homes rely on actuarial and other studies to determine life expectancy and to predict use of nursing home beds. The administrators of many CCRCs view the goal of the wellness nurse as reducingthe need for expensive care
GERIATRIC NURSING Volume 15,Number I
29
given in the nursing home section. If the functional ability of the apartment residents is preserved, they can continue to reside in the least-restrictive (and leastexpensive) section of the community. More research is needed to determine the impact of wellness activities on the health of the clients. Profile of Apartment Residents Retirement communities attract that segment of the older population that has the financial means but little or no family. My own survey of one Midwest CCRC indicated that nearly 40% of the residents were in two categories: never married or married but never had children. CeRCs aim to provide the security of a family in case of need. The decline of some urban neighborhoods and fear of crime is cited as a reason for relocating to a CCRC. Communalliving in a secure environment-frequently a physically beautiful setting-is attractive to those older adults of means. Residents living in CCRCs tend to be very health conscions." In one CCRC the residents sought medical care on a regular basis: 96% had visited their physician within the prior 6 months (personal observation). Some of the residents may have been overly concerned about their health. As Resnick- noted, they would come regularly to the nursing staff because of minor complaints. In another retrospective study, the data indicated that less than 10% of the requests for medical care by the apartment residents actually required the attention of a physician.
trauma. Friendly visits by other residents to show the newcomers "the ropes," to accompany them to activities, to include them in the next bridge game or shopping trip may be needed, not only for a few days but for months following the move.P The change in eating and sleeping habits and the change in medication regimen and the physical strain of moving may exacerbate existing health problems such as bowel patterns, back conditions, osteoarthritis, and heart and respiratory disease. New residents should be told to pace themselves after the relocation. Fatique and musculoskeletal discomfort is common and temporary. A monitoring of the health status of new residents will detect early onset of new illnesses.
If the relocation to a CeRC is imposed by the children, the move may be traumatic. Studies of relocation effects among the elderly have cited that a realistic understanding of life in the new residence is fundamental; unrealistic expectations may trigger stress and anxiety.f It is essential that the resident have a clear understanding of the terms of the contract: inclusions, exclusions, cost of extra services. Residents frequently have high expectations of the community; disappointment after the resident has moved in may contribute to relocation trauma.
Relocation
Health Services for Apartment Residents
For most residents, the move into a CCRC is a longanticipated event, often taking years of planning. The selling of a home and the disposing of possessions often signifies the release of homeowner responsibilities. However, if the sale of the home was done solely for the payment of the entrance fee, the resident may feel resentment. Because the contract is with the resident, he or she should be the decision maker, set the timetable, and control the pace of the move. If the move is imposed by the children-or by the sequelae of an illness or the death of family member-the relocation may be traumatic. Resnick' identifies two other groups who may have relocation trauma: clients moving from another state or city and clients with any decline in memory. The severing of ties with long-standing friends and physicians from the old neighborhood, the frustration of not knowing where to shop, the difficulty of making new friends-these are major problems for new residents. Many established residents in some CCRCs are related to each other or come from the same church or parish and have no need to make new friends. The transition to segregated, congregate living may be reassuring to some, but the added noises, unfamiliar smells, and loss of privacy may also be disturbing. If you meet with new residents soon after they move, you should be able to identify those at risk of relocation
CCRCs are not required to provide nursing or medical services for apartment residents. A survey of 10 CCRCs in a large metropolitan city revealed that they all have a 24-hour emergency response system but that there was a variation in the level of emergency services provided and the level of training of those who would be answering an emergency call in an apartment. The person answering the call may be a security guard, a maintenance worker, the building manager, a staff nurse, or a nursing supervisor from the nursing home section of the community. These emergency responders may not have first aid or CPR training.
