Long-term care patients are referred to as residents of the healthcare facility administering care

Residential care environments

Residential long-term care environments are relevant for an aging population who are no longer able to manage independent living, as well as for those who are born with, or have an acquired disability in similar circumstances. Physical and culturally appropriate residential environments for these types of individuals requiring long term care are many and varied. Australian statistics indicate that 86% of those in permanent residential care on 30 June 2018 had at least one diagnosed mental health condition (most commonly depression), or behavioral problem and 52% had dementia [3]. This is in addition to declining functional capacity amongst an aging population and any number of health issues due to one or more chronic co-morbidities. These factors define the complexity associated with the provision of residential care. Prevalent variations in the knowledge and skill sets of care staff, inequity in the level of healthcare support able to be provided, the challenges associated with building good relationships with multiple stakeholders and existing funding mechanisms define the challenges to be addressed [4].

Meeting caring needs for an aging population is compounded by the presence of intellectual disabilities, mental health needs or dementia. This is especially difficult for those who are living in single person households. Personality and individual lifestyle preferences also need to be considered when evaluating the capacity to care by providing community-based support services. This means that those eligible for residential care tend to be over 75 years of age, have some form of cognitive impairment, require extensive assistance with activities of daily living and have complex needs [5]. Many countries have experienced significant increases in care demands for their long-term residents. In many instances, workforce capacity, in terms of numbers, knowledge and skill, have not been able to meet these growing demands.

The aim of caring is to prevent adverse consequences, accommodate adversity, manage disease and disability whilst minimizing adverse impacts on desired lifestyles. It is imperative that personal, interpersonal and societal factors associated with aging are also able to be addressed to ensure individuals can maintain a sense of overall comfort and wellbeing irrespective of individual ill health, disability or adversity. This usually requires teams of people, each providing a unique type of service. Team members need to be able to communicate and collaborate not only with each other but also with the resident and their significant others within the context of the resident's own social/cultural network. Caring activities provided for such individuals in long term care remain constant for much longer periods of time when compared with the acute sector.

The philosophy of care is about providing for and supporting daily living activities in accordance with desired individual lifestyles, whilst maintaining general wellbeing and comfort in culturally appropriate ways. The latest trend in service provision for this population is to provide person centred community based support services in the home and their community, to enable residents to live independently wherever and for as long as possible [5, 6]. Ideally physical and social environments available for the provision of residential care, can support desired lifestyles for most of its residents, whilst responding appropriately to the biological and physical changes associated with the aging process of people. Staff need to have access to supporting occupational health and safety devices as their work requires a considerable amount of manual handling of people which is associated with a high incidence of musculoskeletal disorders for staff. Improving resident mobility capacity also minimizes these risks for staff. Workplace environments, including staff capacity and care models, need to be constructed to benefit both residents and staff [7].

Many supportive digital devices and assistive technologies are now available to support a wellness model of care, empower individuals to prevent illness, minimize risk of adverse events and provide residents with caring solutions that are focused on health and wellbeing. Those in residential environments require others to organize a suitable device that will be of benefit to them. This includes providing advice to design or to select the most suitable device. Health care workers who have a good appreciation of functional abilities and who work closely with the residents concerned should be involved at the design or selection stage to ensure usability. Supportive work environments where health care workers work together as a collaborative team are known to have positive impacts on residents.

