Читать книгу Making The Right Move - Gillian Eades Telford - Страница 28

Your regional health board may also supply meals, senior centers, adult day-care programs, and palliative and respite care.

Meal programs such as Meals on Wheels, Congregate Meals, or Wheels to Meals are run by volunteers but usually have a paid staff overseer. In the Meals on Wheels or Wheels to Meals programs, the hot and nutritious meals are provided for people who cannot do their own cooking. The client can purchase frozen meals for weekends. The food is usually prepared in a facility or government-inspected catering establishment where meals are wrapped, and volunteers deliver them to homes. The cost of meals is on a sliding scale depending on the client’s income. Congregate Meals is a program where clients gather to eat in a common place. The food is prepared off-site, and is brought and served by volunteers.

Many senior centers have preventive and supportive health programs for elders, such as friendly visiting, free transportation, help with shopping, and help with legal questions, bill paying, or other financial matters.

Palliative care provides support for people who are dying. Usually, the elder will get an increase in the number of hours of care in the home so he or she may die at home. Respite care is provided to the family to relieve them of their responsibilities for a while so that they can continue with some of their day-to-day activities. Family members can book their elder into an intermediate care facility if they are going on holiday. Respite can also take place in the home, and workers will be provided on a 24-hour basis to take care of the client at home while the family has a break. The continuing care division of the health department usually pays respite care.

In the US, it depends on what medical insurance or Medicaid to which the person qualifies. Often respite care is private pay.

An Encounter with the Quick-Response Program

One morning, at age 82, Mrs. Martino was going to feed her fish in the half-barrel when she slipped on the icy patio. She managed to crawl to the phone and call 911. The ambulance arrived and took her to the nearest hospital emergency that had a quick-response program.

To reduce the use of expensive acute-care hospital beds, some hmos and regional health boards have introduced programs that supply home care to clients on a short-term basis. A social worker usually arranges through a contracted agency to provide homemakers on a short-term basis of one to five days. Depending on an individual’s situation and whether or not the health board has previously assessed him or her, the service may be free or based on the person’s income.

Mrs. Martino was assessed by a physician, who determined that the only care she needed was bed rest while the vertebrae she broke during her fall healed. The emergency ward social worker called her son and told him that his mother could be discharged home, and she would receive home care for 16 hours a day for three days.

Unfortunately, it took longer than three days for her broken vertebrae to heal, so Mrs. Martino and her son needed to look beyond the quick-response program for help. If she had had no family, and if no interim rehabilitative places existed in her community, the hospital would have admitted her for a few weeks until she was sufficiently mobile to look after herself with some home care. Keeping her in the acute care hospital would have been a waste of those resources, however, because she really had no need for 24-hour care from registered nurses.

Luckily, Mrs. Martino had the support of her family, and her son arranged for a homemaker to help her while she recovered.

Assistive devices

During her recovery, Mrs. Martino was in a lot of pain. Her physician changed the type of painkillers she was on and also suggested she use some assistive devices. An assistive (or adaptive) device is a piece of equipment that assists the user in the operation of self-care, work, or leisure activities. Eyeglasses can be considered an assistive device. If an assistive device is deemed medically necessary, some insurers will cover the cost. For example, Medicare will pay for some medical equipment as long as the equipment —

• can withstand repeated use,

• is primarily and customarily used to serve a medical purpose,

• is generally not useful to a person in the absence of an illness or injury, and

• is appropriate for use in the home (e.g., wheelchairs, hospital beds, walkers).

Mrs. Martino purchased a tens (transcutaneous electro nerve stimulator) machine. This machine reduced the need for medication by using an electrical current to cut the nerve pathways for pain. With the pain under control, she could lie on her side for short periods and eat comfortably.

However, she could not raise her head to watch tv, nor could she hold a book. So, for entertainment, the library provided “talking books” that kept her occupied when visitors were not there.

As time passed, Mrs. Martino became troubled by her loss of sight. She could not play Scrabble anymore because she could not keep score. Her son bought her a large-tiled Scrabble board, but not being able to keep score or read the dictionary made playing too difficult. Her son also bought her a large tv, and she learned the remote control buttons by experimenting and just turned the volume up until she could hear. Bridge was becoming a problem, even with the large playing cards. Usually one of the four could see well enough to score, but even using the big cards were getting difficult.

