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• W1987345067 abstract "My friend Gertrude just had her 90th birthday. I wouldn't have known it if she hadn't recently been admitted to her second nursing home after two intervening hospitalizations and a surgical procedure within the last 2 months. That's because she never told anyone her age. She was active, lithe (in spite of her arthritis), forward thinking, down to earth, yet a little eccentric. She avoided medical and dental interventions as much as possible. She is a former teacher, social worker, and probation officer, with two pensions, who never married. She used to awake early, spend the morning at the YMCA exercising and swimming, lunch with cronies at McDonalds, and then nap a little. What she did with her late afternoons, in the years that she and I no longer taught the Arthritis Self Help course together, I don't know, but she would fall asleep in her chair in front of the television mid-evening, take herself to bed around 11 pm, and arise at about 7 am the next day, to begin the cycle again. I didn't recognize her when I visited her in the nursing care facility because her real hair was showing! I hadn't ever seen her without her perky, short, salt-and-pepper wig. She actually had long whispy thin gray hair, as I too will have if I live to be her age. She didn't have her glasses on, and her vision is markedly impaired as a reult of myopia, presbyopia, and voluntarily untreated cataracts. Recently she had voluntarily curtailed much of her driving. My interaction with Gertrude and the facility staff has been interesting and instructive. The facility is small, with a beautiful garden in the front. Most of the rooms open onto a sunny paved courtyard with tables, chairs, umbrellas, and evidence of resident gardening activities (of the potted plant variety). The Minimum Data Set (MDS) nurse knows all about Gertrude's clinical status and her progress. She is able to recite from memory and find in the chart all the information about Gertrude's functional status post-CVA and post-hip fracture and replacement. We discuss her appetite and eating, her cognition, her lack of progress in rehabilitation. When I visit, Gertrude is always dressed, although the whereabouts of some of the jogging suits (her favorite uniform) her friend has brought to her is unknown. She and her clothes are relatively clean. But rehabilitation has been discontinued because of a lack of potential. The interventions used to manage Gertrude's care (as she becomes increasingly agitated, getting up and falling frequently) seem to be diapering, distraction (activities and television), and imposition of a schedule designed to keep her awake all day in the hope that she might sleep at night. Under this regimen, she is becoming more and more exhausted, less and less “Gertrude.” There is no doubt that the facility is providing adequate to good clinical care as we define it, and the professional and caregiving staff know Gertrude, are kind to her, and are concerned about her. Who can blame them for being unmotivated to keep Gertrude's glasses on her when she frequently announces that they make no difference? Who can blame them for not toileting her, when, small as she is, she is nearly a two-person lift, not having gotten the hang of even trying to help transfer. But Gertrude's experience calls into question the “medicalization” of the nursing care facility, which the implementation of the RAI promulgates further. In spite of MDS items related to lifestyle and psychosocial considerations, the Resident Assessment Protocols (RAPs) focus on the early identification, diagnosis, and care planning of clinical conditions. While this is all well-meaning, what are some alternate visions for Gertrude's life now? What of Bill Thomas's A Life Worth Living,1 in which he documents decreases in hospitalization and mortality based on creating the nursing care facility as a Garden of Eden, where plants, animals, and children abound and there are more meaningful activities of caregiving and caring by residents about the living things in their environment? What of P.K. Beville and Neil Shulman's dream weaver,2 assigned to ascertain — and fulfill— the most often simple wishes of nursing facility residents? Would these approaches bring Gertrude back to us in some small way? See also pp 977, 986, 994, 1002, 1011, 1017 In this issue of the Journal, a series of articles attempt to carefully and scientifically evaluate the effects of a comprehensive assessment and care planning system, the RAI. The authors have all pointed out3-6 that there are missing links in the causal cases they wish to build. Phillips et al.4 ask the question, “How was this improvement really achieved?” In other words, what went into it? For at least 30 years, the entire field of evaluation research has been grappling with such methodological issues of large scale social experiments as: was the social experiment actually conducted as intended? what were the intended and unintended consequences of the social experiment? how can outcomes be measured reliably and validly? could measurable outcomes or changes in process be attributable to some other factors? One element missing from these papers is a qualitative