7.12.3.4 Spotlight Setting: Residential Care (Nursing Home)

The demand for short- and long-term residential care will likely increase as the global population ages (World Health, 2015). The prevalence of older adults requiring assistance with one or more ADL is higher among people 75 years and older (vs 65–74 years) and prevalence is particularly high in Mexico, the Russian Federation, South Africa, Ghana, and India where a majority of adults 65 and older have ADL care needs (World Health, 2015). In the U.S., projections suggest that over half of all adults 65 years and older will have need for long-term care services at some point during their life, with more than 1 in 5 requiring services for 5 years or longer (Favreault and Dey, 2021). Nursing homes or residential care facilities are only one component of a system of long-term care services and supports that are offered across home, community, and healthcare settings; however, changes to family and societal structures are increasing the need for formal long-term care in many countries, particularly low- and middle-income countries (World Health, 2015). Characteristics associated with long-term care service users substantially overlap with late-life suicide risk factors, such as high rates of depression, disease, and functional disability (Harris-Kojetin et al., 2019; Van Orden and Conwell, 2011). Fear or refusal of nursing home placement, fear of becoming a burden, and loss of independence were recorded as suicide precipitants for approximately 10% of older suicide decedents in the U.S (Choi et al., 2019). Conversely, nursing homes may represent a place for increased social connection and some people experience disconnection after discharge (Simons et al., 2020). Transitions in or out of nursing homes may represent times of increased risk for suicide, and thus also key times for implementing suicide prevention measures (Mezuk et al., 2019).

Suicide among older adults in residential care is understudied. Although reported suicide deaths are rare in nursing homes, estimates of SI tend to be higher than in community-dwelling older adults. The reported proportion of deaths attributed to suicides among nursing home residents ranges from 0.6% to 3.1% of all nursing home deaths and 4.3% of injury-related deaths (Murphy et al., 2015, 2018; Mezuk et al., 2014). Male residents have a five-fold greater risk of suicide than females (Murphy et al., 2018). The most frequently reported methods of suicide in nursing homes include hanging, jumping or falls, and plastic bag asphyxia (Mezuk et al., 2014; Murphy et al., 2018). Perhaps due to lack of access, suicide by firearm is less frequent compared to community-dwelling older adults (Mezuk et al., 2014). With regard to thoughts of suicide, published rates of current SI among nursing home residents range from 12% to 17% for the past week and 7%–33% for the past month, with as many as 43% endorsing current death wishes (Zhang et al., 2020; Nie et al., 2020; Mezuk et al., 2014). Conversely, a study by Temkin-Greener et al. (2020) reported 2-week rates of SI below 2% among post-acute and long-stay residents in U.S. nursing homes based on national data from the Minimum Data Set (MDS) 3.0.

The most commonly reported individual-level risk factors for suicidal thoughts and behaviors among nursing home residents include male gender, depression, pain, poorer health or greater medical comorbidity, loneliness or poor social support, and functional disability (Temkin-Greener et al., 2020; Nie et al., 2020; Mezuk et al., 2014; Murphy et al., 2015). A study of residents in Hunan Province, China found additive effects of depression with ADL impairment and social support, respectively (Nie et al., 2020). Conversely, a retrospective data linkage cohort study of deceased older nursing home residents in Australia found that risk of suicide death was not associated with depression and was associated with greater functional independence and younger age (Murphy et al., 2019). The discrepancy may be due to differences in the control or comparison sample across studies (i.e., deceased versus all residents). Suicidal thoughts and behavior tend to be highest at or within 1 year of admission, and have also been found to be elevated within 6 months of discharge, suggesting that care transitions may be a particularly important period for targeted assessment and intervention (Temkin-Greener et al., 2020; Mezuk et al., 2014).

Organizational-level risk factors have been examined in two studies, both in the U.S (Osgood and Brant, 1990; Temkin-Greener et al., 2020). Osgood and Brant (1990) reported that suicide and suicide attempts were associated with high staff turnover rate, larger facility size, lower bed cost, and private facilities. Temkin-Greener et al. (2020) found that SI was associated with non-profit status and higher CNA staffing levels. The authors speculated that these findings could be due to the nature of CNA responsibilities—putting them in more frequent, close contact with residents—whereas lower staffing levels and higher staff burdens associated with for-profit facilities could contribute to underreporting—which may explain the relatively low rates of observed SI compared to other studies of nursing home residents; however causality cannot be inferred from this cross-sectional study so further research and exploration is needed to explain the findings.