Transportation

She was still driving her car but not during the evening, because she knew she could not see at night. She did not want to give up driving because it gave her so much independence. Actually, Mrs. Martino was a menace on the road. Many jurisdictions require people over the age of 65 or those with a medical condition to take a driver’s re-examination every couple of years. If you have trouble checking over your shoulder, or seeing at night or in poor weather, you may be putting yourself and others at risk.

It was past time for her to give up driving, but she had to make the decision herself. After an incident where she ended up driving on the sidewalk, she reluctantly stopped. It was one of the more difficult decisions for Mrs. Martino to make, and she was not used to spending money on taxis. However, over time she realized that there were some benefits to not driving. She could sit back and relax as a passenger, and she could save money by not having to maintain a car. Also, she learned that she could take her disabled parking permit with her to use for any vehicle in which she was a passenger.

Mrs. Martino was getting lonely and loathed cooking and eating by herself. Her son suggested that she contact her local health board and sign up for congregate meals. This would prevent her from being tied at home every day at noon to receive the volunteer and would also put her in contact with other people. Volunteers served the meals in an apartment common room a few blocks away from her apartment.

Because her blindness and chronic congestive heart failure prevented her from driving, Mrs. Martino qualified to use the local elder transportation service run by her health board. By making a phone call, she could book the minibus to pick her up and deliver her back to her apartment. They would also drive her to her medical or other appointments. The only problem was that she had to book the bus well in advance because it was often full.

Mrs. Martino liked eating with other people and enjoyed the good nutritious meals. When she couldn’t take the elder minibus, she took a taxi. Luckily, because her physician had assessed her unable to take public transport, she qualified for taxi savers and paid only half the cost of the taxi fare.

Private home support

Mrs. Martino still swam every nice day and had visitors. With the help of her son, they found a suitable cleaning person and he and his family had her over for dinner once or twice a week. During this year, she had another congestive heart failure attack. Luckily, her apartment neighbor heard her cries and called 911. She was taken to the hospital to be stabilized for a few days, then returned home.

After the heart attack, Mrs. Martino became weaker and needed more help. Her son called a private agency to hire a homemaker to supervise the bath and make two meals daily. The homemaker also did the shopping.

Mrs. Martino was not pleased with the arrangement because she still did not like to have strangers in her apartment. She resisted any formal help and felt that her son could give her all the help she needed. Her son felt otherwise. He explained to his mother that he wanted to be a son, not a caregiver, and he felt that having to do the cleaning, grocery shopping, and preparing meals when he came to visit cut down on their time together.

After a time, Mrs. Martino came to know and trust the homemaker, and the agency assured the son that the same person would be there daily. Mrs. Martino hated paying so much for help, but luckily the private home support agency was cheaper than the government agency through the regional health board.

Environmental support facilities

As Mrs. Martino became frailer, she needed to make environmental changes to her apartment to make things easy and safe. Getting in and out of the tub was a problem, so grab bars and a hand-held shower were installed in the bath to make it safer. Her son looked at the apartment to see how barrier free it was. With a few exceptions, it was almost barrier free: the step-off platform on the balcony and the sliding door tracks to the balcony were not recessed. Her son installed a sloping cover on the raised door tracks to make the balcony accessible, and a small ramp on the raised step-off platform of the balcony allowed her to water her plants.

If the hall furniture was removed, it was wide enough for a wheelchair or walker. Neither the kitchen nor bathrooms were designed to accommodate a wheelchair. However, the master bathroom had room to transfer from a wheelchair to the toilet.

Private personal care homes

In her 87th year, Mrs. Martino was having a difficult time. She hated not being able to see, she was tired all the time, and if she did any kind of activity, she was short of breath.

She looked into a private personal care home nearby where she had some friends. Personal care homes are private, nongovernment-supported institutions of more than three people that provide some nursing care to clients (usually less than a half-hour per client per day). Because the facilities are private, they are usually fairly expensive.

