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Trends in Society
1.1 Aging of the Baby Boomers will be one of the most important factors during the future of healthcare.
What Percent of the U.S. population will baby boomers hold in the next ten years?
What are the characteristics of these consumers of healthcare?
How will the large percentage of older adult’s impact healthcare and case management?
What kind of healthcare needs will these adults have?
What are the practice implications for case managers?
Population growth and shifting demographics in the U.S. will have a major influence in the new millennium. Aging Baby Boomers will be an ongoing impetus for change and innovation in the way healthcare is provided as well as other services in the years to come. A full 91 percent of survey respondents in the AHA trends survey agreed that aging of Baby Boomers will be one of the most important factors for the future healthcare environment (American Hospital Association, 2000).
In the next decade, Americans will be getting older and living far longer than in the previous century. By 2010 the average life expectancy will be up to 86 years of age for a Woman and 76 years for a man (Robert Wood Johnson Foundation (RWJF), 2000) Added to this aging is the fact that more than 100,000 people will be over the age 100 in the year 2010 (RWJF). !OO year birthday parties will seem to become commonplace in our Country .
As the Baby Boomers become 50 years old and older, they will become the United State's most powerful consumers of healthcare services. This group of consumers is often Providing care for aging parents while also meeting their own personal care needs. Soon, The 79 million American born between 1946 and 1964--one third of the U.S. population-- Will begin to experience the first acute episodes of chronic health conditions (AHA). Baby Boomers will lead long, healthier lives than their parents or grandparents, and have more care needs or options for lifestyle changes than those who have gone before them.
The influx of Baby Boomers will bring a "large group of people taking their Knowledgeable, intelligent, cranky behaviors and applying them to healthcare" (RWJF). These consumers will also say that they care given in the past was not good enough, and that they demand better healthcare. This group of older adults will continually redefine What most nurses and doctors, and the public, think of aging. There will continue to be More healthy 90 and 100 year-olds in our country.
At the same time, many of the older Baby Boomers will have active and mobile Lifestyles but may begin to suffer from chronic disease. Those with chronic disease will Live with their disuse, such as diabetes or heart disease, for a long period of time. The Longer lives of many women will also lead to strained financial and personal resources When they have outlived their spouses and loved ones.
Baby Boomer Impact at the State Level
The progressive growth of older Americans and the future influence of the Baby Boomers can be seen by examining age-gender population pyramids. The "Baby-Boom Bulge" appeared in the California census in 1990 in the ages 25 to 44 (California Department of Finance, 1993). During the 1990s, Baby Boomers were in their Economically most productive years and were 35 percent of California's population. By 2010, Baby Boomers will represent 25 percent of California's population and will be in the Pre- and early retirement years by 2020 (California Department of Finance). This large Cohort of elderly residents will strain the services and programs required by an aging population.
Compounding this shift to increased numbers of elderly in California is the aging of the nursing profession in the state. About the time that the Baby Boomers begin to need Various healthcare services, the large number of older nurses (who now average about 45 Years of age) will be retiring and leaving healthcare. California legislators are struggling To prepare for this near-future shift by encouraging healthcare and nursing leaders to Address the recruitment and retention of qualified nurses in hospitals and qualified faculty Within nursing schools.
The well-educated and informed Baby Boomer consumers will want different kinds Of care options than before. The term "healing environments" will begin to become more Common as consumers demand healthcare surroundings that make them feel better. Healthcare architects and designers are responding to this demand with new and Remodeled facilities that emphasize natural light, way finding, privacy and spirituality (AHA). Some facilities are building healing gardens and labyrinths for meditation, to Balance high-tech care with high-touch (AHA). The economic and clinical impact of Healing designs will be an important measure to help this type of trend become more Mainstream.
One example of a specially designed hospital is the Heart Hospital in Rancho Mirage, California. This facility, specializing only in cardiac procedures, provides Spacious private suites that resemble swanky hotel rooms with Italian tile floors and Leather sofas (Japing, 2000). Does this hospital cater only to the wealthy? Contrary to Some impressions, the hospital works with "ordinary, insured patients" taking advantage of The newest trend in medical care: specialty hospitals that by limiting their practice to a Single high-revenue procedure can pour profits back into patient comfort.
The patients driving this trend for comfort and care are the baby boomers. Those Moving toward specialty hospitals have anticipated the demand from aging boomer Patients who are drawn to luxurious touches such as tropical aquariums and herb gardens-- Features absent in traditional hospitals.
