CHAPTER 292

Provision of Care

Providing medical care to older people can be complicated. People often have many different doctors at different locations. Travel and transportation issues become more difficult as people age. The drugs that are covered by the new Medicare prescription drug plan vary between insurance companies and change frequently. Assistance by a team of health care practitioners under the leadership of a primary care doctor or geriatrician is the best way to deal with these complexities. However, this ideal solution is often difficult to achieve.

Continuity of Care

Continuity of care is an ideal in which health care is provided for a person in a coordinated manner and without disruption despite involvement of different practitioners in different care settings. Also, all people involved in a person’s health care, including the person receiving care, communicate and work with each other to coordinate health care and to set goals for health care.

Continuity of care is not always easy to accomplish, especially in the United States, where the health care system is complicated and fragmented. When continuity of care is missing, people may not adequately understand their health care problems and may not know which practitioner to talk to when they have problems or questions.

CHALLENGES TO CONTINUITY

Continuity of care is a particular concern for older people. Older people are particularly likely to have several doctors (each specializing in one organ system or problem) and thus to move from one care setting to another (called transition of care). They may receive care in several doctors’ offices, in a hospital, in a rehabilitation facility, or in a long-term facility.

Many Practitioners: Having many practitioners at many places may disrupt the continuity of an older person’s health care. For example, one health care practitioner may not have up-to-date, accurate information about the care provided or recommended by other practitioners. That practitioner may not know the names of the other practitioners involved or may not think to contact them. Information about care may be misremembered, miscommunicated, or misunderstood, particularly when older people have disorders affecting speech, vision, or cognition that make it more difficult for them to communicate effectively. An older person may mention an important detail to one practitioner and forget to mention it to the others.

To ensure that care is continuous (and optimal), all practitioners involved must have complete, up-to-date, and accurate information about what other practitioners have done—particularly about tests done and drugs prescribed. When this information is missing or miscommunicated, the following can result:

Diagnostic tests may be needlessly repeated.

Inappropriate drugs or other treatments may be prescribed.

Preventive measures may not be taken because each practitioner assumes someone else has provided them.

Different practitioners may have different opinions about a person’s health care. For example, practitioners in a hospital may disagree with a person’s primary care doctor about whether surgery is required or about whether the person should go to a nursing home after being discharged. The person and family members may be overwhelmed and confused by differences of opinion among the various practitioners.

People taking many prescription drugs, as is common with older people, may fill their prescriptions at different pharmacies (for example, the one nearest each specialist’s office). When different pharmacies are involved, each pharmacist may not know all the drugs people are taking and thus will not know when a newly prescribed drug might interact negatively with a current one.

Many Settings: Moving from one care setting to another, such as going from a hospital to a skilled nursing facility, increases the chance that errors in care may occur. New drugs may be prescribed in the hospital, and they may duplicate or negatively interact with the person’s other drugs. Sometimes old, needed drugs may be unintentionally omitted. Even when changes in people’s drugs are appropriate, the changes may not be communicated to all involved health care practitioners, such as the primary care doctor.

To prevent such problems, current regulations in the United States require health care organizations to do drug reconciliation whenever the care setting is changed and new drugs are ordered or existing orders are rewritten. Drug reconciliation involves comparing people’s drug orders to all the drugs they were previously taking and thus make sure no drugs are duplicated or omitted. When changing care settings, older people or their caregiver need to ask one of the hospital staff members, such as a nurse, doctor, or social worker, whether drug reconciliation was done. People should also be sure to obtain their own copy of the current drug regimen. They should then compare it with the list of drugs that they have been taking and check to make sure that no drugs are duplicated. If they have any questions, they should contact their primary care doctor. Making an appointment with the primary care doctor soon after discharge from the hospital is always a good idea. The doctor can then review all of the drugs and instructions recommended by the hospital.

Many Rules: The health care system has many rules that affect continuity of care. The rules may be made by the government, insurance companies, or professional organizations for health care practitioners. For example, some insurance companies limit which hospital people can go to. The person’s doctor, if not on staff at that hospital, may be unable to provide care there. As a result, important information about the person may not be communicated.