30
GERIATRIC NURSING January/February 1994
Wellness Nurse In addition, all but one of the CeRCs in this survey had nursing staff, wellness nurses, assigned to the apartments during some portion of the day. The total compliment of nursing personnel varied from one wellness nurse working part time, to a staff of six directed by a gerontologic nurse practitioner. Advocacy, assessment, and coordination of services are often the components of the position. The amount of direct "hands-on" nursing care depends on the available wellness nurses and the scope of their functions within the organization. Individual CCRCs
Petit
may restrict the number and type of services that are allowed in the apartments. A wellness nurse often must be resourceful and creative to provide necessary care for residents within organizational contraints. For example, treatments, dressing changes, enemas not provided by the well ness nurses are at times performed by trained family members, by privately hired companions, or by home health agency staff coordinated by the wellness nursing staff. It is helpful to obtain a clear understanding of the organization's expectations of the well ness nurse. Are vital signs be to taken? Are supplies available for simple treatments? Is the nurse's role to provide care or to facilitate transportation elsewhere for care? The wellness nurse may have input into the decision to relocate a client within the community or to another facility in order to find the least restrictive environment that also meets the client's needs. Most facilities allow for continuity of care or for movement from one level of care to another according to the contract and criteria set by the CCRC. The wellness nurse is in a pivotal position to facilitate such movement through the community to ensure the best placement for the resident. The wellness nurse needs to understand what behavior or functional impairments trigger the transfer from one level of care to another according to the CCRe's contract. For those residents who are temporarily placed in the nursing home section, the wellness nurse is able to share information about past responses to illnesses, family dynamics, and support systems. By individualizing the plans of care, the nurse can assist the residents to return to their apartment, which is their home with all their worldly possessions. For the well ness nurse there is satisfaction in seeing the resident through both major and minor problems. In periods of discouragement, this nurse is able to remind the resident of past difficulties successfully overcome.
need to simplify the daily routine and provide cueing to accommodate memory loss. Volunteers acting as guides, bank trust officers managing finances, and support groups or day care providing spousal respite help to delay movement to the nursing home.
A realistic expectation of life in the
Summary
new residence is crucial; unrealistic
As the number of CCRes increases, nurses will have more opportunities for autonomous practice, largely because this industry is largely not regulated. It is important to understand factors that may influence the scope of practice. In the roles of consultant, advisor, triage nurse, and friend, the wel1ness nurse can greatly affect the heal th of apartmen t residents living in retiremen t communities. _
expectations may trigger stress and anxiety. Nursing in a retirement community is similar to home health care. Assessment of the residents in their living environment yields valuable information concerning their ability to function within that setting. The goal of both the resident and the CCRC is for the resident to remain in the apartment. Being knowledgeable and able to coordinate services from the larger community outside the CCRC, the wellness nurse can playa major role in ensuring a nurturing environment, that is, one which encourages independence-the key to apartment living. Not only are physical changes frequently needed, such as grab bars and raised toilet seats, but there is also the
Petit
A weI/ness nurse often must be resourceful and creative to provide necessary care for residents within organizational constraints. The wellness nurse may be the first to recognize and assist in the management of such under-reported problems as urinary incontinence." The nurse can enhance the resident's decision-making ability with accurate information about when and where to seek treatment. Wellness Educational Program The Wellness Educational Program is a forum where experts, such as physicians and therapists, from the larger community outside the CCRC present information to the apartmen t residents on topics chosen by the residents. The purpose is to educate, inform and stimulate discussion about medical, legal, and regulatory changes with the goal of influencing lifestyle decisions. This program links the apartment residents to the larger health care community and empowers them to choose their health care providers. The wellness nurse screens the topic for relevance, checks the speaker's credentials, and is available to individualize the material.
REFERENCES I. [Anonyrnous.] Communities for the elderly. ConsumerReports 1990Feb: 123. 2. Gurland S. Homes with nursing that aren't nursing homes. Business Week 1992 May 4:182. 3. Continuing Cure Accreditation Commission. Accredited facilities list. Washington: American Association of Homes for the Aging, J 992. 4. Sloane PD. How to maintain the health of independent elderly. Geriatrics J984;39(10):93-104. 5. Resnick 8M. Care for life. GERIATR NURS 1989;10:130-2. 6. Mirotznik H. Ruskin A. Interinstitutional relocation and the elderly. J Long Term Care Adm 1985;13:127-30. 7. Burgio KL. Urinary incor.tinence: why people do not seek help. J Gerontol Nurs 1992;18(4):15-20.
GERIATRICNURSING Volume 15, Number I
31
JEANNINE
MILLETTE
PETI T
ontinuing ca re ret irement communities (CCRCs ) offer nurses unique opportunities to practice autonomous, case-managed nur sing in settings that provide a continuum of care for the geriatric client. At CCRCs, nurses-often called "well ness nurses"-work with the most functional elderly. To perform their jobs effec tively, wellness nurses need an understanding of the entrance contract, the expectations of the clients, and the philosophy of the organization . The scope of practice for the wellness nurse is often defined by the services that are made avai lable within each setting and the cost of extra services. The goal of the wellness nurse is to maintain the health of the apartment residents by understanding relocation trauma, by providing continuity of care, and by taking part in educational programs, such as a wellness program, a forum designed to enhance the health care decision-making ability of the geriatric client.