The informed consumers will also continue with demands for quality care. In the next few years there will be report cards from many avenues that rate the quality of care in a hospital-by-hospital, doctor-by-doctor basis (AHA). More and more healthcare agencies Will need to demonstrate positive outcomes of the care provided. Also, concern for medical Safety and errors will continue. This topic is discussed in Chapter six of this text. While as Many as 93 percent of hospitals report doing CQI or TQM (total quality management) Programs on an ongoing basis, fewer than half of their employees report receiving training On quality topics (AHA). In comparison, at Motorola all employees are trained in quality Topics (AHA).
Patients can now go online to access reports on hospitals, doctors, nursing homes, hospices, and other providers of care. Such web sites as http://www.Healthgard.com, touted as an informative source for consumers to learn about. The quality of care at a given provider to Promote choices, also encourages hospitals and other care providers to register with them to take part in the rating process. This web site listed reports on more than 5,000 hospitals, and even more physicians and nursing homes when accessed during late 2000. Of note is that complementary provider such as acupuncturists and naturopathic physicians are also listed in this data base of information and provider profiles. Sites such as this will become more common and more in demand as educated boomers seek to guide and direct their personal healthcare.
The coming wave of elderly Boomers cannot be discussed without addressing the impact this group will have on the cost of care and type of care needs they may hayed. As the recent years have shown, there will be ongoing concern about Medicare cuts an me affordability of care for U.S. senior citizens. Also, today seniors spend about 19 percent of their disposable income on out-of-pocket costs and prescription drugs are 17 percent of that personal spending (AHA). Stories of older adults splitting pills in half to make a prescription drug last longer have worried doctors, pharmacists, and legislators. Right now there is no pharmacy benefit for Medicare consumers, and the rising costs of pharmaceuticals will make this a priority issue for older voters as this issue continues in the political arena.
President Clinton, during early 2000, said that a report showed Medicare enrollment would double by the year 2025 (Mindscape, 2000). Not only will those over 65 years of age need Medicare coverage, they will need a consistent source of funds at the Federal level to secure Medicare coverage during their longer projected life span. Not only will acute care settings be challenged by this factor, so will home care and, rehabilitation, and long-term care settings. Changes and challenges in Medicare and other insurance funding is discussed further in chapter five of this text.
Those over 65 years of age, particularly those with life-threatening illness or end- stage diseases, will also be faced with end-of-life care choices and decisions. Nurses, case managers, and other care providers should encourage patients and families to discuss end- of-life care to maximize meeting the patient's personal care desires. Too many nurses and case managers have seen instances where patients and families suffer undue stress when a loved one has not made their end-of-life care wishes known.
An advance directive, often referred to as advance care directive by nurses, is a blanket term referring to a statement that a person makes, while in possession of decision- making capacity, about how treatment decisions should be made at some future time if he or she loses capacity to make decisions, and is recognized under state law (Parkman & Calfee, 1997). It may give instructions about treatment, or it may designate another person to make decisions, or a directive may do both.
The best time to make and write down health care decisions is before a person's health does not make it feasible to do so.
A Properly Completed Advance Directive is Intended To:
All adult patients have the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for healthcare) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy (American Hospital Association, 1992).
Every year, thousands of patients and families must face life and death choices about medical care. As nurses know, many have not yet dealt with the issues surrounding receiving, withholding, or withdrawing life-sustaining medical treatment in serious illness or accidents. During these times of crisis, distraught families often do not understand what is really going on or what to do, and may say "what does our Dad want done or not done to him?" These families need support, and the nurses who work with them need to understand the importance of encouraging adults to complete advance care directives before they suffer an unexpected illness, or are not able to make decisions for themselves.
Many elderly come into contact with medical and long-term care without having completed an advance directive, as seen in the increase in the use of legal guardians for elderly. The use of legal guardians is often due to the increase in the numbers of frail, or vulnerable elders (Thomas, 1994). Family may seek guardianship when there is disagreement about implementing decisions to withhold or withdraw treatment. The court may assign a guardian to manage every aspect of the patient's affairs, including personal health care decisions, yet there is little evidence that the legal system is aware of what comprises a thorough assessment of each elder person's and family's needs (Thomas). Many people, the elderly and chronically ill in particular, fear a loss of control over their medical treatment, and ultimately, their living and dying.
Illnesses that produce serious physical and psychological challenges for adults such as Alzheimer's disease, Parkinson's Disease, and other dementia as such as Dementia with Lowy Bodies, present serious healthcare dilemmas in their terminal stages of disease. At those times, the patient often has no ability to represent their own wishes and choices regarding care, and healthcare providers must turn to a surrogate or a pre-assigned agent who can honor their wishes late in life? In addition, illnesses such as terminal cancer, end- stage lung diseases or other illness also present the need for communication of healthcare Choices when end-of-life decisions and needs arise. The reason to plan ahead for end-of- life needs is to assure patient choice to the extent that is most possible.