Lack of Access to Care: Continuity of care may be disrupted when people do not have access to health care. For example, older people may miss a follow-up appointment because they do not have transportation to a doctor’s office. They may not see a doctor or specialist because they do not have insurance and cannot afford to pay for health care themselves.

STRATEGIES TO IMPROVE CONTINUITY

Improving continuity of care requires efforts by the health care system, by the people receiving care, and by family members.

Health Care System

Managed care organizations and some government health care plans coordinate all health care and thus contribute to continuity of care. Also, the health care system has developed several strategies to improve continuity of care. Examples are

Interdisciplinary care

Geriatric care managers

Interdisciplinary Care: Interdisciplinary care is coordinated care provided by many types of practitioners, including doctors, nurses, pharmacists, dietitians, physical and occupational therapists, and social workers. These practitioners make a conscious, organized effort to communicate, cooperate, and agree with each other about a person’s care. Interdisciplinary care aims to ensure that people move safely and easily from one care setting to another and from one health care practitioner to another. It also aims to ensure that the most qualified health care practitioner provides care for each problem and that care is not duplicated. Interdisciplinary care is not available everywhere.

Interdisciplinary care is particularly important when treatment is complex or when it involves movement from one care setting to another. People who are most likely to benefit include those who are very frail, those who have many disorders, those who need to see several different types of health care practitioners, and those who have side effects from drugs.

The practitioners who care for a particular person are called the interdisciplinary team. One practitioner, often the person’s primary care doctor, coordinates care.

Sometimes the health care practitioners on an interdisciplinary team do not work together on a regular basis (an ad hoc team). They come together to meet a particular person’s needs. In other situations, there is an established team with the same members who usually work together and who care for many people. Some nursing homes, hospitals, and hospice organizations have established teams.

Team members discuss plans for treatment and inform each other about changes in the person’s health, changes in treatment, and results of examinations and tests. They make sure that the person’s records are up-to-date and that the records accompany the person through the health care system. Such efforts help make changes in care setting or in health care practitioners smoother and less traumatic. Also, tests are less likely to be repeated unnecessarily, and mistakes or omissions in treatment are less likely.

The interdisciplinary team also includes the older person being cared for and family members or other caregivers. For effective interdisciplinary care, these people must actively participate in care and must communicate with the health care practitioners on the team.

Geriatric Care Managers: These people are specialists who make sure that an older person receives all the help and care needed. Most geriatric care managers are social workers or nurses. They may be members of an interdisciplinary team. Geriatric care managers can make arrangements for the services needed and supervise these arrangements. For example, care managers may arrange for a home nurse to visit or for an aide to help with housecleaning and preparation of meals. They may locate a pharmacy that delivers drugs or arrange for transportation to and from the doctor’s office. Geriatric care managers are relatively uncommon.

People Receiving Care

To help improve the continuity of their care, older people or their caregivers can take a more active part in their care. For example, they can learn more about what can interfere with continuity, how the health care system works, and what tools are available (such as care managers or social workers) to improve continuity of care. Being familiar with their disorders and the details of their health insurance plan can also help.

Active participation begins with communication—giving and getting information. When older people have special health care needs or questions, they or their family members should tell their health care practitioners. For example, older people often need help determining which drugs are covered by their Medicare prescription drug plan.

When an interdisciplinary team or geriatric care manager is unavailable, people who are receiving care or their family members need to become proactive in care. For example, older people or their caregivers need to establish an ongoing relationship with at least one health care practitioner, usually the primary care doctor, to minimize the problems created by having several health care practitioners. Older people should make sure the primary doctor is aware of changes in their condition and their drugs, especially when a specialist has made a new diagnosis or changed a treatment regimen. They may need to ask one health care practitioner to call and talk with another to make sure that information is communicated clearly and that treatment is appropriate.

Active participation also includes seeing a health care practitioner (usually the primary care doctor) regularly and following the instructions of health care practitioners. It means asking questions about a disorder, treatment, or other aspect of care. It includes learning how to prevent disorders and taking the appropriate steps to do so.

