Addressing the Looming Demand for Care as Americans Age

How Nurses Are Reshaping Long-Term Services and Supports

    • January 20, 2015

Within four decades, as many as 84 million Americans will be 65 or older — twice the current number of seniors, and almost 20 percent of the total U.S. population. The great majority of these Americans will likely seek assistance in maintaining their health and well-being, making it essential that the nation develop effective and affordable ways to provide the long-term services and supports (LTSS) they need.

This issue of the Robert Wood Johnson Foundation’s Charting Nursing’s Future (CNF) policy brief series offers ample evidence that nurses have developed creative, sustainable, and compassionate ways to care for people who, because of disability, frailty, or illness, cannot care for themselves. In a variety of ways, nurses are making it easier for older, chronically ill individuals to stay healthier, remain in the community with their families, and avoid developing expensive debilitating conditions. The brief describes a number of innovative LTSS programs, as well as their collective potential to reshape the future of care for older Americans.

Such programs have a number of goals, including:

  • Improving care transitions,
  • Enabling older adults to live in the community,
  • Preventing physical and cognitive decline,
  • Coaching and supporting family members, and
  • Making institutional care more homelike.

Transitional Care

Nurses have long worked to find better ways for patients to transition from hospital to home. One early innovator was Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware professor in gerontology at the University of Pennsylvania, who pioneered the design of a transitional care model that uses advanced practice registered nurses (APRNs) to coordinate care for high-risk older adults within and across health care settings. The model has been shown to reduce readmissions, improve patients’ quality of life, and save money. Another model, developed by University of Colorado professor Eric Coleman, MD, MPH, uses RNs and has also produced impressive results. The success of these models led Congress to allocate $500 million for such efforts as part of the Affordable Care Act.

The Central New Jersey Care Transitions Program (CNJCTP) is one site taking part in the ACA-funded Community-Based Care Transitions Program. Six hospitals in the CNJCTP region work with registered nurses (RNs) and social workers, who together act as health coaches to teach self-care strategies to high-risk, chronically ill Medicare beneficiaries. RNs focus on beneficiaries’ symptoms and health care needs, including medication management, while social workers attend to socioeconomic needs that may lead beneficiaries to return to the hospital. Coaches visit patients in their homes within three days of discharge, facilitate a follow-up visit with a primary care provider, and follow up by phone for a month after discharge.

Supported at Home

Twenty years ago, Jennie Chin Hansen, RN, MS, FAAN, recognized the potential of a pioneering local initiative serving San Francisco’s low-income frail, older adults and helped turn it into the federally funded Program of All Inclusive Care for the Elderly (PACE). It now serves 30,000 beneficiaries through 104 programs in 31 states.

PACE provides health promotion, health maintenance, and full medical and social services to adults 55 and older who qualify to be in nursing facilities but who instead remain in their homes with significant support from PACE. Each program uses a PACE center as a focal point for providing services. Enrollees spend two to three days a week at the centers, where they can see a primary care provider, receive physical therapy or personal care, refill prescriptions, and join in social activities. PACE provides care from a home health aide when necessary and evaluates members’ homes to ensure a safe living environment. Interventions range from removing hazards such as poorly placed electrical cords to installing assistive devices.

Nurses have a high degree of clinical autonomy within the program, and they often operate as leaders of health care teams that include physicians, other nurses, social workers, dietitians, nurses’ aides, drivers, and physical, occupational, and recreational therapists.

Delaying Decline, Coaching Family Caregivers

Nurses have taken the lead in creating several innovative programs intended to delay patients’ physical and cognitive decline, and support family caregivers—two strategies for postponing the need for LTSS.

For example, in 2001, Claudia Beverly, PhD, RN, FAAN, director of the Hartford Center of Geriatric Nursing Excellence at the University of Arkansas for Medical Sciences College of Nursing, facilitated the launch of the Arkansas Aging Initiative. The statewide network of nine aging centers serves as many as 1,600 older adults.

Each center is owned and managed by a local hospital and employs a geriatrician, an APRN, and a social worker to provide both primary care and education about chronic conditions. The team supports people as they navigate various health care settings and provides care in the home when needed. The centers also offer programs to family caregivers, health professionals, and students on how to assist people with LTSS needs. In addition to coping strategies, family caregivers learn the proper use of such assistive devices as hospital beds, walkers, canes, lifts, and transfer equipment.

In Milwaukee, Wis., Beth Meyer Arnold, RN, MS, a specialist in gerontology, and Lyn Geboy, PhD, an environmental gerontologist, have developed “Optimize: Your Brain and Health.” The eight-week program for people with mild cognitive impairment aims to slow the course of their decline and to support care partners. The curriculum emphasizes a healthy lifestyle and physical and social activities that engage the brain. Once a week for two hours, individuals with mild cognitive impairment meet in a group. They exercise, learn about cognitive functioning, and work on creative artistic projects to keep the brain challenged. Participants learn about diet, communicating effectively, and other strategies for managing cognitive deterioration.

An RN or social worker meets separately with the individuals’ care partners to teach them about the progression of dementia, coping strategies, and community resources for support.

Homier Nursing Homes

According to Mary Jane Koren, MD, MPH, a geriatrician and expert in long-term care, “Nursing homes are the only health care setting that has a statutory requirement for individualized, person-centered care,” but more than a quarter century after Congress enacted a law to transform such facilities, few nursing homes have fully embraced the vision.

Those that have tend to be less hierarchical, according to the CNF brief, employing a more collaborative approach to providing care. In such models, certified nursing assistants (CNAs) often cross-train to assist residents with a mix of personal, household, and health care needs. The direct-care staff is also encouraged to work in teams that manage their own work throughout the day. RNs function in more of a leadership capacity, deploying their expertise and other resources to enable the work of the direct-care team.

In one skilled nursing facility in Canton, Mass., for example, nurses dress in street clothes and share meals with residents, underscoring the homelike feel of the community. At the initiative of the facility’s director of nursing, RNs, licensed nurse practitioners (LPNs), and CNAs are trained to seek resident input in care decisions and work more collaboratively with each other, permitting direct-care staff more autonomy in problem-solving within their scopes of practice. The training has resulted in lower turnover and increased job satisfaction for staff, and a reduction in bedsores, urinary tract infections, and falls among residents.

Educating Nurses for the Future

As the brief notes, fewer than 1 percent of the nation’s RNs are certified gerontological nurses, many fewer than will be needed in a few years. That looming shortage prompted the Institute of Medicine to call on nursing schools to do more to educate students about geriatric care.  Foundations, nursing schools, and professional associations are collaborating on a number of initiatives to breathe life into this effort.  Additionally, the Affordable Care Act authorized $200 million over four years for a novel Graduate Nursing Education Demonstration program whose goal is to increase the number of APRNs trained to provide primary care to Medicare beneficiaries.

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About the Series

For more than a decade, Charting Nursing’s Future has assembled research and expert opinion to inform readers about policies and best practices that are transforming nursing, health care and public health. Propensity LLC currently produces this series.