Current practices for preventing suicide in residential care settings include staff education, environmental risk assessment, and patient risk screening. Research on prevention efforts in residential settings is limited to a handful of studies that examined staff education programs and gatekeeper training, life review therapy, telepsychiatry, and telephone-based assessment post-discharge (Mezuk et al., 2014; Chauliac et al., 2016; Luci et al., 2020). The U.S. Substance Abuse and Mental Health Services Administration published the Promoting Emotional Health and Prevention Suicide toolkit for senior living communities that can be accessed for free in English and Spanish (https://store.samhsa.gov/).

Overview

Since the inception of Medicare, nursing homes (also referred to as skilled nursing facilities) have been the predominant form of residential long-term care in the United States. They provide 24-hour nursing care, supervision, help with activities of daily living, meals, and medication administration to people who cannot manage independently. They also provide rehabilitative services, including physical, occupational, and speech therapy, to assist those recovering from acute conditions such as stroke or hip fracture. The vast majority of nursing home residents are elderly, and in general, nursing homes have consistently housed approximately 5% of the US population age 65 and older.

The predominant model of nursing home care is medical, ordered by physicians, planned primarily by licensed nurses, and delivered by certified nursing assistants and other professional or paraprofessional staff. Because nursing homes are tightly controlled by federal regulations, much of the administrative structure, staffing, and physical characteristics of one facility are similar to those of any others. However, as discussed later in this article, the field of long-term care is embracing a culture change movement, which may allow for more diversity, and improved quality of care, in these settings.

Abstract

In this chapter, the main focus of discussion pertains to security of medical facilities, programs and services not located on a main hospital campus, addressing the full spectrum of care, to include public health, long term/residential care, home care and home health, environmental health and a variety of community based services, often integrated with their traditional acute care/hospital services This new security frontier has the potential to dominate the healthcare landscape as baby boomers hit the healthcare system with millions more needing care, presenting challenges to security and safety often not experienced in the hospital environment. Issues facing the security programs such as resident on resident violence, elopement, lone workers in high risk community settings, violence against staff and protecting centralized warehouses are examined.

Staffing Considerations

In addition to training family members, behavior analysts can develop procedures for teaching behavioral skills to care providers in other settings such as adult day care centers (ADCs), assisted living facilities (ALFs), supportive living facilities (SLFs), and nursing homes (Burgio & Burgio, 1986). Staffing has emerged as a key focus of quality of care in various residential long-term care settings. The annualized turnover rate is found to be the highest among certified nursing assistants at 74.5%, followed by registered nurses at 56.1%, and licensed practical nurses at 51.0% (Donoghue, 2010). Castle, Wagner, Ferguson, and Handler (2014) demonstrated that low staffing levels in nursing homes were associated with more frequent facility deficiency citations during routine state survey visits. Hunt, Corazzini, and Anderson (2014) have also shown that upper-level management turnover in nursing homes was detrimental to resident safety and can destabilize the quality care delivered.

Staff training in geriatric long-term care is often brief and relies heavily on didactic techniques that frequently are insufficient for changing staff behavior (Rahman, Applbaum, Schnelle, & Simmons, 2012). Behavior analysts have developed and evaluated a number of effective staff training and management procedures that are employed in facilities for individuals with ID and, to a lesser extent, in psychiatric facilities. Researchers should focus on adapting these procedures to the needs of long-term care aging settings (Burgio & Burgio, 1986).

Family and professional nursing aides have limited understanding of how their behavior can affect the behavior of the elderly individual (Burgio & Burgio, 1986). In addition, family caregivers and professionals working in long-term care settings are not usually trained or prepared to effectively manage the behavioral and psychological symptoms of dementia (BPSD) (Brodaty, Draper, & Low, 2003) such as depression, wandering, verbal aggression, and physical aggression (Buchanan et al., 2011). Lack of appropriate training is also an issue in ALFs and SLFs. These facilities are limited by the amount of care that can be provided and usually have regulations that require them to discharge individuals with BPSDs because they do not have adequately trained staff to manage these behaviors.