For people who have a disorder, active participation may involve self-monitoring. For example, people with high blood pressure can regularly monitor their blood pressure. People with diabetes can regularly check the level of sugar in their blood.

Keeping a copy of their medical record can help people participate in their health care. They can often obtain a copy from their doctor. A copy of the medical record is useful as a reference for information about disorders present, drugs being taken, treatments and tests done, and payments made. This information can also help people explain a problem to a health care practitioner. File boxes, binders, computer software, and Internet programs have been designed for this purpose. When more than one doctor is involved, people can keep their own records of their care, including the type and date of examinations and procedures and a list of their diagnoses. At a minimum, people should keep a record of all drugs (prescription and nonprescription) they are currently taking, plus the doses and the reason they are taking the drug. They should bring this record with them each time they visit a doctor.

When people go to a hospital or to a new health care practitioner, they should check with someone at the new location to make sure that their medical record has been received.

Buying all drugs (prescription and nonprescription) at one pharmacy or through one mail order service and getting to know a pharmacist there are also important. Older people can ask their pharmacist questions about the drugs they are taking. They can also ask for containers that are easy to open and labels that are easy to read.

Care Providers: Practitioners

People, particularly older people, often need to see several types of health care practitioners. Sometimes a group of health care practitioners work together to provide care. This type of care is called interdisciplinary care (see page 1903).

Doctors: Older people may see many different kinds of doctors: family practice doctors, general internists, specialists in such areas as heart disorders (cardiologists) or cancer (oncologists), and surgeons. Sometimes general internists and different specialists work together in a group practice. A group practice makes referrals and communication among doctors easier, and people do not need to travel to many different locations.

Geriatricians are doctors, usually internists or family practice doctors, who are trained specifically to care for older people. A geriatrician may be the person’s primary care doctor or may be called in for a short time for consultation. Geriatricians are trained to manage many disorders and problems at once. They have studied how the body changes as it ages, so that they can better distinguish when a symptom is due to a disorder rather than to aging itself. They evaluate older people in terms of social and emotional as well as physical needs. Then they can help older people live as independently as possible. The people most likely to benefit from seeing a geriatrician include those who

Are very frail

Have many disorders

Need to see several different types of health care practitioners

Take many drugs and are thus likely to have drug side effects

Nurses: Nurses may work in a doctor’s office, a hospital, a rehabilitation or long-term care facility, or a senior center, or they may provide care in a person’s home. Nurses may help coordinate care by communicating information to the different practitioners involved, the person, and family members. Also, they are often more readily available for questions that older people may have about their disorders or treatment. Nurses may teach older people about measures to help maintain good health, such as diet, safety, stress management, sleep, and exercise. Other duties include checking vital signs (blood pressure, pulse, and temperature), taking samples of blood, giving treatments, and teaching people how to care for themselves. Nurses may ask questions about the person’s health (for the medical history) and home situation.

Registered nurses (RNs) often provide most of an older person’s health care. RNs supervise care provided by licensed practical nurses (LPNs) and nurses’ aides. RNs are taught to do a physical examination and check for changes that need to be evaluated by a doctor. They also can administer drugs to the person, as prescribed by a doctor. LPNs may do many functions but always under the supervision of an RN.

Nurse Practitioners: Nurse practitioners are registered nurses who receive additional training in diagnosis and treatment. Thus, these nurses have more responsibilities than RNs. They can write prescriptions and order tests for people. Some nurse practitioners, called geriatric nurse practitioners, are specially trained to care for older people.

Physician Assistants: Physician assistants (PAs) have some of the same functions as doctors and nurse practitioners but always under a doctor’s supervision. Their functions include the following:

Asking about the person’s health (for the medical history)

Doing physical examinations

Ordering diagnostic tests

Helping doctors develop treatment plans

Assisting in surgery

Doing routine procedures, such as giving shots and stitching up wounds

Providing people with information about following their treatment plan and taking care of themselves (such as information about a healthy diet and exercise)

PAs work in most care settings, including long-term care facilities. They may provide health care in a person’s home. Some PAs specialize in treating older people.

