L " C " g essons in arln : A 'Care by Caregiver' Program

Before the patient leaves the hospital, home caregivers should understand more about the new responsibilities ahead.

B Y S U Z A N N E S H I V L E Y / A N N E M A R I E D J U P E / P A T R I C I A L E S T E R

A change in the health of an elderly loved one of- ten results in hospitalization. As discharge draws near, loved ones often have to make dif-

ficult decisions regarding who will care for the aged per- son at home. Many complex issues come into play, such as the fami ly ' s beliefs and values, their avai labi l i ty , health, and financial status. Michael Meyer, president of the Michael Meyer Corporation of New York City, says that there are two different types of caregivers for older persons: some are younger and still employed, others are older and retired, l Caregivers often feel overwhelmed by their new responsibilities. They need basic information and guidance on where to go for services.

Hospitals can design services that provide the general information these caregivers need-- informat ion that is especially helpful in the initial phases of caregiving. Hos- pitals can also provide such services as home health and respite care.

There are many caregiver courses being developed and offered in the community, and there are caregiver support groups. Still, we believed there needed to be earlier edu- cational intervention, while the patient was still in the hospital, to prepare the family for the initial phase of caregiving. The Care by Caregiver p rogram was pat- terned af ter our Care by Parent program, which gives family members the opportunity to stay at the hospital and learn how to care for their child before discharge.

With the Care by Caregiver program we had two goals. First, we wanted caregivers to learn how to care for their loved one and, therefore, take them home with more con- fidence. Second, we wanted spouses, families, and other caregivers to know enough to recognize when the care

SUZANNE SHIVLEY, RN, is a nurse clinician and ANNE MARIE DJUPE, RN-C, MA, is director of Parish Nursing Services at Lutheran General tlealth Systems in Park Ridge, Illinois; PATRICIA LESTER, RN-C, BS, is director of management services, Revere Health Care. GERIArR NURS 1993;14:304-6. Copyright © 1993 by Mosby-Year Book, Inc. ISSN 0197-4572/93/$1.00 + .10 34]1]42766

might be too much for them and determine that other ar- rangements would be necessary. By trying out caregiving in the safe environment of the hospital with supportive people around, caregivers could make an appropriate de- cision.

Over the years we had recognized that it is not uncom- mon for a spouse or other loved one to make a pact to never place the partner in an institution. People who have made such promises are determined to take the patient home, regardless of their inability to care for the individ- ual and inadequate knowledge about the care required. Such was the case with Mr. K. and his wife.

Mr. K was an 89 year old, hospitalized because of a eere- brovascular accident. After the acute phase of his illness, dis- charge planning was begun. He was evaluated for transfer to our rehabilitation program but was denied because staff felt he would not tolerate the therapies or benefit from the program. Mrs. K, who was 87 years old, was determined to lake her hus- band home despite pressure from her children to place Mr. K in a nursing home. Mr. K was placed in our Care by Caregiver

304 GERIATRIC NURSING November/December 1993 Shivley, Djupe, and Lester

program, with Mrs. K as the primary caregiver. Instruction was begun that evening by the nurse. The nurse noted that Mrs. K was nervous and unable to perform return demonstrations of very simple procedures. Repeated attempts at instruction were unsuccessful. Mrs. K stayed through the night but was unwill- ing to participate any further in his care. In the morning, Mrs. K approached the day nurse and stated that she was unable to follow through with the program. Her decision was supported, and nursing home placement was implemented. Mrs. K was ori- ented to the nursing home and shown how she could assist in her husband's care.

Development

A natural place to develop this program was in our ge- riatric unit, which is part of a 713-bed hospital that serves a large number of elderly clients. The program was es- tablished on a 28-bed unit with two private rooms that have a full bath connected. No major renovation of the rooms was required. A hide-a-bed for the caregiver, a ta- ble for meals, lamps, and other items were purchased to simulate a home setting. These two private rooms could be easily converted back to two-bed patient rooms when not needed for the Care by Caregiver program.

It was vital that the team act early

so as not to increase the length of

stay.

The head nurse developed the proposal, set goals and a budget, and presented it to the hospital's administrators. The major identifiable costs of establishing the program were for equipment, converting a two-bed room to private for 48 hours, and the cost of the multidisciplinary team's time and the education of the nursing staff. A multidis- ciplinary task force was developed to work out the details of evaluation, admission, education, discharge planning, and follow-up. The task force consisted of the head nurse, a nurse clinician, a geriatric clinical specialist, a social worker, a chaplain, a physical therapist, and an occupa- tional therapist. Each member was responsible for the ed- ucational tools in the area of their expertise, as well as promoting the program within their department . The head nurse met with administrators and dealt with issues such as cost, staffing, and bed capacity. Fliers were made and dis tr ibuted to physicians and nursing units. The nurse clinician and the clinical specialist developed the assessment tool, the teaching materials for the patients, and the teaching program for the nursing staff. The nurse clinician and the head nurse also met with various groups of physicians to explain and promote the program. A fre- quently asked question by physicians was whether this program would increase hospital stay. The response was no. It was imperative that the physician and nursing staff recognize which patients were appropriate for the pro- gram early in the hospitalization so that the patient and family could participate in the program the last 48 hours before discharge. Considering DRG limits and the third-

party reimbursement systems, it was vital that the team act early so as not to increase the length of stay.