The advance directive forms are not the same in every state, and it is important for the nurse and the patient to know the law's of their own state (Parkman & Cal fee). A traveling nurse needs to be familiar with the laws in the states in which they accept assignments. Even so, there are common features to the health care power of attorney and living will statutes, as listed in Table 1. Although states provide statutory forms, a patient does not have to follow them, but using the forms helps assure compliance with the law (Parkman & Cal fee). This is particularly important for individuals who travel to or live each year in more than one state. Use of their "home" state's legal forms usually assures acceptance in another state (Parkman & Cal fee).
Completing an advance directive is a significant step, and a statement of personal choices and beliefs about health care. Before completing an advance directive, the individual is encouraged to explore feelings about life-prolonging, or death-delaying, treatment and quality of life. An individual can consider what care they would want if incapacitated, and how their personal relationships affect their decisions, and whether their physician shares their treatment preferences.
It is also important that the individual understand the basic features of life- prolonging measures and terminology, such as intubations, CPR, tube feedings. A list of terminology that nurses, case managers, and physicians should be ready to discuss with patients and family members as the need arises is displayed in Table 2.
If they choose to appoint an agent, they should consider who would be appropriate, and whether the individual's would be willing to be an agent. Ideally, patients think over these issues and related topics, and talk it over with those close to them, prior to a hospitalization. When this has not occurred, a patient should be allowed to talk with a clergy person, their physician, their nurse, a social worker, friends, and family members, while in the hospital, to get any needed help in making health care choices
Once the advance directive is completed, the person should give copies to their physician, their family, and to the hospital at time of an admission. Developing and writing the advance directive is the first phase; implementing it when it becomes necessary is the second phase.
Case managers should become familiar with the issues surrounding end-of-life care, as well as life care planning, a new field in case management. The well-informed care provider can advocate for patient's right to make care decisions in advance of care needs, and to assign a person to speak for them when they are no longer able to express their personal desires for care (Parkman & Calfee).
Creating loyalty with Baby Boomer consumers may be one of the best long-term investments for all healthcare providers and organizations (AHA). Boomers are concerned with their own health, and the care of loved ones and aging parents. Specialized programs for Boomers, such as women's centers, men's health centers, fitness centers, wellness centers, and alternative care programs will be desirable and a source of revenue for providers.
Also, innovation in creating new customer models with fresh designs for outpatient care and hospital makeovers will be a solid strategy for success. The Boomer demand for high quality care can be met with a high degree of access to care, convenience, and close-in parking, and other consumer amenities (AHA). The trend toward specialty hospitals can have a negative impact on traditional full-service hospitals. Some attest that specialty hospitals siphon off procedures that pay well (have higher reimbursement) and chip away at the financial stability of full-service community hospitals (Japing).
Regardless of the negative impact of small specialty sites on large hospitals that feel they cannot compete with these types of offerings, the outcomes of the specialty hospitals may prove they have much to offer healthcare. For example, patients at the Rancho Mirage, California hospital mentioned previously experience a much short length of stay, often discharged home within three days of surgery. Conventional heart surgery patients in traditional settings may average a full seven day stay or more. Such reductions in length of stay with positive patient outcomes can be promising statistics. In addition, with the hotel-like environment, patients experience less ICU confusion seen often in traditional ICU settings. The most remarkable outcome is a current rating of zero mortality postpone (Japing). Such data on the outcomes of specialty hospitals will serve as interesting material for all care settings to consider.
Implications for Case Management
If all the predictions about Baby Boomers come to pass, it could mean substantial changes for case managers in how they interact with patients and where care is provided. Experts predict that the patients of the future will bring more opportunity and responsibility for nurses and case managers. Patients will be more informed, and that means case managers will also need to become better informed.
Such shifts in healthcare will lead to new roles and opportunities for case managers as specialists in long-term care and life-care planning, or consultants in management of chronic disease for a client's loved one. Essentially, case managers will need to remain open to change. In other words, the assessment planning, and evaluating models and methods used in the past may not be adequate for interacting and caring for the Baby Boomer client's of the future. Nurses and case managers will be involved in more holistic care and shared decision-making for more informed consumers. This role will require patience, good communication skills, knowledge of care options, and the willingness to help the older consumer find the best care they can afford.
Joseph H. is a 72 year-old man who was admitted to the hospital for observation and evaluation after suffering an apparent cerebral vascular accident in his home. He follows commands, but is unable to speak, and his left arm and leg are weak. His vital signs are: T 98.5 F, P 82, R 18, and BP 155/88 in his right arm. Joseph's wife, Marie, reports that he had a serious case of stomach flu in the past week, and was not able to follow his usual drug regimen, which includes medication to control his blood pressure, and had complained of headaches and weakness in the past twenty-four hours.