Pharmacists: In addition to dispensing drugs, pharmacists evaluate prescriptions to make sure that appropriate drugs are being used. Pharmacists can check to make sure that older people are not taking drugs that pose special risks for them. Pharmacists also make sure that instructions are clear and include information about how much and how often a drug is to be used. They keep track of a person’s prescriptions and refills. In this way, they can check for interactions between drugs.

Some pharmacists specialize in the care of older people. They are sometimes called consultant (senior care) pharmacists. They often work in nursing homes. They provide other practitioners with information about how to use drugs appropriately in older people.

Dietitians: Dietitians assess how well nutritional needs are being met. When needs are not being met, they provide specific recommendations about which foods to choose and how to prepare foods. About 1 in 6 older people are undernourished. Many older people can benefit from the assistance of a dietician.

Therapists: Different types of therapists may be needed, depending on the disorders and problems a person has.

Physical therapists (see page 48) evaluate and treat people who have difficulty moving—for example, difficulty walking, changing positions (standing up, sitting down, or lying down), transferring from bed to chair, lifting, or bending. They work with people who have had problems such as a stroke, amputation of a limb, or hip surgery. Treatments may include exercise, heat, and ultrasound.

Occupational therapists (see page 50) evaluate and treat people who have difficulty caring for themselves (for example, dressing or bathing), working, and doing other daily activities.

Speech therapists help people who have difficulty using and understanding language (see page 56).

Social Workers: Social workers help coordinate discharges from hospitals and transfers between institutions. They may help people fill out insurance and other forms. They help people identify services that can be provided in the home and community and often help arrange for these services. They also evaluate how people are responding to the care and services obtained.

Social workers may bring family members together for discussions about important health care issues. Many social workers counsel people with anxiety, depression, or difficulty coping with a disorder or disability.

Most social workers are familiar with the special needs of older people. But some are specially trained to counsel older people and to determine whether they need supervision or additional help.

Nurses’ Aides: Nurses’ aides care for people in hospitals, rehabilitation facilities, nursing homes, assisted living communities, or other medical facilities under the direction of nurses, doctors, and other medical staff members. They are sometimes trained to do some simple assessments of health. For example, an aide may measure temperature, pulse, and blood pressure.

Nurses’ aides may respond to signal lights or bells indicating that someone needs help. They bathe, dress, and undress people. They serve and collect food trays and feed people who need help eating.

Home Health Aides: Employed by home health care agencies, home health aides do many of the same tasks that nurses’ aides do, but in the home. They help with daily activities, especially with dressing and grooming. These aides may prepare meals, help the person out of a wheelchair, or take the person for a walk. They sometimes help with light housework. They may also do some simple health assessments under the supervision of a registered nurse.

Medical Ethicists: Medical ethicists help resolve conflicts about moral issues that come up during health care. For example, health care practitioners and family members may disagree about whether a treatment that appears to be ineffective should be stopped. Medical ethicists may be doctors, other health care practitioners, lawyers, or other people who have been specially trained in medical ethics. Some hospitals have a medical ethicist or a team of medical ethicists on staff.

Care Providers: Family and Friends

Some older people have family members, friends, or neighbors who are willing and able to provide help and care. Such people may be called caregivers. Occasionally, members of religious or other groups help or take over the role of caregiver altogether at no or low cost. Caregivers may provide help with basic activities (such as eating, dressing, and bathing) or with household chores (such as cooking, cleaning, shopping, paying bills, mowing the lawn, and taking drugs as prescribed).

Of the nearly 36 million people aged 65 or older in the United States, about 7 million need a caregiver’s help on a daily basis. More than 22 million caregivers in the United States provide ongoing care for older people. They may provide care for a few hours a week or around the clock.

Most caregivers are the spouses or children of the people they care for, and most are women. About two thirds of caregivers work full- or part-time in addition to providing care.

Determining whether an older person needs care can be difficult. Most older people resist the idea that they need any help. Observing how well an older person is able to do the following can help concerned family members make this decision:

Eating: Is clothing frequently stained by food? Is the person losing weight without an obvious explanation?