Patient Criteria

Criteria were developed for admission to the unit. The criteria were as follows:

• Patient requires total or near total care • Caregiver(s) must be willing to stay at the hospital

24 to 48 hours and assist with all physical care under the guidance of an RN

• Physician approval • Approval by the geriatric unit manager A patient would be seen or evaluated by each member

of the multidisciplinary team before being admitted into the program. Once the patient was accepted, the room could then be set up to simulate a home setting. Teaching the caregiver(s) then could begin immediately after the patient was settled in the room.

Educational Aspects

Physical therapy and occupational therapy groups par- ticipated by developing teaching materials for patients, as well as providing inservice programs for the nursing staff regarding transferring patients and the use of safety belts and other assistive devices. Social services developed a tool to assess the patient's home situation and the capa- bilities of the caregiver(s) before they entered the pro- gram. They discussed several discharge options with the family so that if placement was necessary, it could be quickly facilitated to prevent a longer hospital stay. They also identified community resources to assist caregivers in the home.

The nursing staff had to be educated about the pro- gram itself, the teaching materials, and principles of teaching older adults. Written teaching instructions in- cluded such things as skin care, feeding techniques, po- sitioning, and procedures related to activities of daily liv- ing. The written instructions helped the staff understand how to teach family members and, more important, pro- vided consistency in the teaching of the caregiver(s). The RN assigned to the caregiver room used the appropriate written instructions to teach the caregiver. The initial as- sessment tool used before patient admission to the pro- gram was used to determine what the caregiver needed to learn. A teaching checklist was developed for documen- tation of the instruction and return demonstration by the caregiver(s). The RN maintained this so there was con- tinuity from one shift to the next. Each shift determined areas in which a caregiver needed more intensive instruc- tion. Routine nursing care continued to be documented on the medical]surgical flow sheets. The head nurse had to consider staffing patterns. It was determined that the nurse would also need to care for other patients, as well as the one in the program, but that this nurse would have a lighter assignment. The main functions of the RN as- signed to the caregiver room are as teacher and observer. The RN was responsible for initiating and reinforcing the teaching the caregiver would need to care for a loved one at home. The caregiver(s) would then provide the 24- hour care necessary under the guidance of the RN.

Shivl~,, Djupe, and L~tcr GERIATRIC NURSING Volume 14, Number 6 305

Patients were admitted to the program between Sun- day and Thursday so they could receive optimal benefit f rom the entire team. An example shows how the pro- gram worked:

A 70 year old with metastatic cancer, Mrs. P was transferred to our unit for the Care by Caregiver program. Mr. P, also 70, and their daughter, Jean, 47, were the identified primary care- givers. After discussion with the social worker, it was deter- mined that Jean would be the primary participant in the pro- gram. Jean stayed with her mother for the 48 hours. During that time she learned such things as bathing, skin care, Foley catheter care, nephrostomy irrigation, body mechanics, and giving an intramuscular injection. She was also given informa- tion regarding community resources, options for respite care, and how to include her father in caregiving. The RN and Jean planned a daily schedule of treatments and medication for Mrs. P. She also received a folder of written materials pertaining to the procedures she was taught. By the end of the 48 hours, the members of the geriatric team felt Jean was pre- pared to care for her mother at home. The nursing staff also called Jean 24 hours after her mother was discharged from the hospital. Jean reported she was doing well in caring for her mother and was grateful for the teaching she had received. She felt the program was beneficial in preparing her to care for her mother. A visiting nurse was also arranged to follow up with Mrs. P.

E v a l u a t i o n

Such a program provides an opportunity for families to learn about the care their loved one will require at home.

It provides family members a time to appraise their abil- ities to provide the necessary care.

Some lessons we learned from our program: • Forty-eight hours was a limited time. Families may

have a high anxiety level that impedes learning. It is important to teach staff techniques to allay caregiver anxiety so that the value of whatever time is available is maximized.

• Some patients and families had built a rapport with a particular nurse from another unit. These nurses are bet ter equipped to implement the program on their unit. In such cases, rather than transfer the patient, the Care by Caregiver staff acted as consultants to them.

• Timing was of the essence. It may be difficult to coor- dinate with the physician, multidisciplinary team, pa- tient, and family for optimal benefit without prolonging the patient stay.

• It took ongoing reminding and advocacy to determine which patients were appropriate for the program. This part of a new program takes time and persistent effort. Our Care by Caregiver program provided a unique op-

portunity for caregivers to receive a realistic view of the care their loved one would require at home. More appro- priate discharge planning was then possible. This does not negate the need for communi ty -based caregiver pro- grams. Caregivers need much more assistance and sup- port once they leave the hospital so they can leave feeling more confident of themselves and their future decisions. •

REFERENCE

I. Droste T. Caregivers: generations of opportunities, tIospitals 1988;62:46.

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306 GERIATRIC NURSING November/December 1993 Shivley, Djupe, and Lcster