This private facility had independent living with congregate meals. Mrs. Martino thought it would be nice to have her meals provided and a place to entertain. If she got sick, she would receive 24-hour nursing care in a special area until she got better. Unfortunately, if she deteriorated until she could not walk and was assessed at an extended care level (see Chapter 3), she would be transferred out of the facility. This meant that she would not be able to age in place.

This private home called Mrs. Martino on a number of occasions to say a room was available, but she always declined in the end. A move was just too much trouble, and her son kept assuring her that meals could be provided or whatever help she needed. As well, she thought she might be cramped in the private home because she would only be given a two-bedroom apartment.

More and more days passed when she just had to rest. She did not have the energy to go out, but if she did go to get groceries and arranged to have them delivered, she was just too tired the rest of the day. Swimming in the morning meant she had to rest several hours afterward before she had the energy to have someone to tea.

Live-in home care

Then Mrs. Martino got pneumonia. She was hospitalized in a very weak, frail state. When her son visited her in hospital, he found his mother very unhappy with the nursing. On two occasions, he observed one of the nurses abusing his mother by saying, “You don’t need to go to the bathroom again! We just moved you up in bed.” This prompted him to take his mother out of hospital and home to the apartment.

He had a choice: he could move his mother into a nursing facility or organize live-in home help. Having a live-in homemaker cost more than moving into a nursing facility, but he wanted his mother to age in place. So he rented a wheelchair and a commode and hired a live-in homemaker from the same agency to replace the homemaker who came daily. One homemaker lived in for five days, and a second one came on weekends.

Geriatric assessment

Mrs. Martino was deteriorating. She was depressed and she felt useless. She wanted to die. A geriatric assessment team came to the apartment and did an assessment to try to work out what was best for her. The team did assessments, made recommendations, and monitored her progress. Getting her on some antidepressants was their first priority.

(In the United States, health maintenance organizations (HMOS) and the Program for All-Inclusive Care for the Elderly (PACE) have geriatric assessment teams. In Canada, they are usually associated with a hospital and may be funded partly through the hospital and partly through the regional health board. The team, a group of professionals intent on keeping elders out of facilities, usually consists of a geriatrician, a clinical nurse specialist, a physiotherapist, a social worker, and other personnel as needed. Your physician or hospital can refer you for a geriatric assessment.)

Mrs. Martino’s family and friends still visited, but she was very weak and in bed all the time, except to go to the bathroom, which was a great effort. She was too tired to even listen to the talking books, and she was not interested in food at all. The pneumonia got better, but she was still depressed, and life was just too hard. Eventually, the pneumonia returned, and Mrs. Martino died at home in her own bed with the homemaker agency woman in attendance.

Conclusion

If Mrs. Martino had had no financial resources, she may have been eligible for hospice services. These are comprehensive services for terminally ill clients and their families (see Chapter 5). However, she chose to not go into a facility and was wealthy enough to afford the care she needed to die at home. Mrs. Martino was always mentally alert, so she was able to direct her own care and express her own wishes. If she had had some dementia, her choices would have been more limited, and her children would have been more concerned with her safety. Luckily Mrs. Martino never needed any type of special care unit.

Mrs. Martino’s encounters with the health care system were typical of many elders. More than 90 percent of North American elders are living in their own communities, with their families providing most of their care, and formal care as supplement or last resort. This generation tends to be fiercely independent, proud, and private, and it is difficult for them to give up this independence (e.g., by accepting home help and giving up their driver’s licenses).

Mrs. Martino was fortunate that she did not need to access the public health care system much because she had many resources — money and a knowledgeable family. She was grateful that she didn’t have to go through financial-means testing. In fact, she would probably rather have done without than go through that assessment.

Many elders, however, do not have the option of private home care, and they cannot think of anything to do but take themselves to the emergency ward of a nearby acute-care hospital. Elders use acute-care hospitals more than other population groups: they use 48 percent of all patient days in hospitals. Unfortunately, 20 percent of all visits to hospital emergency rooms result from adverse drug reactions among elders.

Mrs. Martino’s encounters with the health system are but one example of how elders cope with their failing bodies near the end of life. The episodes to hospital became more frequent in her last years, and yet the stays were of short duration. Family was used as the first resource, followed by just a cleaning lady, until in the end, Mrs. Martino had 24-hour care. Poor elders without families are the people most at risk for being cared for in nursing homes.