In summary, the first step in becoming involved with behavioral gerontology is to become familiar with the paradigm and the target populations. Once familiar, there are still many considerations that behavior analysts must be aware of with regard to research and clinical work. These considerations fall into three general categories that are discussed in the following material. The first category, hurdles for behavior analysts, highlights considerations that span across both research and clinical work in elder-care settings. The second category, single-case research design, addresses those considerations that are unique to conducting and publishing important behavior analytic findings for an aging population. Finally, the third category, considerations in clinical services, addresses how to transition from consuming the empirical support for an intervention to beginning to implement behavior analytic clinical services in an elder-care setting.

35.7 Elderly Gut Care

Diet is known to play a central role in influencing the composition of the gut microbiota and unfortunately, due to many common physiological and lifestyle changes, malnutrition is common in the elderly years. Therefore, it is quite plausible that a major contributor to the drastic microbiota changes found in the elderly is alterations in the diet. The elderly should thus be encouraged to consume a diverse diet – one with adequate intakes of macro- and micronutrients, specifically fiber and antioxidant/anti-inflammatory vitamins and minerals, such as vitamins C and E. Diets that include antioxidant and anti-inflammatory foods are also important for the elderly to reduce oxidative damage and overall inflammation. A varied diet based on whole grains, fruits, and vegetables can promote an anti-inflammatory state, a diverse and healthy gut microbiota, and healthy GI functioning.

Community living also enhances the health of the elderly, likely in part due to more bacterial exposure, and therefore a more diverse gut microbiota. It appears that these populations (compared to long-term residential care) have better diets, more SCFAs, less inflammation, and less frailty [16]. Physical activity is also often minimal in the elderly. Exercise brings blood flow to the gut and has been shown to lower inflammation in the elderly, so is of utmost importance [64].

Probiotic consumption/supplementation has been shown to improve many aspects of aging, and should also be encouraged in the elderly. Modulation of the intestinal microbiota via probiotic supplementation may be able to prevent the pathogenic bacterial overgrowth that is commonly found in the elderly by reducing luminal pH, enhancing the secretion of antimicrobial compounds, preventing bacterial adhesion, and enhancing the immune response of the host. Most probiotics currently sold provide the Lactobacillus and Bifidobacterium genera of bacteria; however, further research should identify specific age-related changes in the gut microbiota and interindividual responses to probiotics to provide a more specific treatment to the elderly. For example, because an age-related inflammatory environment is known to exist, it is possible that administration of bacteria such as F. prausnitizii, a newly identified anti-inflammatory probiotic bacteria, may be suitable for probiotic products marketed for the elderly.

Probiotic supplementation in the form of a dietary supplement is a simple way for the elderly to consume beneficial bacteria. It is generally recommended that a supplement contains at least a billion living organisms per serving to be effective. In lieu of formulation specifics for the elderly, it is also generally recognized that a broad range of bacterial species most likely offers a broader range of benefits. The species and strains that have been shown in clinical trials to have a positive effect on the immune system of the elderly are good to seek out. Currently, there is also a wide variety of functional foods available in the marketplace, including probiotic-enhanced foods and drinks that are easy to consume and digest, that may benefit the elderly. Probiotic-enhanced milk, juices, coffee, cereals, energy bars, and even chocolate bars have become commonplace in grocery stores. Fermented foods that naturally contain live bacterial cultures are another option: yogurt, certain cheeses, crème fraiche, kefir, sauerkraut, pickles, miso, tempeh, kimchi, or Kombucha can also be incorporated into the elderly diet. A more focused, research and population-based approach to these products in the future is likely to provide the most benefit to the aging community; however, the wide variety of products on the market today offers opportunities for convenient probiotic supplementation that is likely to offer health benefits to the elderly.

Union Context and History

The HEU represents more than 80% of the staff working in most of BC’s licensed residential care facilities—licensed practical nurses, resident care attendants, activity workers, rehabilitation assistants, dietary staff, and housekeeping staff—everyone other than registered nurses and rehabilitation/recreation therapists. The union’s role in preventing resident abuse in long-term care dates back to the 1970s when HEU first organized the staff in the private nursing home sector in BC.