Getting in and out of a chair or bed: Does the person rock back and forth several times before actually getting up? Are nearby furniture items or objects used for support? Does sitting down seem to involve falling backward into a chair?

Using the toilet: Is clothing soiled or wet?

Bathing: Are the person’s skin and hair dirty?

Grooming: Does the person look rumpled or disheveled?

Walking: Does the person seem unsteady or have falls?

Taking prescribed drugs: Do prescriptions last longer than they should? Are prescriptions used up faster than they should be? Are pills mixed together in one container?

Using the telephone: Does the person seem to understand phone conversations? Is the phone consistently answered when the person is known to be home?

Managing money: Are bills unpaid, leading to overdue notices? Has the person repeatedly been notified of overdrafts on accounts?

Preparing food: Are food items kept past expiration dates? Do pots and pans seem to become scalded repeatedly? Has the stove been found left on?

Doing laundry: Are clothes clean?

Rewards and Challenges

Caregiving can be very rewarding, even when it is hard work and causes stress. Many people choose to care for a spouse, partner, or parent out of love and respect. They find new meaning in their own life by making a difference in another person’s life, even if their efforts are not always appreciated. However, no one can ever be fully prepared for the challenges of caregiving.

Physically, mentally, financially, and emotionally, caregiving can be demanding, as in the following situations:

Caregivers may have to do all household tasks, dress and bathe the person, make sure the person follows the prescribed drug regimen, manage the person’s finances, or a combination.

They may spend their life’s savings while they care for a dependent parent or spouse, or they may have to quit their job to care for the person.

They may have to continually attend to the person’s emotional needs.

They may have to give up activities they enjoy.

Family members may disagree or argue about who should provide or pay for the care and about other aspects of care.

The demands may be more trying when caregivers themselves are frail, have been thrust into their role unexpectedly or reluctantly, or must care for someone who is uncooperative or combative.

Avoiding Caregiver Burnout

Caregivers can help avoid burnout by doing the following:

Learning about the cause, symptoms, and long-term effects of the older person’s condition

Anticipating changes in the older person and in the level of care the older person needs

Letting the older person make decisions and solve problems as much as possible

Knowing their own limits

Not taking the older person’s anger, frustration, or difficult behaviors personally (these behaviors may be symptoms of a disorder such as dementia)

Avoiding arguments

Discussing responsibilities with other family members and friends, then asking them to help when appropriate and possible

Discussing feelings and experiences with a friend, someone who has had similar experiences, or people in a support group

Eating and exercising regularly and getting enough sleep

Scheduling regular time for relaxing, enjoyable activities

Obtaining information about the older person’s financial resources

Avoiding depleting personal finances

Contacting organizations that can provide information and referrals for caregivers

Using day care or respite care to get a temporary break when needed

Hiring a home health aide or health care practitioner, such as a licensed practical nurse (LPN) or nurse’s aide, to help if needed

Talking to a counselor, therapist, or clergyman if needed

Remembering that an assisted living facility or a nursing home may be the best option

The many responsibilities and conflicts that come with caring for an older person can isolate a caregiver, compromise relationships, and threaten job opportunities. They can lead to mounting anger, frustration, guilt, anxiety, stress, depression, and a sense of helplessness and exhaustion. These feelings are sometimes called caregiver burnout. Burnout can affect anyone at any time but is more likely when the person being cared for cannot be left alone or is disruptive overnight. In the worst cases, when caregivers are unaware of or are unable to obtain help, burnout can lead to abandonment and even abuse of the older person (see page 1934).

To determine how to provide the help an older person needs and to avoid caregiver burnout, caregivers often need to talk with different practitioners, including doctors, nurses, physical and occupational therapists, social workers, and a care manager (a specialist trained in making sure that older people receive all the help and care they need—see page 1903). Caregivers can also use strategies to prepare themselves for caregiving and to avoid caregiver burnout.

Long-Distance Caregiving

In a modern, mobile society, family members sometimes live hundreds or even thousands of miles apart. Such distances complicate efforts to ensure that older family members receive the care that they need. Longdistance caregivers—usually adult children—have many challenges.

