Retirement and Continue Nursing Care
A Continuing Care Retirement Communities,Types Continuing Care Retirement,Historical Perspectives,Marital Status As A Factor.
A Continuing Care Retirement Communities
A continuing care retirement
community (CCRC) is a type of facility that provides housing, meals, and other
services, including nursing home care, for older adults in exchange for a
one-time capital investment or entrance fee, and a monthly service fee.
Most
CCRCs are sponsored by religious or other nonprofit organizations, but
for profit organizations have entered into the retirement business as well.
The
CCRC is usually con- structed as a village or community, and the individual
remains within this community for the remainder of his or her life. All CCRCs
have a written contract that residents must sign.
Types Continuing Care Retirement
The terms of the contract
vary, and have been separated into three categories by the American Association
of Homes for the Aged:
(1) Type A homes are “all inclusive” as they
offer guaranteed nursing care in the nursing facility at no increase in the
residents’ monthly fee
(2) Type B CCRCs do not guarantee unlimited nursing
home care but have a contractual agreement to provide a specific number of days
per year or lifetime of the resident in the nursing facility
(3) Type C
CCRCs are based on a typical fee-for-service approach. Financial stability,
particularly of Type A and Type B CCRCs, depends on high occupancy rates in the
independent living apartments and maintaining the residents’ optimal health and
function so as to need fewer health care services.
Historical Perspectives
The number of CCRCs has increased
dramatically (50%) during the 1980s and has continued to grow. CCRCs are
located throughout the United States although five states (Pennsylvania,
California, Florida, Illinois, and Ohio) are home to more than one-third of
the nations’ CCRCs.
Despite the growth of CCRCs, proportionally they account
for a smaller percentage of senior housing than previously. This is due to the
dramatic increase in assisted living facilities.
Marital Status As A Factor
Generally older adults who live in
CCRCS are those who were never married, or married without children, are well
educated, and health conscious (Krauskopf, Brown, To- karz, & Bogutz, 1993;
Petit, 1994, Resnick, 1989, 1998a).
Initially CCRCs were for affluent older
adults; however, CCRCs are becoming more affordable and attracting those with
more moderate incomes (Kitchen & Rouche, 1990).
The decision to move into a
CCRC requires a good deal of planning and adjustment for older adults,
especially if they are relocating to another city or state, and/or moving from
a large home to a smaller apartment.
The initial research in CCRCs
focused on the adjustment to the community and the impact this had on the
older adult. Resnick (1989), using a qualitative approach, described the
challenges of adjustment to a CCRC and identified groups of individuals who
were particularly at risk for relocation stress:
(a) those who had experienced
a recent loss
(b) those with a decline in mental status
(c) the young-old
(60 to 70 years) age group
Anticipating problems and letting residents know
that they might have certain feelings helped residents in the adjustment
process.
The study also identified the need for frequent follow-up in the first
6 months to a year following the move-in as many residents did not begin to
grieve over their losses until they fully completed the work of the move. Petit
(1994) implemented the findings of this work as she developed the role of the
wellness nurse in a CCRC.
The majority of the nursing research
done in CCRCS has been on the health practices and health promotion of these
individuals (Adams, 1996; Crowley, 1996; Resnick, 1998a; Resnick, Palmer,
Jenkins, &c Spell- bring, 2000; Resnick, 2003).
Generally, these are
descriptive surveys in which residents are asked about specific health
behaviors such as getting vaccinations, monitoring cholesterol land dietary fat
intake, exercise activity, alcohol and nicotine use, and participation in
health screenings including mammograms, Pap tests, stools for occult blood, or
prostate examinations.
The majority of residents in the CCRCs studied did get
yearly flu vaccines and a pneumonia vaccine, and approximately 61% had an
up-to-date tetanus booster. A smaller percentage (approximately 30%) monitored
their diets.
About 50% of those living in CCRCs drink alcohol regularly, only a
small percent use nicotine (11%), and under 50% exercise regularly.
Approximately 40% to 50% of the residents get yearly mamograms, 31% to 37%
get Pap tests, 65% to 80% get prostate examinations, approximately 60% have
stools checked for blood yearly, and a little over 50% monitor their skin for
abnormal growths regularly.
Overall, there is better participation in health
promoting activities of older adults living in CCRCS when compared to older
adults in the community (Blustein & Weiss, 1998; Smith et al., 1999).
The
findings, however, suggest that even in this population continued education is
needed to encourage personal decision making related to health promotion activities.
The findings can also be used to develop interventions to improve specific
health behaviors.
In a series of analyses examining
the relationships between health behaviors among residents of CCRCs, age was
the only variable that was significantly related to health behaviors and
accounted for 7% of the variance.
increased age the residents participated
in fewer health-promoting or preventive behaviors. Age, gender, physical and
mental health, self-efficacy expectations, outcome expectations, and stage of
change related to exercise directly and/or indirectly influenced exercise
behavior in the residents (Resnick, 1998a; Resnick et al., 2000; Resnick &
Nigg. 2003).
The influence of these variables on exercise behavior was
supported in a qualitative study (Resnick & Spellbring, 2000) which focused
on what helped older adults in a CCRC adhere to a regular walking program and
what decreased their willingness to adhere.
Crowley (1996) also considered
the health behaviors of older adults in a CCRC and the outcomes of a wellness
program which encouraged regular exercise. A total of 21% of the 225 residents
exercised, and case reports identified positive outcomes such as weight loss
and improved recovery following a fracture.
Resnick (1999) explored the
incidences and predictors of falls in a CCRC and found that the number of falls
was the only variable associated with having an injurious fall. Resnick (1998b,
1999) also used a combined qualitative and quantitative approach to explore
what increased or decreased residents’ willingness to participate in and
actual performance of activities of daily of living, such as bathing, dressing,
and ambulating.
Personality (i.e., determination), beliefs in their ability,
the unpleasant sensations associated with the activity, goals, and fears, such
as the fear of falling, were identified as common themes that influenced
performance of functional activities.
Based on quantitative findings,
motivation (self-efficacy expectations, outcome expectations, and the
personality component of motivation) as well as physical condition (standing
balance and lower extremity contractures) were the most important predictors of
functional performance in these individuals.
Although not extensively
studied, Russell (1996) considered the care-seeking behavior of older adults
living in a CCRC. This was a qualitative study using ethnographic field
research that incorporated semi-structured interviews, participant observation,
and focus group interviews.
The care seeking process was described as
sequential phases and stages that evolved over time. Resnick (2003) tested the
impact of an individualized approach to health promotion in these sites, and
Resnick and Andrews (2002) tested an educational intervention to help older
adults make end-of-life treatment preferences.
Some work has also been done to
test exercise interventions in these settings (Resnick, Wagner & House,
2003; Vaitkevicius et al., 2002).
CCRCs continue to be a viable living
environment for older adults. In order for these facilities to keep costs down
and remain lucrative it is imperative that there be a focus on maintaining
health and function.
Continued research needs to build on the preliminary
findings from exploratory studies and begin to develop and test interventions
that will help older adults in CCRCs maintain their health and function. For
example, many CCRCs have “wellness programs” which are nursing driven.
The outcomes of these programs need to be considered both from a health
perspective as well as a fiscal perspective.
Other important areas of research
within CCRCs that nursing should consider include care processes around
relocation to different levels of care, end-of-life issues, injury prevention,
health care utilization patterns and the impact this has on nursing care
services.