Transitions between community and nursing home residence in an urban elderly

Abstract: Over the course of a three year observation and study period, some 6% of a representative community residing urban elderly population were admitted to nursing homes. Nearly half of this group were still living in nursing homes at the end of this observation period. One third had died after entering the nursing home, and the remaining people had returned to their own homes in the community. These three groups had significantly different mean lengths of stay in nursing homes; nearly two years for those whose stays were more permanent, 50 days for those whose stays were shortterm, and 153 days on average for those who died following admission.

At baseline, the three groups also tended to have different patterns of health, functional and social characteristics. The short term stayers and those who died following admission to a nursing home differed from respondents who did not enter nursing homes--primarily in terms of prior living arrangements and levels of social support. The permanent stayers differed from the two other nursing home sub-groups, and from community residents, in that they tended to be older and more functionally and mentally impaired. However, at baseline they appeared at less risk to expire than those people who later died following admission to nursing homes.

Clinical and research implications based on these findings are discussed.

Background

Issues concerning the place of nursing home care in a continuum of long term care services continue to occupy the attention of health care planners, administrators, clinicians, and researchers. This has been the case for a number of reasons.

First, more than 1,350,000 elderly Americans currently reside in nursing homes, and the number of nursing home beds now exceeds the number of acute care hospital beds. While at any one moment in time only 5% of the population 65 years old, or older, are nursing home residents, the life-time risk of being admitted to a nursing home has been variously estimated as upwards of 40%.

Second, costs for nursing home care are substantial. They are second only to hospital care as a proportion of all expenditures for health care? Nursing home costs encompass approximately 40% of all Medicaid costs and force many otherwise income independent elderly individuals into poverty.

Third, the availability of and access to nursing home beds and to quality care in nursing homes is poorly and unevenly distributed. Finally, having to relinquish residence in the community for institutional living is an abrupt and radical transition that is seldom welcomed by elderly persons or their family members except in cases of extreme hardship or sickness among care givers and is accepted only as a last resort or when other care options are either not available or have been exhausted.

The magnitude and urgency of the problem of providing nursing home care--particularly in an era of budgetary stringency--and its likely growth over time due to the graying of the population and increase in the proportion of the oldest segment of that population, continues to give rise to a large body of research. These efforts included information on characteristics of nursing home populations, determinants of nursing home admissions and outcomes, costs, policies and planning, and the treatment of medical conditions. Much of this literature is beyond the scope of this paper.

Studies of diverse elderly populations ranging from those few that include broadly representative groups as well as populations of frail or disabled individuals, those living in special housing environments, or participants in special programs, have commonly identified advanced age and functional deficits as high risk factors for nursing home placement. Studies of elderly populations living in nursing homes indicate that the resident populations have become older, more disabled, and have high rates of hospitalization and death. Other studies have documented significant local and regional variations in both the numbers and characteristics of referrals to nursing homes and resident populations, and have described variations in length of stay among those admitted to nursing homes.

Despite these and other advances in our knowledge of the nursing home as a social and health care institution, and its use by elderly populations, significant gaps in the precision and range of this knowledge remain to be closedLittle is known, for example, of the dynamics of the transition from community to nursing home residence and, for some, return to living in the community. Our inability to predict or to identify more accurately persons at high risk of nursing home placement has limited our ability to provide community-based services that could substitute or prevent nursing home placement. Because we have infrequently studied representative community populations longitudinally, data on incidence and prevalence are also limited.

A longitudinal study of health, health care and aging in a representative urban population of elderly persons residing in the community provided an opportunity to explore certain of the transitional dynamics, characteristics, and outcomes of study participants who were admitted to nursing homes during the course of a three year period of observation. In this paper we present first our findings from analyses of the occurrences of nursing home admissions followed by the results of analyses of the health and social characteristics of respondents who experienced one or more nursing home admissions.

Study Sample

Seventy-three percent of a randomly selected population of elderly residents (age 65 or over) of a defined health area in the North Central Bronx in New York City agreed to participate in

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外文文献PART 1

Issues concerning the place of nursing home care in a continuum of long term care services continue to occupy the attention of health care planners, administrators, clinicians, and researchers. This has been the case for a number of reasons.

