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PubMed1979

A survey of preceived oral health needs of homebound patients.

1. While almost 60 percent of all patients reported dental needs, it is assumed that actual needs were in fact considerably higher. Problems relating to dentures were the most freqeuntly expressed complaint. 2. A strong relation existed between the ability of homebound patients to get to a dentist and the time elapsed since last dental visit. Number of teeth was a significant determinant in frequency of seeking care. Persons with teeth or dentures sought treatment more often than those who were edentulous. Pain was the only variable for which a difference was noted between the two groups in the effect on time of last dental visit. 3. The study revealed an inaccessibility of dental care for the majority of patients confined to their homes. Ability to get to the dentist was identified as a major barrier to care for the homebound. The delivery of dental services to such patients in their immediate surroundings, by specially trained dental professionals using mobile units, must therefore be seriously considered as a means for improving access to care for this population.

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PubMedDate not supplied

Advance directives among patients in a house call program.

BACKGROUND: Advance medical directives (the living will and the durable power of attorney) provide a means for competent persons to influence treatment decisions in the event of serious illness and loss of competence. Advance directives among elderly homebound patients. METHODS: In a house call program for 120 elderly patients, a standardized telephone interview was conducted with 116 patients or their caregivers. They were asked whether they had a will, a living will, or had assigned a durable power of attorney. Those without advance directives were asked whether they knew what each directive was. Demographic and medical data were assessed by interview and chart review. RESULTS: More than 60 percent of the patients knew about the durable power of attorney, and more than one-half had assigned a durable power of attorney. About one-third knew about living wills, but only 5 percent had one. One-third of the patients had a will. CONCLUSIONS: Advance directives are important mechanisms whereby patients can extend autonomy over the circumstances of dying. Physicians and patients should consider and discuss the issues that surround treatment in the event of terminal illness or permanent unconsciousness.

Activities of Daily Living↗
PubMed2002

The elderly nutrition program: an effective national framework for preventive nutrition interventions.

OBJECTIVE: To guide national policy, Congress mandated the 1992 research evaluation of the Elderly Nutrition Program (ENP), the nation's oldest framework for providing community- and home-based preventive nutrition and health-related services to older persons. This article summarizes key findings on the program's influence on nutritional health, the targeting and costs of its nutrition services, and the study's policy implications. DESIGN: The research included a nationally representative sample of ambulatory and homebound ENP participants And a matched sample of nonparticipants drawn from the US Health Care Financing Administration's Medicare beneficiary listings. Interviews conducted in respondents' homes considered demographic and health characteristics and assessed anthropometry and physical functioning, nutrient intake and socialization patterns, and utilization of ENP program services (participants only). Administrative and service delivery data were gathered from all levels of the ENP infrastructure. RESULTS: The ENP program currently provides congregate and home-delivered meals and other nutrition- and health-related services to about 7% of the older population overall, including an estimated 20% of the nation's poor elders. Compared with nonparticipants, ambulatory and homebound ENP participants are better nourished (4% to 31% higher mean daily nutrient intakes; P<.001) and achieve higher levels of socialization (17% higher average monthly social contacts; P<.001). Federal spending on ENP nutrition services is efficiently leveraged by funding from other public and private sources, allowing ENP to more than double the nutrition services it provides to program participants. CONCLUSIONS: ENP is a well-targeted, effective, and efficient federal program available to dietetics and other professionals for providing elderly persons with community-based and home-delivered nutrition and related services. The ENP infrastructure offers a potential model for preventive nutrition intervention programs in ambulatory and homebound at-risk older populations.

Activities of Daily Living↗
PubMed1992

Psychiatric status among the homebound elderly: an epidemiologic perspective.

OBJECTIVE: To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors. DESIGN: Survey. SETTING: Epidemiologic Catchment Area (ECA) project in New Haven, CT. PARTICIPANTS: 2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area. INTERVENTION: None MAIN MEASURES: Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination. RESULTS: Cognitive impairment (21.8% vs 11.0%, P less than 0.001), depression (2.3% vs 0.7%, P less than 0.01), dysthymia (3.9% vs 1.7%, P less than 0.01), and anxiety disorders (2.2% vs 0.4%, P less than 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P less than 0.01) was significantly more prevalent among elders confined to a bed or chair. CONCLUSIONS: The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.

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PubMed1983

Management of functional disability in homebound patients.

Five percent of the population aged over 65 years, or more than 1 million people, are homebound. Musculoskeletal dysfunction is the final common pathway of all forms of arthritis and many neuromuscular disorders and is the prime cause for being homebound. The US health care system, with its emphasis on acute illness, does not address adequately the functional problems of homebound patients. Many can be helped by modification of the home environment or physical and occupational therapy. This paper outlines the diagnosis and management of common functional disabilities found in homebound patients.

Activities of Daily Living↗
PubMed1990

Elderly dental care. Needs and costs in three different resident settings.

