The CARE Program: a nurse-managed collaborative outpatient program to improve function of frail older people. Collaborative Assessment and Rehabilitation for Elders.

BACKGROUND AND OBJECTIVES: Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home-based, and institutional long-term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse-managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time-limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed. SETTING: The program is housed in renovated space devoted to the care of older people. The academic and clinical offices of the University of Pennsylvania's nursing and medical gerontologic and geriatric faculty are in the same building. PARTICIPANTS: We have targeted those persons older than age 65 who have complex health problems and are living at home. Individuals must need multiple services, including at least one rehabilitation therapy, and they must be unsuitable-for inpatient rehabilitation. DESCRIPTION OF THE POPULATION: In its first 8 months of operation, the program received 97 referrals and admitted 53 clients. Clients were, on average, 78 years of age. Over three-fourths (77%) were women and 58% were black. The average stay in the program was 6 weeks. FIM scores, which improved a mean of 2.4 points, were found to lack sensitivity to the functional improvements achieved by clients. CONCLUSION: Under existing Medicare and third party reimbursement policies, it is feasible to establish a nurse-managed comprehensive outpatient rehabilitation program designed to meet the needs of frail older persons. Preliminary data support the beneficial effects of the program as well as the economic feasibility of this approach.

Pygmalion in the nursing home. The effects of caregiver expectations on patient outcomes.

Several characteristics of nursing home care can diminish rather than enhance the clinical status of older residents. In view of evidence from other settings that "interpersonal expectancy effects" can influence outcomes in a variety of relations, we conducted a randomized controlled trial to test the effects of caregiver expectations on the clinical status of nursing home residents. Within 2 weeks of admission, 63 older residents at six nursing homes were given a comprehensive assessment of cognitive, functional, and emotional status. Residents were then randomly assigned to a "high-expectancy" or "average-expectancy" condition. Nurses and aides were told that, in comparison with other residents having similar problems, residents in the high-expectancy group were predicted to perform above average in their rehabilitation. The assessment was repeated 3 months later; information on the health and psychosocial status of residents was drawn from their medical records covering the same period. Aides reported having higher expectations for treatment group residents. When assessed by a blinded research assistant, residents in the high-expectancy group experienced greater relief of depressive symptoms but showed greater decrements in functional independence in comparison with control residents. Treatment group residents were admitted significantly less frequently to hospitals despite a comparable number of emergency ward visits, suggesting a lower incidence of severe illness despite comparable medical surveillance. There was also a trend toward improved performance in mental status testing among the high-expectancy residents compared with controls (P = .08). Additional research is needed to define further the magnitude and mechanisms of expectancy effects in relations between nursing home caregivers and residents.

The effects of nursing and physician services: some preliminary results.

This paper examines the relationship between the future staff cost of nursing home patient care and the type and level of nursing and medical services these patients receive. Nursing times are grouped into eight categories based on a principal components analysis. We then investigate the effect of the level and type of nursing care and of physicians' services given in an earlier period on the staff cost of nursing home care in a later period. Psychosocial nursing care (emotional support, education) and number of physicians' visits given in the earlier period were found to be negatively associated with costs in a later period. The most powerful predictor of future costs were actual costs in the earlier period. These results suggest that more investment in psychosocial nursing effort and physicians' services may yield modest cost savings in future nursing home patient care.

Rehabilitation: an 'everyday' motivation model.

In this article a model is presented to deal with motivational problems of rehabilitation patients. The problem of motivation is not covered yet in relevant psychological disciplines like rehabilitation psychology, neuropsychology and health psychology. An important source of the model is cognitive psychology. Applications are presented in the communication between rehabilitation workers and the patient. The model can be put into practice in a wide range of patients with physical and/or cerebral handicaps.

Home dialysis: lessons in patient education.

The concept of home haemodialysis for the regular treatment of renal failure was first put into practice in 1964, 30 years ago. It proved extremely successful. This paper describes the epidemiology of renal failure, the reasons for home haemodialysis and the educational role necessary to ensure its success. Continuous ambulatory peritoneal dialysis (CAPD), or autonomous dialysis, is a self-care peritoneal treatment which developed after 1978 for a wider age range of patients. Its rapid expansion needed a professional approach to patient education. Also discussed are the problems patients encounter with conceptual skills, as opposed to the easy acquirement of practical skills and the paper demonstrates how persons, without formal medical and nursing education, can master complex treatment skills.

A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy.

