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Settings for Care

by Barbara Resnick, PhD, CRNP

Health care practitioners may provide care for older people in a variety of settings.

Practitioner's office

Most older people receive medical care in their doctor's office (see The Primary Care Practitioner). The office may be in a medical office building, a clinic, a hospital, or elsewhere. Diagnostic tests, such as blood tests or x-rays, are often done in a doctor’s office. Some doctors' offices offer treatments such as physical therapy.

Hospitals

Hospitals provide the most comprehensive medical care (see Hospital Care). For older people in particular, staying in a hospital increases the risk of problems such as infections, pressure sores, confusion, and incontinence (see Problems Due to Hospitalization). Because of these risks, older people should be hospitalized only if they are very ill. Older people may enter the hospital through the emergency department or be scheduled for admission by a doctor.

A doctor (who may be the person's primary care doctor, a specialist, or a staff doctor at the hospital) is in charge of the person’s care in the hospital. Sometimes several other doctors are involved. Nurses, who are available 24 hours a day, provide much of the care. A nurse is always available, but doctors may come and go at more irregular times.

Many other people may help provide care in a hospital. They include pharmacists, dietitians, physical and occupational therapists, social workers, medical technicians, nurses' aides, and volunteers.

How long people stay in the hospital depends partly on how sick they are, what the diagnosis is, and, if needed, what arrangements for continuing care can be made after discharge. The health care practitioners involved determine whether and what type of continuing care is needed. This care may be provided in a rehabilitation facility, in a long-term care facility, or in the home by a visiting nurse.

Observation care is care within a hospital for people who are not well enough to go home but are not ill enough to meet the requirements for actual hospital admission. With observation care, practitioners can do tests and give treatments for a day or two before deciding whether people need to be admitted. Such people are observed briefly in an emergency department, a special observation unit, or a regular hospital room, even though they are not actually admitted to the hospital. The difference between admission and observation is important because Medicare considers observation care an outpatient service. Thus, Medicare does not cover rehabilitation services after observation care.

Surgical centers

Surgical centers are places where same-day surgery or other procedures may be done. Such procedures include those that typically require anesthesia, that are too complicated to be done in a doctor’s office, but that do not require an overnight stay in a hospital. Common examples are endoscopy, colonoscopy, and removal of cataracts. Surgical centers may be located in a hospital or be a separate, free-standing facility.

Many communities have surgical centers. Then, people can have procedures in their own community without needing to travel to a more distant hospital.

Rehabilitation facilities

After discharge from the hospital, people with a severe disability may need to continue their recovery in a rehabilitation facility (see Rehabilitation). A facility may be located in a hospital or a nursing home. These facilities provide skilled nursing care and physical, occupational, and speech therapy. Usually, people need to have been admitted to a hospital for 3 days to be eligible for Medicare to pay for the rehabilitation facility.

When people are admitted to a rehabilitation facility, an interdisciplinary team tries to anticipate how long their stay will be. For older people, the stay may range from a few days to a few months. Goals for progress are set, and progress is evaluated every day. Thus, the types and amount of therapy can be adjusted as needed.

Some older people may be able to stay at home and get rehabilitation therapy as an outpatient at a rehabilitation facility.

Home health care

People who are frail or who have recently been discharged from a hospital or rehabilitation facility often need care in their home. This care is often provided by family members and/or friends. But when such help is not available or when older people need more help than family members and friends can provide, older people may be eligible to receive home health care services from a home health care agency (see Care in the Home). These agencies send registered nurses, therapists, home health aides, and/or social workers depending on the person's needs and insurance coverage.

Currently, the number of practitioners who will visit people in their home is increasing. A house call can be very helpful because it is more convenient for older people, and it enables practitioners to see how people are doing in their usual living environment.

End-of-life (hospice) care may also be provided in the home (see Hospice care).

Community services

In the United States, one source of support services and health care in the community is a senior center. These centers provide social, recreational, and educational activities, and some serve meals—an important service for people who cannot prepare their own.

Day care centers are another community-based service (see Day Care). Day care centers charge for services. However, they can provide a break for caregivers during the day so that caregivers can, for example, keep their job. Some day care centers also provide some health care. For example, these centers may have a nurse and/or nursing assistants on duty. The nurse can check blood pressure, make sure people are taking their drugs as instructed, and provide health information. Nursing assistants can help make sure that older people's toileting needs are taken care of and that they are fed as needed during the day. When there are medical concerns, the nurse may contact the person's primary care practitioner or family members. Some day care centers provide day care for people with mild to moderate dementia, and some provide physical and occupational therapy.