Although the real dental treatment needs of the elderly has been established, the costs for these needs has not been determined. This report compares dental services and costs required for older adults living in three different resident settings. Dental needs and costs have been evaluated from a sample of 305 aged persons living in nursing homes (N = 156), low-cost housing facilities (N = 79) or dependent on home care services (N = 70). This study indicates that the homebound or institutionalized elderly population presents with poor dental and periodontal conditions, a high rate of edentulousness, and inadequate dentures. Dental needs are essentially characterized by the repair or replacement of prosthesis, the screening and treatment of mucosal lesions of prosthetic origin, and scaling/curettage of remaining teeth. The average rehabilitative dental costs was Can. $720 and there was no difference between the three types of residence. Important differences in cost, however, were observed between the dentate and edentulous population. The F-test (P less than .05) and chi-square were used to analyze differences in dental treatment needs and costs between different residences. Maintenance care corresponds to Can. $80/year/person.

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PubMed1992

Clinic-based primary care of frail older patients in California.

We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.

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PubMed1992

The home visit in resident education: program description and evaluation.

A home visit rotation was developed to provide family practice residents with a more comprehensive understanding of the effect of patient life-style on health status. The rotation emphasizes geriatric, community, and rehabilitative medicine. In addition, the curriculum addresses issues related to patient compliance, assessment of activities of daily living, patient psychosocial needs, community services, and exposure to medical equipment of potential use to homebound individuals. Over a three-year period, 209 home visits were made. Program evaluation data suggest that at the end of the three-month rotation, residents were less concerned with personal safety and more likely to agree that home visits were an important part of residency training. A comparison of pre- and post-test knowledge scores indicated significant increases in geriatric medicine, patient compliance issues, patient functional status, and community services. A follow-up telephone interview with patients found that some patients experienced anxiety when the home visit was scheduled, but the majority were positive about the experience.

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PubMedDate not supplied

Living with chronic illness: social support and the well spouse perspective.

Progressive neurologic disease has a significant impact on family members, particularly those living with and caring for a homebound adult. Focus groups were conducted with women who were the primary caregiver for their disabled husband. The women described themselves as being restricted to the home by caregiving requirements. Multiple sclerosis was a critical personal hardship for them, involving persistent struggle that often resulted in anger and frustration. Because of the social isolation created by their caregiving responsibilities, these women depended on their disabled husband for support. Yet, never having time away from the husband strained the marital relationship and threatened the supportive nature of the relationship. The women in this study found it necessary to have personal time and space away from their husband. They created space for themselves by setting apart a place in the home that was theirs or by declaring time out for themselves. These strategies helped them avoid or reduce negative outcomes of the social support received from their husband.

Adaptation, Psychological↗
PubMed1981

Geriatric education in a teaching hospital: the role of geriatric services.

Geriatric education and training are most successful when taught in a setting that provides the medical and social services that elderly persons often require. At Mount Zion Hospital and Medical Center, medical students and trainees participate in several geriatric services that introduce them to the special health needs of the elderly, including the ambulant and the homebound. In the Mount Zion/University of California, San Francisco, geriatric education and training program, we have defined three principles of geriatric medicine that are unique to the field and are best applied directly within the service setting. This setting emphasizes (1) the special body of knowledge regarding aging and health care of the elderly, (2) the importance of assessing functional capacity and (3) the role of the health team. Our experience indicates that when students and trainees observe the application of these principles in a range of geriatric services they begin to understand the complex health problems with which geriatric medicine is concerned.

California↗
PubMed1992

Life-sustaining interventions in frail elderly persons. Talking about choices.

BACKGROUND: Engaging older persons in consideration of use of life-sustaining measures, such as cardiopulmonary resuscitation, tube feeding, and urgent intubation, is widely recommended, yet uncommon. METHODS: We studied the short-term impact of a physician-initiated discussion, geared toward guiding informed decision-making, with 20 frail elderly homebound patients. A battery of psychologic rating scales was administered in a pre-post design. Eighteen subjects completed the protocol. Fifteen of the mentally capable surviving subjects were reinterviewed 18 months following the initial discussion to evaluate durability of their decisions. RESULTS: Most welcomed the discussion and clear choices regarding future care usually emerged. Depression rating scales decreased slightly for the entire sample. For the subgroup having relatively internal locus of control, there was an increase in life satisfaction scores. No patient demonstrated signs of emotional trauma consequent to the discussion. On follow-up, several patients were indecisive about their choices. CONCLUSION: Involvement of these patients in decision-making appeared to have no adverse effects, and, for some, it was therapeutic, possibly through enhancement of personal control. Durability of their decisions was not a consistent finding, however.

Advance Directives↗
PubMedDate not supplied

Bringing home mental healthcare. In-home peer counseling benefits the elderly.

Elderly persons who live alone often feel isolated and depressed, especially when they live in remote rural areas. Humboldt County, CA, is known for its rugged mountain terrain and as much as 39 inches of precipitation each winter. This can lead many homebound elderly to feel isolated. So in 1987 Humboldt Home Health Services, Eureka, CA, together with other county agencies, established a free, in-home peer counseling program for area residents over age 60. After attending a free, five-day peer counseling session, representatives from HHHS and other county agencies discussed which agency would be responsible for certain peer counseling program tasks and began the counselor recruitment process. In June 1989, 12 volunteers attended the first training session. Once they complete their training, the volunteer peer counselors commit to working at least eight hours a week for one year. The eight hours are taken up by counseling sessions, travel time, meetings with supervisors, group discussion, and record keeping. Peer counselors have been trained to listen and respond to calls for help. Unlike professional counselors, however, they do not diagnose and treat complex pathological problems. On the other hand, because they have smaller caseloads than professional counselors, peer counselors are able to spend more time with their clients.

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