C
quently there are gradations between independent and total care, a spectrum referred to as continuing care. CCRCs evolved from facilities that were either nursing homes or apartment complexes started by religious or fraternal organizations. More recently, hotel chains, such as the Marriot Corporation , have built retirrnent communities. In the past, to enter these complexes, services were given in return for all of the individual's financial assets. The more common arrangement today is an entrance or accommodation fee, in addition to a monthl y fee . All CCRCs have various health status, financial assets , and income requirements . Some CCRCs are custom-built, two-bedroom luxury high-rises with balconies; others a re small efficiencies. Most have communal dining rooms, some resembling restaurants, others more like cafeterias. CCRCs usually provide transportation, housekeeping serv ices, garden plots, libraries, beauty shops, and activities.
Background Types There are 800 CCRCs in the United States, and their number is expected to double by the year 2000. 1 A quarter of a million people , with an aver age age of 82, live in CCRCs ,2 The age distribution of the popula tion in one retirement community in the Midwest places the majority of the residents between 75 and 85 years old. Eight percent were over 90 years old (Figure I) . CCRCs offer different levels of living arrangements, from ind epend ent apartments to nurs ing home care. Fre-
JEANNINE MILLETTE PETIT, RN , MS, GNP , is a ge rontolog ical nur se prac titioner at the Veter an 's Adm inistr a tio n Med ical Center in M ilwaukee.Wiscons in. GaR 1/\TR
N URS 1994;15:28-31.
Copyright
@
1994 by Mos by-Year Book, Inc.
0197-4572/94/$3.00 + 0 34/1/48944
28
GE RIATRI C N URSI NG Janullr)'/ Februory 1994
All CCRCs have contracts with t h eir residents. Each CCRC's contract may va ry in terms of what is included but usually is intended to remain in effect for the life of the res ident. This financial agreement enables the owners of the community to obtain financing for new construction and remodeling. The American Association of Homes for the Aging separates CCRCs into three categories . In 1992 type A homes had a median entrance fee of $70,529 for a one-bedroom apartment plus $1,145 as a monthly fee .? This type of contract is considered " all inclusive" because it offers guaranteed nursing care in the nursing home section of the commun it y without a n increase in the monthly fee. The cost of nursing home care can be as much as $3,600 per month, or three times the monthly fee of a type A CCRC. Therefore the resident
Petit
40 ..,---- - - - - - -- - - - - -- - - -- -- - - ----,
c 0
..-
30
0 :l 0... 0 0...
'+-
0
20
Q)
OJ
0 ..-
cQ) U L Q)
CL
10
0-+,- - - -' 65 - 70
7 1- 7 5
76- 80
8 1-8 5 86 -9 0 9 1- 95 Age Range
96 +
FIGURE 1. Age distribution of apartment residents. (From Census Bureau Survey of 1990, "Survey of Economic and Program Participation.")
Regulatory Aspects entering into the contract knows that the cost of nursing home care will be reduced substantially. The fear of losing all of one's assets to pay for nursing home care is one of the main reasons that a person may desire a CCRC with a life care contract. The all-inclusive aspect, however, may not pertain to all of the services rendered. For apartment residents, emergency care may be included but medication assistance is at an extra cost. Although residents meet the financial requirements, they may be reluctant to spend their money for these extra services. Type B CCRCs do not guarantee unlimited nursing home care but have a contractual agreement to provide a specificnumber of days per year or lifetime in the nursing home. Many give priority placement or reduced rates for those who live in the community. The additional amenities may be similar to those of a type A home but come at extra cost. Type C homes are the "pay-as-you-go," or fee-forservice, type. The entrance fee is less. This arrangement appeals to those who are reluctant to initially invest large sums of money and feel less likely to need nursing home care. The cost of care is shifted to the time when the care is needed, assuming that resources remain. Type C homes usually do not have a financial obligation to those who have spent all their money. Consequently, the resident who cannot afford care will then need to relocate should nursing home care be needed.