PURPOSE/OBJECTIVES: To examine the effects of a comprehensive rehabilitation program on facilitating physical and psychosocial adaptation of women with breast cancer who are receiving adjuvant chemotherapy. DESIGN: Experimental. SETTING: Breast evaluation clinics of two New England medical centers with comprehensive cancer treatment programs. SAMPLE: 14 women (mean age = 44 years) receiving adjuvant chemotherapy for breast cancer (86% stage II) following surgical treatment. METHODS: Subjects were assigned randomly to the experimental group or the usual care group. Experimental group members began a structured exercise program of walking and attended support group meetings. All subjects were tested before beginning chemotherapy, during the course of chemotherapy, and one month following chemotherapy completion. MAIN RESEARCH VARIABLES: Performance status, physical functioning, psychosocial adjustment, self-concept and body image, and 12 symptoms (e.g., fatigue, nausea, anxiety). FINDINGS: Measures of physical performance, psychosocial adjustment, and symptom intensity revealed improved adaptation in subjects who completed the walking/support group program. CONCLUSIONS: Physical and psychosocial benefits from a modest walking exercise program and a support group are possible for patients receiving adjuvant chemotherapy. IMPLICATIONS FOR NURSING PRACTICE: Although more detailed research is necessary to answer some of the questions raised by this study, implementing the walking program and forming a support group are achievable in an outpatient setting.

Expanding the role of nurses in rehabilitation.

The role of nurses in geriatric rehabilitation is an aggregate of responsibilities directed toward planning realistic and meaningful restorative measures for disabled elderly persons. Nurse practitioners in this field are challenged to provide intelligent, competent bedside care, but it is equally important that they strive to create a milieu in which meaningful stimulation and sensory input are deliberately introduced. The geriatric rehabilitation nurse may be defined as a jack-of-all-trades and as a master of innovation. In the absence of a physical, occupational, or speech therapist, the nurse should be able to institute safe and stimulating activity programs. In the absence of a social worker, the nurse should have the interviewing and counseling skills that will enable intelligent intervention with helpful guidance in a social crisis.

Effectiveness of a handwashing program.

A pilot study to develop and evaluate a program to teach 13 Grade 1 children with disabilities about handwashing was conducted at Glenrose School, which is located within Glenrose Rehabilitation Hospital. Children aged 6 to 8 years were taught how and when to wash their hands. Handwashing skills were evaluated before the teaching began, immediately following the teaching program, and at 1, 3, and 5 months postteaching. The children's handwashing skills did improve, with the girls generally scoring higher than the boys on both washing techniques and times of washing on all the testing occasions. Although the children had fewer visits to the doctor, took fewer prescribed antibiotics, and had fewer infectious illnesses than they did for the same time period the previous year, other variables, in addition to the teaching program, may have contributed to the outcome. A revised handwashing program is now included in the Grade 1 curriculum.

Using critical incident technique to inform aged and extended care nursing.

Flanagan's critical incident technique was used to explore the beliefs of a cross-section of careers (both nursing and others) and consumers about the value of nursing and the nature of nursing's contribution in aged and extended care. The exploratory study found that nurses' being there, with and for residents, their families, and other health professionals, was influenced by two major themes that emerged from the data: personal and structural considerations. In this article, the potential of critical incident technique as a research method in nursing and for generating information about critical aspects of nursing work in aged and extended care is demonstrated.

A legislative perspective on the school nurse and education for children with disabilities in New Jersey.

The New Jersey Dept. of Education has proposed a new direction for interpreting the "Education for All Handicapped Children Act of 1975" (Public Law 94-142). If implemented, a new and broader scope of addressing learning and/or behavior and health problems for the school-aged child will be provided. In this article, the special education process in New Jersey is analyzed, reflecting on political, economic, and social movements that affected past and present legislation. The effects of the new proposal on students, families, school personnel, and community resources are emphasized. Role implications for the school nurse in formulating, interpreting, and managing the child with disability in school are provided.

Implications for nurses in approaches to the management of stroke rehabilitation: a review of the literature.

There is as yet no general agreement on how best to manage stroke rehabilitation in terms of the approaches to the management of this client group. Approaches include the Stroke Rehabilitation Unit (SRU), applying the principles of SRU management to general medical wards and the use of peripatetic stroke therapy teams. Each of these approaches has implications for nurses yet the contribution of nurses to the rehabilitation of stroke patients receives only scant attention in the literature. It is suggested that understating and undervaluing nursing leads to under use of this essential resource.

Effects of an educational intervention on students' attitudes toward the disabled.

The purposes of this study were to determine if the attitudes of nursing students toward the disabled would improve following participation in a one-day educational conference on care of the physically disabled and to identify variables influencing these attitudes. Nursing students completed Yuker and Block's Attitudes Toward Disabled Persons scale (ATDP) (1986) prior to and one month following the conference. T test indicated that subjects had significantly higher ATDP scores following the rehabilitation conference (p = < .0001). Subjects with prior work experience with the disabled had significantly higher scores on the ATDP, indicating more positive attitudes toward the disabled.

Enhancing recovery via neuro-rehab rounds.