Other services available in the community include meal programs (such as Meals on Wheels), transportation services, help with daily activities, support groups, and respite care. Some religious communities provide many of these services. These services are usually inexpensive, and some are free.

People can obtain information about community services, including senior centers, from the hospital discharge planning or case management department, home health care agencies, local health departments, and religious communities. Senior centers can also be found by looking in a local telephone book or on the Internet.

Did You Know...

  • Some senior day care centers have a nurse on duty to provide some health care, such as checking blood pressure.

Long-term care

The prospect of needing long-term care services concerns many older people. The likelihood of needing long-term care increases greatly as people age because older people are more likely to develop chronic disorders and to have problems functioning. How long care is needed varies from weeks to years to indefinitely.

Long-term care focuses on helping people function. It helps them do the activities necessary to care for themselves and to live as independently as possible. These activities include basic daily activities (such as eating, dressing, bathing, grooming, and walking) and other activities (such as shopping, balancing a checkbook, doing laundry, and housecleaning). Long-term care usually includes help with health care. Most long-term care facilities also provide social and recreational activities.

Many people have their first experience with long-term care after a hospital stay. During an illness or after an injury, many older people lose some or all of the ability to care for themselves. Thus, although they may be well enough to leave the hospital, they may need to go to a long-term care facility for rehabilitation and recovery. This move can be physically and psychologically demanding. People have to adjust to many new faces and to new routines for sleeping, bathing, dressing, eating, and other daily activities. The move happens quickly, with little time to adjust.

Most people associate long-term care with a change in residence:

Older people may be particularly concerned about moving to an institution. People live in institutions for a variety of social and economic reasons. The most common reasons are physical problems and/or problems with mental function (cognition) plus lack of adequate social support.

What type of arrangement is possible depends partly on a person's needs (medical, functional, social, and emotional), preferences, and financial and social resources (such as long-term care insurance, availability of state waiver programs, and family members’ willingness and ability to help). One person may be able to live at home with the help of a spouse. Another person with similar problems but without family support may need to go to a nursing home. Learning about the many types of long-term care facilities can help people choose the right time and place for long-term care. Each type of long-term care facility provides different services and levels of health care.

After the type of arrangement is determined, a particular facility must be carefully chosen. Even within each type, facilities differ considerably in environment, services (including health care), activities, living arrangements, and rules. Sometimes the difference is simply a matter of what people can afford, but even within a price range, quality varies.

Types of Long-Term Care

Type

Services

Typical Living Arrangement

Funding

Assisted living communities

Meals (in a common dining room or in the person’s room)

Social and recreational activities

Help with daily activities

In some facilities, monitors for emergencies (such as intercoms and personal emergency response systems), services of nurses and physical therapists, and 24-hour supervision if needed

Apartments or occasionally just a bedroom with a private bath

Mostly private funds or long-term care insurance

Help from Medicaid in some states

Board-and-care facilities

Meals (in a common dining room or in the person’s room)

Transportation to medical appointments or shops

Social activities

Help with personal care and sometimes some help with taking drugs (for example, reminding people to take their drugs)

Rooms on a common hallway

Mostly private funds

Life-care communities

Meals (usually in a common dining room, except for residents who need more care and who have meals in their room)

Transportation

Social and recreational activities

As much help with daily activities and health care as needed

Varied arrangement according to need

Mostly private funds

Help from Medicare and Medicaid for skilled nursing care when it is needed

Nursing homes

Meals

Help with daily activities

24-hour skilled nursing care

Rehabilitation (physical, occupational, respiratory, and speech therapy)

Hospice care

Oversight by a doctor

Rooms on a common hallway

Private funds

Medicaid

Medicare for skilled care for a short time in certified nursing homes if care is needed daily after a hospital stay lasting 3 days or more

Hospice care

When people have a progressive, incurable disorder, hospice care provides the treatments and services needed to control symptoms, ease pain, and help people and their family members prepare for the death (see Death and Dying). Hospice care may be provided in a person's home, in a nursing home, or in a hospice facility.

Hospice care usually involves a primary care practitioner, nurse, social worker, and others who are trained to care for dying people. For example, pharmacists, counselors, physical therapists, ethicists, and volunteers may also be involved. These practitioners are needed to make sure that all of the person's physical and psychologic needs are met as well as the needs of the family and caregivers. Most people who receive hospice care do not have to go to a hospital before they die. Thus, they can die in a more comfortable, intimate environment, often with loved ones around them. Hospice care also involves helping family members recognize the physical signs that death is near, understand what to do when the person dies, and help them cope with the loss.

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