An alternative model in geriatric care.

An analysis is presented of one long-term care facility's attempt to develop a comprehensive geriatric program including care of the patient in a hospital, a skilled nursing home, a day hospital, or a clinic for care of the ambulatory aged. The goal was to raise issues for debate and discussion, especially in terms of the evolving role of medical directors in long-term care. The need for group professionalism in cooperation with the Board of citizens in community geriatric practice is emphasized.

Toward a comprehensive geriatric educational experience.

A description of the goals and the accomplishments of a program in geriatric education and training is presented. Emphasis is laid on the potential role of departments of family and community medicine, even though vast resources may not be available. Such a program is of great importance, but it must be viewed as only the first step in the development of a comprehensive training model for either a school of medicine or a residency program in primary care. Upon graduation in Family Medicine, residents should not only be aware of the specific health needs of the elderly, but also be clinically competent to meet those needs.

Medical direction in long-term care.

This report presents the views of over 1000 administrators, nurses and physicians with respect to the responsibilities, authority and impact of the medical director in a long-term care facility (LTCF), as well as the nature and future of long-term care and geriatric medicine in the USA. Nurses, administrators and physicians were more able to agree on the bureaucratic functions of the medical director than on the functions which might be considered more clinical or activist in terms of the total needs of the LTCF. There was no consensus about the external factors which might determine the future of LTC, i.e. alternatives to institutionalization, public attitudes or community hospital relations. Instead, concern seemed to focus upon the "low level" of funding for LTC. With respect to the nature of LTC itself, most respondents felt that the area was clinically challenging. However, only 40 percent of the physicians believed that clinical skills were more important than a sympathetic regard for patients. As a corollary, physicians were the least supportive of geriatrics as a new specialty in medicine.

Reliability of palpation of pedal pulses as ascertained by the kappa statistic.

An improved statistic (weighted Kappa) was tested for reviewing the reliability of the palpation of pedal pulses by three observers. Significant improvement was noted after training. Reliability also persisted with respect to a reduced form of the conventional ordinal grading system. The findings indicated that problems of usefulness or reliability may arise when more than five distinctions are made in describing the pulses or when the data are completely reduced to only a dichotomous (present-absent) system.

A survey of the prescribing and administration of drugs in a long-term care institution for the elderly.

The prescription and administration of drugs (especially of the neuroactive class) was observed in 131 patients in an extended care facility. The average number of neuroactive drugs prescribed (2.1) was distinctly different from the average number administered (1.3) because of the large number of pro re nata (prn) prescriptions. More neuroactive substances were prescribed for patients with superior mentation and minimal physical disability; the difference between low and high groups was 1.7 (mentation) and 2.8 (physical status). The most common neuroactive drugs prescribed were: 1) analgesics, 2) major tranquilizers, and 3) hypnotics. Questionable prescribing practices were demonstrated by the fact that 30 patients had prescriptions for 38 "not-recommended"drugs; 23 of these prescriptions were for propoxyphene compound. After requiring physicians to rewrite drug orders every thirty days, a survey made ten months later showed that there was a decline (0.8) in the number of drugs prescribed per patient and a slight increase (0.45) in the number of drugs administered. Professional drug surveillance is crucial for improving the therapeutic process. At least two modifications of current prescribing practices are recommended: 1) a record should always be made of the precise condition(s) under which a drug prescribed "prn" is to be administered; and 2) a strong effort should be made to reduce the total number of drug prescriptions. The results of this survey suggest that certain procedural matters necessitating change are not in themselves the most substantive factors in improvement. Present "third party" review mechanisms likely will not ameliorate the current situation. It will be necessary to implement complex organizational changes in most extended care facilities.

Geriatric care and distributive justice: problems and prospects.