Good communication is often difficult to maintain. Family members may feel that they never get a complete or accurate impression of how the older person is managing or what is needed. Even when needs are understood, family members may feel there is little they can do for the older person unless they are there to do it.

Family members can take several steps to make helping from a distance less worrisome:

Scheduling a regular time for phone calls, which can be reassuring for everyone

Communicating by e-mail or Internet videoconferencing with a computer-mounted camera

Finding a person who can visit their loved one regularly and who agrees to call them immediately if questions or concerns arise

Arranging for participation in some type of meal program (such as Meals on Wheels) if shopping, meal preparation, and eating are concerns

Installing a home security system if security is a concern

Setting up a personal emergency response system (medical alert device) if falling is a concern

Also, family members should have copies of any advance directives, such as a living will or durable power of attorney for health care, so that they can help if their loved one needs emergency treatment.

Family members can get help from people who are familiar with resources in the community where the older person resides. The older person’s primary care doctor may be helpful in arranging for local assistance. Or family members can arrange for a geriatric care manager to oversee the caregiving and health care. However, family members sometimes believe they have no other choice than to go and help directly. The Family Medical Leave Act permits people to keep their job while taking up to 12 weeks of unpaid leave to attend to a dependent family member. Only large employers are required to provide this protection, and there are other restrictions, such as those about employee eligibility.

Settings for Care

Health care practitioners may provide care for older people in a variety of settings.

Doctor’s Office: Most older people receive medical care as outpatients. That is, they see their doctor in an office, then they go home. The office may be in a medical office building, a clinic, a hospital, or elsewhere. Diagnostic tests, such as blood tests or x-rays, are often done in a doctor’s office. If not, they may be done at a nearby clinic. Some doctors’ offices offer certain treatments, such as physical therapy.

Hospitals: Hospitals provide the most comprehensive medical care, usually to people who are very sick. Older people may enter the hospital through the emergency department, or they may be scheduled for admission by a doctor.

A doctor (who may be the person’s primary care doctor, a specialist, or a staff doctor at the hospital) is in charge of the person’s care in the hospital. Sometimes several other doctors are involved. Nurses, who are available 24 hours a day, provide much of the care. A nurse is always available, but doctors may come and go at more irregular times.

Many other people may help provide care in a hospital. They include pharmacists, dietitians, physical and occupational therapists, social workers, medical technicians, nurses’ aides, and volunteers.

How long people stay in the hospital depends partly on how sick they are, what the diagnosis is, and, if needed, what arrangements for continuing care can be made after discharge. The health care practitioners involved determine whether and what type of continuing care is needed. This care may be provided in a rehabilitation facility, in a long-term care facility, or in the home by a visiting nurse.

Did You Know…

Some senior centers have a nurse on duty for several days a week and provide physical and occupational therapy.

Surgical Centers: Surgical centers are places where same-day surgery may be done. Such surgery involves medical procedures that typically require anesthesia, that are too complicated to be done in a doctor’s office, but that do not require an overnight stay in a hospital. Common examples are endoscopy, colonoscopy, and removal of cataracts. Surgical centers may be located in a hospital or be a separate, free-standing facility.

Many communities have surgical centers. Then, people can have procedures in their own community without needing to travel to a more distant hospital.

Rehabilitation Facilities: After discharge from the hospital, people with a severe disability may need to continue their recovery in a rehabilitation facility. A facility may be located in a hospital or a nursing home. These facilities provide skilled nursing care and physical, occupational, and speech therapy.

When people are discharged to a rehabilitation facility, doctors predetermine how long their stay will be. For older people, the stay ranges from several weeks to a few months. Goals for progress are set, and progress is evaluated every day. Thus, the types and amount of therapy can be adjusted as needed.

Some older people need to go to a rehabilitation facility for therapy but do not need to stay there.

Long-Term Care Facilities: When older people need more help than can be provided at home and need it for an indefinite time, a long-term care facility may be appropriate (see page 1917). Older people or family members can choose among several living arrangements that provide different services and levels of health care:

Board-and-care facilities provide a room, meals, and some help with daily activities. Some facilities provide certain basic health care.