First, more than 1,350,000 elderly Americans currently reside in nursing homes, and the number of nursing home beds now exceeds the number of acute care hospital beds. While at any one moment in time only 5% of the population 65 years old, or older, are nursing home residents, the life-time risk of being admitted to a nursing home has been variously estimated as upwards of 40%.

Second, costs for nursing home care are substantial. They are second only to hospital care as a proportion of all expenditures for health care? Nursing home costs encompass approximately 40% of all Medicaid costs and force many otherwise income independent elderly individuals into poverty .

Third, the availability of and access to nursing home beds and to quality care in nursing homes is poorly and unevenly distributed. Finally, having to relinquish residence in the community for institutional living is an abrupt and radical transition that is seldom welcomed by elderly persons or their family members except in cases of extreme hardship or sickness among care givers and is accepted only as a last resort or when other care options are either not available or have been exhausted.

The magnitude and urgency of the problem of providing nursing home care--particularly in an era of budgetary stringency--and its likely growth over time due to the graying of the population and increase in the proportion of the oldest segment of that population, continues to give rise to a large body of research.PART 2

We first formulated a series of questions and then developed sets of analytic comparisons between groups. The first question was whether we could distinguish all those admitted to nursing homes--whether they returned to community or not, or even whether they died or not--from community residents who were not admitted to nursing homes and survived, and from community residents who died. Second, we asked whether there were distinctions between the two community resident groups--those who remained alive and those who died and the nursing home sub- groups--the short term and the long term stayers and those who died following a nursing home admission. Finally, we sought to determine whether there were different sociomedical characteristics that distinguished the three nursing home subgroups from one another--apart from whatever distinctions emerged from their earlier comparisons with the community resident groups.

Summary and Conclusions

The findings of this study can be summarized as follows:

1. Over a three year period 6% of the cross section of community residing older persons were admitted to nursing homes. A third of those admitted died, nearly half continued to reside in nursing homes, and the remainder returned to their homes. While the number of nursing home entrants may seem small, it should be noted that the study sample was limited to those elderly persons residing in their homes and excluded those in hospitals or in nursing homes at the time the sample was selected. The 6% figure can be viewed as the rate of nursing home admission over a three year period in an urban community with a reasonably adequate supply of medical care, health related, and long term care services and facilities.

2. Nursing home subgroups were identified that differed from each other sociomedically and in length of stay. Those admitted for short stays in nursing homes resembled community residents not admitted to nursing homes more than they did the permanent nursing home stayers. Similarly, those who died subsequent to a nursing home admission resembled those who died in the community. In both instances, prior levels of social support and living arrangements were the primary distinction between these two nursing home subgroups and their counterparts in the community.

3. The permanent nursing home stayers, in contrast to the community residents and the other two nursing home subgroups were more likely to be older, more disabled, and mentally impaired, sustained strokes more often, and received more informal and formal social support prior to their admission. The characteristics of this latter nursing home subgroup have come to typify the nursing home population identified in most prior cross sectional studies.

4. The relative importance of health, functional, social support and demographic characteristics in distinguishing among nursing home subgroups varies as does their duration of stay in a nursing home. This suggests that there may be different reasons for admission to nursing homes among these groups.Caution is suggested in generalizing these findings to communities differing in their supply of nursing home resources or in the composition of their elderly populations, or to studies with follow up periods of different durations. Also, greater precision and improvement in accounting for the unexplained variance in the findings might have been achieved were it possible to have measured changes from baseline in the relevent social, health and functional variables closer in time to the actual transition into or out of the nursing home. The findings indicate that different and more focussed clinical and programmatic strategies may be required to intervene with elderly community residents at risk for nursing home entry, if this is indeed a desirable social goal. For one group--those whose characteristics resemble the permanent stayers CNN--intervention might emphasize rehabilitation for strokes and reduction in functional and mental disability. Characteristics of the other subgroups--those who died following admission, for example, suggest that additional social suppo

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