Petit
Because CCRCs are a combination of housing, insurance, and health care, different governmental regulations may apply to various parts of the community. For example, a license is required for the nursing home section, while housing codes need to be met for the apartments. The Continuing Care Accreditation Commission attempts to regulate the industry by accrediting communities that meet standards in the following areas: resident life, finances, governance and administration, and health care.' Buying into a type A CCRC is, in essence, like obtaining a long-term care insurance policy. Similar to other insurance policies that utilize the principle of "risk pooling," CCRCs operate on the assumption that not every client will need expensive nursing homecare. For type A and type B homes, the entrance fee is paid by all but used to subsidize the care given in the nursing home for those who need it. Financial stability of type A and type B homes is dependent on high occupancy rates in the apartments (90%), entrance fees that cover subsidized care, and a realistic estimation of morbidity to accurately project future costs.' Homes rely on actuarial and other studies to determine life expectancy and to predict use of nursing home beds. The administrators of many CCRCs view the goal of the wellness nurse as reducingthe need for expensive care
GERIATRIC NURSING Volume 15,Number I
29
given in the nursing home section. If the functional ability of the apartment residents is preserved, they can continue to reside in the least-restrictive (and leastexpensive) section of the community. More research is needed to determine the impact of wellness activities on the health of the clients. Profile of Apartment Residents Retirement communities attract that segment of the older population that has the financial means but little or no family. My own survey of one Midwest CCRC indicated that nearly 40% of the residents were in two categories: never married or married but never had children. CeRCs aim to provide the security of a family in case of need. The decline of some urban neighborhoods and fear of crime is cited as a reason for relocating to a CCRC. Communalliving in a secure environment-frequently a physically beautiful setting-is attractive to those older adults of means. Residents living in CCRCs tend to be very health conscions." In one CCRC the residents sought medical care on a regular basis: 96% had visited their physician within the prior 6 months (personal observation). Some of the residents may have been overly concerned about their health. As Resnick- noted, they would come regularly to the nursing staff because of minor complaints. In another retrospective study, the data indicated that less than 10% of the requests for medical care by the apartment residents actually required the attention of a physician.
trauma. Friendly visits by other residents to show the newcomers "the ropes," to accompany them to activities, to include them in the next bridge game or shopping trip may be needed, not only for a few days but for months following the move.P The change in eating and sleeping habits and the change in medication regimen and the physical strain of moving may exacerbate existing health problems such as bowel patterns, back conditions, osteoarthritis, and heart and respiratory disease. New residents should be told to pace themselves after the relocation. Fatique and musculoskeletal discomfort is common and temporary. A monitoring of the health status of new residents will detect early onset of new illnesses.
If the relocation to a CeRC is imposed by the children, the move may be traumatic. Studies of relocation effects among the elderly have cited that a realistic understanding of life in the new residence is fundamental; unrealistic expectations may trigger stress and anxiety.f It is essential that the resident have a clear understanding of the terms of the contract: inclusions, exclusions, cost of extra services. Residents frequently have high expectations of the community; disappointment after the resident has moved in may contribute to relocation trauma.
Relocation
Health Services for Apartment Residents
For most residents, the move into a CCRC is a longanticipated event, often taking years of planning. The selling of a home and the disposing of possessions often signifies the release of homeowner responsibilities. However, if the sale of the home was done solely for the payment of the entrance fee, the resident may feel resentment. Because the contract is with the resident, he or she should be the decision maker, set the timetable, and control the pace of the move. If the move is imposed by the children-or by the sequelae of an illness or the death of family member-the relocation may be traumatic. Resnick' identifies two other groups who may have relocation trauma: clients moving from another state or city and clients with any decline in memory. The severing of ties with long-standing friends and physicians from the old neighborhood, the frustration of not knowing where to shop, the difficulty of making new friends-these are major problems for new residents. Many established residents in some CCRCs are related to each other or come from the same church or parish and have no need to make new friends. The transition to segregated, congregate living may be reassuring to some, but the added noises, unfamiliar smells, and loss of privacy may also be disturbing. If you meet with new residents soon after they move, you should be able to identify those at risk of relocation
CCRCs are not required to provide nursing or medical services for apartment residents. A survey of 10 CCRCs in a large metropolitan city revealed that they all have a 24-hour emergency response system but that there was a variation in the level of emergency services provided and the level of training of those who would be answering an emergency call in an apartment. The person answering the call may be a security guard, a maintenance worker, the building manager, a staff nurse, or a nursing supervisor from the nursing home section of the community. These emergency responders may not have first aid or CPR training.