examination of how the RAI was actually implemented. Many of us who work in nursing care facilities have a less than clear concept of how it is being implemented, and it is interesting that the evaluation methodology mimics what we know. The MDS nurse takes the responsibility for carrying out all assessments and ensuring regulatory compliance, most likely to relieve the regular staff of the burden of paper compliance. The authors found that, in fact, nursing staff did complain about this burden as a negative aspect of the RAI. Thus the intention of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) regulations, as described by Hawes, et. al.3 in their article on process quality, is circumvented in that nurses who do not know the residents are going through the motions of recording superficial assessment data of questionable accuracy. In some instances, the MDS nurse is a contractor who goes from facility to facility completing the records. It is no wonder that post-RAI accuracy was documented because the research nurses were as removed from these residents as the MDS nurse often is in the field. Furthermore, it would not be surprising if the presence of standardized assessment data on the residents' records in 1993 may have caused a halo effect for the second cohort. While individualized care planning is the goal of the Resident Assessment Instrument (RAI), little individualization is possible when the actual providers of care (the charge nurse and nursing assistants) are not involved and accountable for assessment and planning. We aren't sure, based on the reports presented here, exactly how and whether the regulations were carried out. Furthermore, while we are told something about the intended consequences of the implementation, there is little examination of unintended outcomes. Mor et. al.5 point out that hospitalizations have decreased without a concomitant increase in mortality. Certainly, increased mortality would have been an unintended outcome. Another unintended outcome that was identified by Fries et. al.5 and Phillips et. al.6 is the decline in health or increase in hospitalization of residents of selected profiles (the most robust or the most frail), with selective improvements for the middle-range group. These authors' explanations are sound. First, the RAI appropriately encourages targeting of residents who are at-risk and/or could improve, and second, resources are finite, and nursing care facilities can only do so much. Although we would like all residents to benefit from comprehensive assessment and care planning, some residents, not analyzed in these reports, are already functioning at the lowest level and are not expected to improve. Of course, the larger unintended outcome may be the atomization and ultimate loss of “Gertrude.” Ouslander7 points out lack of consideration of clinical interventions in these papers and the general absence in long-term care of a broad array of effective interventions. While the study on which these papers were based adds credence to the belief that comprehensive assessment and the planning of care are the basis for effective intervention, again, as the authors point out, the causal link for effectiveness of the RAI is not demonstrated because the quality of the care plans and whether they were actually implemented were not examined in this study. What is really going on here? We may be less sure in the study represented by these papers than we are in some other quasi-experimental studies. What interventions would help Gertrude? A general daily exercise program (such as Schnelle's Functional Incidental Training) in the mornings might really make her feel like herself again. A nap in the afternoon might make her feel much better. In truth, nursing home residents do not view their daily lives as a series of interventions. They want food that they like, a clean environment, a feeling of personal safety and security of belongings, the power to make a few basic choices each day, people to communicate with and among whom they can find companionship, who will help them simply because they are human beings in need of help.10, 11 Yes, they want to be healthy, but many do not feel sick. They feel a little tired, a little old, a little helpless. How can we reconcile the personal and the clinical and make life comfortable and meaningful? As geriatricians, geriatric nurse practitioners, long-term care nurses, physical, occupational, and speech therapists, dietitians, and social workers, we have taught ourselves to call Gertrude a resident, but to us she is still a patient, and the more so as we build an elaborate medical mechanism around her and turn every interaction into an assessment, a care plan, an intervention. As we look forward to a more reliable MDS instrument and to an overlapping instrument for Home Care, as described by Morris et. al.,8, 9 which is very exciting for psychometricians and healthcare policy makers, we need to remember Gertrude. We must think of the people living at home and try not to start “medicalizing” even the Home Care environment." @default.
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• W1987345067 title "Where's Gertrude?" @default.
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