During that organizing drive, the union highlighted issues of resident neglect and low staffing levels, linking poor working conditions for staff with poor caring conditions for residents (Webb, 1994). The success of this organizing drive and public support for the union’s linking of caring and working conditions were critical in pushing the provincial government, in the late 1970s, to establish a legislative and funding framework that would improve quality standards in BC’s long-term care sector (Webb, 1994). This included the passage of the 1978 Long-Term Care Act, the development of funding guidelines for staffing (i.e., the Ministry of Health 1979 Staffing Funding Guidelines), and the provisions of financial and expert assistance to support not-for-profit community organizations in building long-term care residential facilities (Ostry, 2006).

Over the years, the union has continued to advocate for improved working and caring conditions. In 2001, based on growing concerns from members working in long-term care about their capacity to provide appropriate and compassionate care to residents with rising levels of acuity, the union made increased staffing levels a priority bargaining issue. The union worked in coalition with community and seniors groups in advocating for better staffing levels and negotiated an agreement with the provincial government to add 300 new care aide positions in long-term care.

Since May 2001, the union has been on the defensive with the closure of many long-term care facilities, the shift from not-for-profit to for-profit delivery, and the contracting out of health support positions (i.e., cleaning, laundry, and food services). As a consequence, the union has not been in a position to advocate for improvements in care standards, and, in many cases, front-line staff report that working and caring conditions have deteriorated with the increase in the complexity of residents and no equivalent rise in staffing levels or training standards.

The context, however, has begun to shift once again. The combination of signing a new, four-year collective agreement that provides more stability in the sector, and the growing concerns from long-term care administrators, residents, and families regarding quality of care have created new opportunities to address issues of substandard care, abuse, and neglect.

In the fall of 2006, a new multi-stakeholder, provincial-level Residential Care Policy Committee was formed—with representation from the Ministry of Health, health employers, unions, and physicians. Its mandate is to examine training standards, staffing, and quality care issues in BC’s long-term and assisted living facilities. HEU and the other unions in the Facilities Bargaining Association advocated for this Committee during the 2006 round of bargaining as part of policy discussions with the Ministry of Health and the health authorities.

Further discussion on the relationship between union strategies for improving the quality of care, staffing levels and training standards, and abuse prevention are provided in the sections that follow. This chapter looks at the individual, facility, and system level factors that must be addressed in tackling abuse, and proposes a number of abuse-prevention strategies.

Prevalence of incontinence in the elderly

Estimates of prevalence of UI vary widely, depending upon the definition used in the study (the ICS definition ‘any involuntary loss of urine’ says nothing of severity, frequency, duration or impact) and the setting in which the study took place. Generally, the more functionally dependent the study population, the higher the prevalence of UI such that the highest prevalence occurs on frail older people in residential long-term care. Crude prevalence estimates for the most inclusive definitions of UI in women (‘ever’, ‘any’ or ‘at least once in the past 12 months’) range from 5% to 69%, with most studies reporting a prevalence of any UI in the range of 25–45%. There are, however, still gaps in our knowledge; for instance, in a systematic review of incontinence in people with a dementia diagnosis living at home, rates of incontinence varied between 1.1% in a general community population to 38% in those receiving homecare services (Drennan et al., 2013). Men appear to have overall half the prevalence of UI than women. The increasing prevalence in association with age is largely due to the contribution of urgency incontinence (UUI) rather than stress incontinence (SUI). One study demonstrated an increasing rate of UUI from 0.7% between age 50 and 59, 3.4% for 70 years and older men. SUI prevalence was steady at 0.5% and 0.1%, respectively (Ueda et al., 2000). A similar trend of increasing proportions of urgency and UI with increasing age was shown in the United States and a smaller population-based Canadian study (Finkelstein, 2002; Diokno et al., 2007). Conversely, Maral and co-workers showed increasing prevalence of SUI with age, from 0.9% between age 35 and 44, to 4.9% at age 65 and older (Maral et al., 2001).