30
GERIATRIC NURSING January/February 1994
Wellness Nurse In addition, all but one of the CeRCs in this survey had nursing staff, wellness nurses, assigned to the apartments during some portion of the day. The total compliment of nursing personnel varied from one wellness nurse working part time, to a staff of six directed by a gerontologic nurse practitioner. Advocacy, assessment, and coordination of services are often the components of the position. The amount of direct "hands-on" nursing care depends on the available wellness nurses and the scope of their functions within the organization. Individual CCRCs
Petit
may restrict the number and type of services that are allowed in the apartments. A wellness nurse often must be resourceful and creative to provide necessary care for residents within organizational contraints. For example, treatments, dressing changes, enemas not provided by the well ness nurses are at times performed by trained family members, by privately hired companions, or by home health agency staff coordinated by the wellness nursing staff. It is helpful to obtain a clear understanding of the organization's expectations of the well ness nurse. Are vital signs be to taken? Are supplies available for simple treatments? Is the nurse's role to provide care or to facilitate transportation elsewhere for care? The wellness nurse may have input into the decision to relocate a client within the community or to another facility in order to find the least restrictive environment that also meets the client's needs. Most facilities allow for continuity of care or for movement from one level of care to another according to the contract and criteria set by the CCRC. The wellness nurse is in a pivotal position to facilitate such movement through the community to ensure the best placement for the resident. The wellness nurse needs to understand what behavior or functional impairments trigger the transfer from one level of care to another according to the CCRe's contract. For those residents who are temporarily placed in the nursing home section, the wellness nurse is able to share information about past responses to illnesses, family dynamics, and support systems. By individualizing the plans of care, the nurse can assist the residents to return to their apartment, which is their home with all their worldly possessions. For the well ness nurse there is satisfaction in seeing the resident through both major and minor problems. In periods of discouragement, this nurse is able to remind the resident of past difficulties successfully overcome.
need to simplify the daily routine and provide cueing to accommodate memory loss. Volunteers acting as guides, bank trust officers managing finances, and support groups or day care providing spousal respite help to delay movement to the nursing home.
A realistic expectation of life in the
Summary
new residence is crucial; unrealistic
As the number of CCRes increases, nurses will have more opportunities for autonomous practice, largely because this industry is largely not regulated. It is important to understand factors that may influence the scope of practice. In the roles of consultant, advisor, triage nurse, and friend, the wel1ness nurse can greatly affect the heal th of apartmen t residents living in retiremen t communities. _
expectations may trigger stress and anxiety. Nursing in a retirement community is similar to home health care. Assessment of the residents in their living environment yields valuable information concerning their ability to function within that setting. The goal of both the resident and the CCRC is for the resident to remain in the apartment. Being knowledgeable and able to coordinate services from the larger community outside the CCRC, the wellness nurse can playa major role in ensuring a nurturing environment, that is, one which encourages independence-the key to apartment living. Not only are physical changes frequently needed, such as grab bars and raised toilet seats, but there is also the
Petit
A weI/ness nurse often must be resourceful and creative to provide necessary care for residents within organizational constraints. The wellness nurse may be the first to recognize and assist in the management of such under-reported problems as urinary incontinence." The nurse can enhance the resident's decision-making ability with accurate information about when and where to seek treatment. Wellness Educational Program The Wellness Educational Program is a forum where experts, such as physicians and therapists, from the larger community outside the CCRC present information to the apartmen t residents on topics chosen by the residents. The purpose is to educate, inform and stimulate discussion about medical, legal, and regulatory changes with the goal of influencing lifestyle decisions. This program links the apartment residents to the larger health care community and empowers them to choose their health care providers. The wellness nurse screens the topic for relevance, checks the speaker's credentials, and is available to individualize the material.
REFERENCES I. [Anonyrnous.] Communities for the elderly. ConsumerReports 1990Feb: 123. 2. Gurland S. Homes with nursing that aren't nursing homes. Business Week 1992 May 4:182. 3. Continuing Cure Accreditation Commission. Accredited facilities list. Washington: American Association of Homes for the Aging, J 992. 4. Sloane PD. How to maintain the health of independent elderly. Geriatrics J984;39(10):93-104. 5. Resnick 8M. Care for life. GERIATR NURS 1989;10:130-2. 6. Mirotznik H. Ruskin A. Interinstitutional relocation and the elderly. J Long Term Care Adm 1985;13:127-30. 7. Burgio KL. Urinary incor.tinence: why people do not seek help. J Gerontol Nurs 1992;18(4):15-20.
GERIATRICNURSING Volume 15, Number I
31