The neurologically injured patient experiences physiological and psychological disruptions regardless of the type of severity of injury. Through increased knowledge, nurses planning care can minimize loss of functional ability, anticipate complications and enhance recovery. Neuro-rehab rounds were developed to increase the involvement of support therapies for the patient in the neurotrauma intensive care unit (ICU) of a particular hospital. Increasing the critical care nurses' awareness of rehabilitation principles was the secondary goal. This protocol decreased length of stay, increased mobilization of patients in the ICU and provided for continuity of care for the neurologically injured patient. Rounds also redirected and expanded the focus for critical care nurses from episodic to one more outcome related.

Central pontine myelinolysis: a multidisciplinary approach to care.

Central pontine myelinolysis (CPM) is a neurological disorder with a variety of manifestations which may be fatal or result in permanent disabilities. Various factors, most commonly too rapid correction of serum sodium, have been implicated in the development of this osmotic demyelinating syndrome. The patient's survival depends on accurate assessment and prompt intervention by the neuroscience nurse. Optimal outcome depends on collaboration by all members of the health care team.

Effectiveness of bran supplement on the bowel management of elderly rehabilitation patients.

1. Constipation is a common problem in the elderly that affects up to 20% of those 65 years and older. 2. Patients receiving the fiber supplement had a significantly lower number of bowel agents per day as compared to the control patients. 3. Side effects from the additional fiber occurred in a subgroup of patients; thus, institution of additional fiber to the diets of ill, physically dependent patients is best done gradually and with close monitoring.

Caring for the cognitively impaired. Reconceptualizing disability and rehabilitation.

Rehabilitative interventions must be based on remaining cognitive and physical abilities while recognizing the presence of disabilities. Rehabilitation goals should be to provide the least restrictive environment using the least restrictive intervention, thus promoting independence. The use of behavioral strategies that support remaining abilities and compensate for cognitive deficits is recommended as a rehabilitative approach. The behavioral approach requires an assessment of the ADL steps, the range of activities a person is able to complete, and the kinds of caregiver assistance needed.

Developing care plans for psychosocial nursing diagnoses.

In 1992, the Nursing Department Documentation Committee at Spaulding Rehabilitation Hospital decided to revise the process of and forms for documenting nursing diagnoses. A sub-committee developed a format for standardized nursing care plans and piloted its use on two patient care units. The unit nursing staffs selected a number of common nursing diagnoses and, using the new format, developed standardized nursing care plans for them. After refining the process based on this pilot, the development of care plans was extended to all patient care units. A collaborative partnership was then formed between interested Primary Nurses, the Psychiatric Clinical Nurse Specialist and the Nursing Practice Coordinator to focus on developing psychosocially-oriented care plans as well as physically-oriented plans. Although psychosocial diagnoses are less frequently identified in the assessment process and included in nursing care planning, they are still very important for providing comprehensive care. This article describes the process of developing and implementing psychosocial care plans. This article also describes the components of the standardized nursing care plans developed for four psychosocial nursing diagnoses.

Collaboration: the solution to multidisciplinary care planning.

Case management is a patient care delivery system that is transforming health care in the 1990s. The key to its success is its primary tenet of collaboration among all disciplines. Case management enhances communication among all disciplines and coordinates patient care services. Multidisciplinary action plans have been developed as a tool for the multidisciplinary team, to guide health care practitioners toward the highest quality, cost-effective care possible. At Beth Israel Medical Center in New York City, the Multidisciplinary Care Model has proven successful on both the Orthopaedic and Rehabilitation services.

Pulmonary rehabilitation for mechanically ventilated patients.

Pulmonary rehabilitation for the mechanically ventilated patient is a complex process requiring the teamwork of many disciplines. The physician, pulmonary CNS, respiratory therapist, physical therapist, occupational therapist, dietician, speech pathologist, social worker, and chaplain all work together in a coordinated effort. Daily assessment of patient changes and tolerance to therapy is necessary to progress the patient to a relatively independent state. When communication among the team members is effective, few problems go unnoticed. The primary goal of pulmonary rehabilitation is to return patients to their highest functional capacity to enhance their independence and personal ego strength, whether on or off a ventilator, part or all of the time. If chronic mechanical ventilation is the reality, pulmonary rehabilitation must promote a quality lifestyle of independence and autonomy.

Rehabilitation considerations in the care of the acute burn patient.

To be burned is to suffer one of the most dehumanizing events known. Adult burn patients have gone from independent, healthy individuals to totally dependent patients who may survive but be severely disfigured. The ultimate rehabilitation goal is to provide extensively burned patients with the training necessary for them to resume as much of their preburn lifestyle as possible. Prevention and control of scarring processes are the initial vital phases of the process. Reconditioning continues that process by preparing the patients to function within the limits of their present physical ability. All of the activities of daily living that the patient is able to perform with a minimum amount of assistance or independently with the use of assistive devices also move the patient toward independent living. The rehabilitation process is a critical element in the daily care of the burn-injured patient, and all team members providing that care should be encouraged to view the patient as a whole, giving early consideration to the final rehabilitation outcome.