Faecal incontinence is also more prevalent in the elderly although more difficult to measure due to a lack of standard definitions. Prevalence rates were reported to vary between 5% and 10% in community-dwelling elderly aged over 60 years in The Netherlands (88% response rate) (Teunissen et al., 2004). In a single, relatively bias-free study using a standardized instrument to ascertain faecal incontinence, rates varied between 11% and 15% (Macmillan et al., 2004). Faecal incontinence rates show no sex difference, and increase in association with increasing age for both men and women.

With regards to elderly people seeking assistance for symptoms of incontinence, rates of use of health services have been shown to be consistently low across three nationalities, but higher in one study. Andersson et al. (2004) investigated by questionnaire how UI affects daily activities and help-seeking behaviours in a Swedish regional population (n = 2129), and found that only 18% of 65–79-year-olds requested treatment – those with the worst leakage and level of distress. Hannestad et al. (2000) found that only 25% of symptomatic older Norwegian women sought help – again those who were older and with worse symptoms. In the UK, a similar mailed questionnaire to an elderly regional population (n = 915) found that 15% of those with incontinence had used continence services. The most significant factor for continence service usage was being asked about their symptoms by a health professional (OR 15.7, 95% CI 7.3, 33.9). Other significant factors were more severe and bothersome symptoms, and worse general health (Peters et al., 2004). These figures were similar to another UK study, in which only 9% of all adults with severe symptoms sought a consultation, which the authors found was associated with an acceptance of incontinence as normal in older women (McGrother et al., 2004). However, in an Australian study, 73% of women aged 70–75 years had sought help or advice about their incontinence, and these were women with more severe symptoms (Miller et al., 2003).

Although urinary incontinence is widely purported to be a predictor of nursing home admission, data supporting this assertion are few. Whereas Holroyd-Leduc and coworkers investigated the relationship of UI to key adverse outcomes (death, nursing home admission, functional decline) in 5500 community-dwelling elderly, mean age 77 years (69–103 years) and concluded that UI was not an independent risk factor for these adverse outcomes, but higher levels of illness severity and functional impairment were (Holroyd-Leduc et al., 2004).

Elder Abuse in the Institution

Institutional abuse is the mistreatment of older persons living in facilities such as nursing homes, hospitals, or long-term care institutions; it is perpetrated by the formal caregiving staff, and sometimes by other patients or visitors. There is, however, some indication that an abusive relationship at home may not necessarily end once an older person has entered institutional care. Elder abuse and neglect by formal caregivers fall into the same categories as that committed by informal caregivers, but the victims are likely to be more vulnerable to abuse because they require the protective environment of the facility. Some researchers have added violations of basic rights to the list of abuses that can occur in institutions. Such violations include denying elderly people the right to make personal decisions or the right to privacy. Another form of abuse that has been considered is systemic abuse, which refers to abuses resulting from unquestioning regimentation, such as routine use of incontinence briefs instead of helping the person to the bathroom.

There are no reliable data on the prevalence of maltreatment or neglect in hospitals, nursing homes, day care, or residential long-term care facilities. There is enough anecdotal evidence (case studies, governmental reports, ethnographic studies, personal histories) in every country where these institutions exist, however, to suggest that abusive behavior is a widespread, regular aspect of institutional life. There have been reports of material abuse, including the theft of patient's funds and fraudulent therapy and pharmaceutical charges; physical abuse, including rough handling, hitting and slapping, and inappropriate medical treatment such as chemical and physical restraint; and psychological abuse, including social isolation, yelling in anger, and threats. Neglect often reflects deficiencies in the provision of nursing care such as inadequate nutrition and hydration and poor oral and physical hygiene.