Joseph is settled into the unit, and the short-term plan of care is discussed with his wife. While completing the nursing history and assessment, Lisa, the RN, asks Marie if Joseph has ever filled out an advance directive. Marie is "quite sure he's never done so, but he's never felt the need to worry about it." Lisa encourages Marie to look over the advance directive brochure in the admission packet.
The case manager, Judy, meets the wife and reviews the patient's chart on the morning after he was admitted to the hospital. She is concerned that the wife may not be prepared for both her spouse's current status and the probable serious long-term needs he will have should he be discharged home.
On the second day of hospitalization, during the night, Joseph becomes confused and agitated, and his BP is 190/92. His nurse, Kim, consults with the primary physician who orders nifedipine sustained release stat, and Q4h PRN systolic BP greater than 180 mmHg, along with frequent neurological checks and vital signs throughout the night. After a few hours, at 6:15 a.m., Joseph begins to lose consciousness, the left side of his face droops, and left arm and leg are flaccid. Kim calls both the physician and Marie to inform them of the change in Joseph's status.
Marie and her two adult sons, who have flown in from other cities, arrive first, and are very anxious as Kim tells them what has happened during the night. Dr. Newburg arrives and examines Joseph while Marie holds her husband's right hand. Dr. Newburg asks the family to join them in the hallway.
"He has not responded well to medication to control the hypertension, and it appears that the CV A, or stroke, has progressed. This is the outlook--he may get somewhat better or he may not. He is not a candidate for new CV A treatments, so he could continue to deteriorate, or he could even out and perhaps regain consciousness. But, it is unlikely that he will return to a normal status. With CV A's it is often unpredictable. With that in mind, do you want me to write a 'do not resuscitate' order to forego aggressive measures?"
Marie appears bewildered and just stares at the physician, not sure what he means. After a moment, he nods his head in their direction and says quietly, "you go ahead and think it over, as a family, and let me know what you decide."
As the physician heads back to the nurse's station, Joseph's eldest son, Don,approaches Kim, stating, "My mother is very upset. Can you talk with her?"Kim joins the family near the door to Joseph's room, and Marie tearfully asks, "is my husband dying? What does it mean to not do aggressive measures?"
Kim sees Judy on the unit, and asks her to help with the family's questions. What is the case manager's responsibility in this case?
Case Discussion:
Judy consulted with Kim as she explained that an order of 'do not resuscitate' means to not do anything to restart the heart or the lungs should they stop working." Specifically, it means to withhold chest compressions, special cardiac drugs, electricshocks to the heart, and artificial breathing to try to revive a dying person. The doctormentioned it because your husband is very ill and his condition is very serious."
Mrs. H shook her head. "This seems like an impossible thing to do."
While Kim took Mrs. H's hand, Judy placed a call to both the Chaplaincy department and social services, to request assistance with the family's decisions and associated stress and grief. Kim acted as advocate during that time period.
"This is never an easy decision to make, Mrs. H. One thing you can do, sinceJoseph does not have a "living will," is to try to think what your husband feels about prolonging his life artificially, or being resuscitated should his condition deterioratefurther. You and your sons may want to discuss your concerns together. I go off shift in about 15 minutes, so Joseph's day shift nurse can help you with any questions you may have, and she can have you speak with our unit's social worker or chaplain if you desire. Think it over, and let Joseph's nurse know if you need any help in working through this difficult time, and to help you come to a comfortable decision. Dr. Newburg will want to know what you decide, as Joseph's condition is very unsteady right now."
Conclusion
Nurses and case managers will need to understand gerontology and issues surrounding late life, and how to handle challenges of both well clients and those with serious illness. In both acute and long-term care settings, end-of-life care, patient safety, the use of restraints, and prevention of abuse will continue to be a priority for care providers and accreditation bodies such as JCAHO.
Resources on aging and prevention of elder abuse are listed in Table 3.
References
Table 1: Common Features of Advance Directives in Most States
Features of most "Living Wills" and Durable Power of Attorney for Health Care:
Natural Death Act Declaration (Living Will) Features:
Durable Power of Attorney for Health Care Features:
Source: Compiled from Information Contained in Reference # 6.
Table 2: Critical Medical Terms to Clarify for Patients & Families
Source: Compiled from Information in Reference # 5.
Table 3. Resources on Aging and Elder Care.
Agency |
How to reach: |
American Association of Retired Persons |
601 E. St. NW, Washington, DC 20049 of Retired Persons 202.434.2277 |
American Society of Aging |
833 Market St., Suite 512, San Francisco, CA Aging 94103 415.882.2910 |
National Council on Senior Citizens |
1331 F. St. NW, Washington, DC 20004 Senior Citizens 202.347.8800 |
Society for the Right to Die |
250 W. 57th St., New York, NY 10107 to Die 212.246.6973 |