Assisted living communities are similar to board-and-care facilities. However, they provide more health care, and most provide 24-hour supervision of the resident if needed. Some of these facilities have a registered nurse on site.

Nursing homes provide nursing care, including giving residents their drugs, in addition to help with daily activities. Nursing homes have at least one registered nurse on site at all times. They also employ licensed practical nurses and nurses’ aides. Some homes provide physical and occupational therapy.

Life-care communities provide different levels of services and care, depending on need. For example, if people have early dementia, the community may provide only help with taking drugs and an environment where stimulation is minimized. As the dementia worsens, the community can provide help with all daily activities as needed. Life-care communities guarantee that people, regardless of their health, are cared for within the community for the rest of their life.

Home Health Care: After discharge from the hospital, many older people who are well enough to go home need some help with daily activities or with managing their health care. Home health care agencies provide this help. These agencies employ registered nurses, therapists, home health aides, and social workers.

Some people need home health care for a short time after they leave the hospital. For example, a nurse may be needed to change wound dressings. Other people, especially those with a chronic disorder, need home health care for a longer time. People with a heart or lung disorder may need a nurse to visit regularly and check whether they are worsening or improving. The nurse can also adjust a drug dose if needed. Or a nurse may regularly visit people with diabetes to make sure they are following their treatment plan, to monitor drug use, and to adjust doses as needed. A physical therapist may be needed to help people regain strength and balance or recover from a stroke. A home health aide may be needed to help with shopping, preparing meals, going out in a wheelchair, taking a walk, or bathing. A social worker can determine whether people are receiving the services they need and recommend additional services if needed. A social worker may help arrange for rides to and from medical appointments.

Community Services: In the United States, one source of support services and health care in the community is senior centers. In addition to social, recreational, and educational activities, some senior centers serve meals—an important service for people who cannot prepare their own. Often, senior centers are a place where family members who care for a person full-time can take the person and get a break from care (a service called respite care).

Many senior centers also provide some health care. For example, some senior centers have a nurse on duty at least a few days a week. The nurse can check blood pressure, make sure people are taking their drugs as instructed, and teach people about their disorders. The nurse also helps people with health problems determine whether they need to see a doctor. Sometimes the nurse contacts a person’s doctor or family members. Some senior centers provide day care for people with mild to moderate dementia, and some provide physical and occupational therapy.

Other services available in the community include meal programs (such as Meals on Wheels), transportation services, help with daily activities, support groups, and respite care. Some religious communities provide many of these services. These services are usually inexpensive, and some are free.

Information about community services, including senior centers, can be obtained from the hospital discharge planning or case management department, home health care agencies, local health departments, and religious communities. Senior centers can also be found by looking in a local telephone book or on the Internet.

Day Hospitals: Day hospitals provide hospital care only during the day. They are usually located in a hospital. They enable people to have complex tests and treatments without having to check into an overnight (inpatient) hospital. Day hospitals are particularly useful for people who need rehabilitation over a period of time—for example, for people who have had a stroke or amputation of a leg. These hospitals also provide meals and transportation to and from medical appointments and therapy sessions.

The primary care doctor or a hospital may send a person to a day hospital. Day hospitals are usually used for a limited period of time (6 weeks to 6 months).

Hospice Care: For people who have a progressive, incurable disorder, hospice care provides the treatments and services needed to control symptoms, ease pain, and help people and their family members prepare for the death (see page 60). Hospice care may be provided in a person’s home, in a nursing home, or in a hospice facility.

Hospice care usually involves a doctor, nurse, and social worker trained to care for dying people. Pharmacists, counselors, physical therapists, ethicists, and volunteers may also be involved. These practitioners are needed to make sure that all of the person’s physical and psychologic needs are met as well as possible. Most people who receive hospice care do not have to go to a hospital before they die. Thus, they can die in a more comfortable, intimate environment, often with loved ones around them. Hospice care also involves helping family members prepare for the death and understand what to do when the person dies.