The first prevalence study of abuse in nursing homes was carried out in the United States. In a random survey of 577 nurses and nursing home aides in 1989, staff were asked to report on abuse perpetrated by others and to report on their own abusive actions. Only physical and psychological abuse were considered. The researchers found that, overall, 36% of the sample had seen at least one incident of physical abuse in the preceding year. The most frequent type of physical abuse observed by the staff was the excessive restraint of patients. A total of 81% of the surveyed staff had witnessed at least one psychologically abusive incident in the preceding year. Ten percent of the nurses reported that they themselves had committed one or more physically abusive acts, the most common being the excessive use of restraints (6%). Forty percent of the nurses admitted to psychological abuse, the most common form being yelling at a patient (33%). A more recent training project conducted a non-random survey of 77 certified nurses aids (CNAs) about whether they had witnessed abuse. Their reports supported the first American study. Fifty-eight percent of the CNAs said they had seen a staff member yell at a resident; 36% had seen residents insulted, 11% had witnessed threats to hit or throw something at a resident, and 21% had seen a resident grabbed, pushed, shoved, or pinched in anger.

In a random telephone survey of 804 nurses and nurses aids in Ontario, Canada, 20% reported having witnessed abuse of patients in nursing homes, 31% witnessed rough handling of patients, and 28% witnessed yelling and swearing at patients. A study of workers in Sweden (which included a few home-care workers) revealed that 11% of workers knew of at least one incident of abuse in the last year.

As in the analysis of domestic abuse, several North American scholars identified a number of factors that they believe contribute to the abuse of elderly residents by staff in nursing homes. These factors include the lack of comprehensive and consistent policies with respect to the infirm elderly, the fact that the long-term care system is characterized by built-in financial incentives that contribute to poor-quality care, the poor enforcement of nursing home standards, the lack of highly qualified and well-trained staff, the powerlessness and vulnerability of the elderly residents, especially those with some type of dementia or memory loss, and the tendency of staff to avenge patient aggression.

In a partial test of a model developed to explain abuse in institutions, the researchers found evidence that the maltreatment of nursing home patients appeared to be a response to highly stressful working conditions rather than a consequence of the characteristics of the nursing home such as the size or ownership status of the institution. Staff who were younger, who were burned-out, and who experienced aggression from patients were more at risk of becoming abusive toward their elderly patients.

Formal Care

Compared to persons younger than 65 years of age, older persons disproportionately utilize more acute and long-term health-care services, whether home- and community-based or institutional (hospital and nursing home). Consequently, they and their informal caregivers are more widely affected by legislation that significantly changed reimbursement for health care and led to corresponding changes in health-care provision. In 1983, the implementation of the Medicare Hospital Prospective Payment System dramatically altered admission and discharge patterns, effectively transferring 21 million hospital days to home and community. The ‘sicker and quicker’ discharge of older persons from the hospital placed a heavier burden on informal caregivers and spurred the growth of hospital-based and proprietary home-care agencies.

Another important piece of legislation designed to improve the quality of care in nursing homes was the Omnibus Budget Reconciliation Act (OBRA), passed in 1987. It led to an increase in training requirements for nursing home staff and changes in resident care planning and monitoring. OBRA also addressed the pressing issue of the frequent impoverishment of community-dwelling spouses of nursing home residents. It mandated policies allowing these spouses to retain the equity in their home and one-half of their other assets so they could continue living independently. However, it is not clear that these changes actually resulted in improved care, more positive attitudes toward nursing homes, and decreased spousal impoverishment.

The National Family Caregiver Support Program (NFCSP), funded through the Older Americans Act reauthorization in 2000, is the most comprehensive federal legislation that supports caregivers of older relatives, grandparents, and other relatives who care for children 18 years of age and younger, and older adults caring for persons with developmental disabilities. As part of the NFCSP, states are expected to work with area agencies on aging (AAAs) to develop multifaceted systems of caregiver support in five areas: (1) information about available caregiver services, (2) assistance in gaining access to services, (3) counseling and the organization of support groups and caregiver training, (4) respite care, and (5) other services that complement the care provided by caregivers. As yet, it is unclear how these dramatic changes in reimbursement and the organization of health-care systems will affect older persons’ patterns of formal service use and their outcomes, alter the role of family caregivers, and affect attitudes toward and patterns of nursing home use.