KIE: This paper introduces a series of 16 essays on cross-national perspectives in geriatric care and distributive justice. Gill and Ingman first provide an overview of the "broad parameters under which distributive justice decisions have been and are being taken in the American medical care system," with special reference to John Rawls' A Theory of Justice. They then briefly summarize the topics of the other essays, which are organized into three sections: I. The U.S.A.: Underdevelopment of the Welfare State and Limited Geriatric Care; II. Nursing Homes: Industry or Public Service?; and III. Geriatric Care in Other Selected Countries. The authors conclude that funding health care for the elderly in terms of distributive justice is creating a dilemma for all societies. They propose the decommodification of medical services as a solution to the problem in the United States.^ieng

Health care provision and distributive justice: end stage renal disease and the elderly in Britain and America.

Considerations of distributive justice impacting upon the provision of geriatric care and the treatment of patients with end stage renal disease (ESRD) are compared and contrasted between the U.S. and the U.K. Comparisons are drawn from differing degrees of individualist and collectivist idealogies between the two countries and analysis is further developed through use of the concepts of equity, uniformity and public accountability. Notwithstanding the predominance of an individualist ideology in the United States the provision of ESRD services is based on a collectivist format. Geriatric care and other welfare services more directly reflect the differences between collectivist and individualist ideologies in the two countries.

Medicalization, public policy and the elderly: social services in jeopardy?

This paper examines the medicalization of community-based services for the elderly; a process of restructuring to provide more highly medical services to a frail older population at the expense of providing a broader range of social and supportive services to older persons with varying levels of need. Medicalization is tied to changes in government policy (particularly Medicare reimbursement) which have led to increased competition within the health and social service sector. The paper utilizes data on services, policy impact and staffing from the DRG Impact Study conducted at the Institute for Health and Aging (UCSF), a 3-year study of the impacts of federal policy on 7 types of community providers of services to the elderly. Data are presented from telephone interviews conducted at two points in time (1986 and 1987) with directors of a representative sample of home health agencies (HHAs). Findings include: HHAs were more likely to report adding highly medical services and cited social/supportive services (as opposed to highly medical and/or highly technical services) as the most commonly requested services they cannot provide. Policy effects and societal implications of the medicalization of home care are considered.

The regulation of home health care quality.

This descriptive study examined state regulatory activities for home health agencies in California and Missouri. In California, the state survey agency was increasingly unable to meet its annual survey requirements. Missouri's survey agency was able to remain current with its survey activities. Neither state used enforcement actions to any great extent for those facilities with problems to any great during the 1983 to 1988 period. Regulatory activities for home health agencies were not given a high priority in either state, and many barriers to the effective regulation of agencies were identified. This study suggests that additional research should be directed toward the study of state regulation and its relationship to quality of home health care.

A randomized controlled evaluation of an educational program in adults with high psychosocial risk of morbidity.

This clinical trial tested the efficacy of a psychosocial intervention in a panel of white adults with a high level of recent stressful life changes and weak social supports. One hundred seventy users of three family practices were randomly assigned to receive a six-month educational program provided by a nurse practitioner or to a control group. Outcome variables were assessed over a 12-month follow-up period by mailed questionnaires and validated when possible by review of medical records. During the six months immediately following the intervention, recipients had a lower rate of restricted-activity days than controls. During the follow-up period, symptom experience, physical function, social function, and emotional function were similar in the two groups. While the overall improvement in social supports was not significantly better at the completion of the intervention for recipients than for controls, those recipients who developed strong supports had fewer restricted-activity days than those who continued to have weak supports. This educational program may provide temporary benefit to adults with high psychosocial risk for health impairment.

Utilization of specialized ambulatory care by the elderly. A study of a clinic.

Specialized ambulatory geriatric care remains an understudied topic. This article analyzes the organization of one special clinic that was established in an apartment block of elderly housing. The findings indicated that as the number of nurse practitioners and case workers' visits rose steadily during the first four years of the clinic's existence, visits to the clinic physicians declined by approximately one visit per client per year. The clinic population utilized less inpatient hospital care than other nonusing residents, and less than other residents of similar age in Connecticut. There was reduced usage of intermediate nursing home care (as opposed to skilled nursing care). Hence, how geriatric ambulatory care is delivered affects institutionalization. In the interests of general well-being and economy, more attention should be paid to this extramural phase of medical care of the elderly.U