Home alone ...

Some se­niors just want to be left alone, which can lead to prob­lems.

The Star Malaysia - Star2 - - Health - By JU­DITH GRA­HAM

THE 84-year-old man who had suf­fered a mini-stroke was in­sis­tent as he spoke to a so­cial worker about be­ing dis­charged from the hos­pi­tal: He didn’t want any­one com­ing into his home, and he didn’t think he needed any help.

So the so­cial worker can­celled an or­der for home health­care ser­vices. And the pa­tient went back to his apart­ment with­out plans for fol­low-up care in place.

When his daugh­ter, Lisa Win­s­tel, found out what had hap­pened, she was fu­ri­ous. She’d spent a lot of time try­ing to con­vince her father that a few weeks of help at home was a good idea.

And she’d asked the so­cial worker to be in touch if there were any prob­lems.

Sim­i­lar sce­nar­ios oc­cur sur­pris­ingly of­ten: As many as 28% of pa­tients of­fered home health­care when they’re be­ing dis­charged from a hos­pi­tal – mostly older adults – say “no” to those ser­vices, ac­cord­ing to a new re­port.

Un­der­stand­ing why this hap­pens and what can be done about it is im­por­tant – part of get­ting smarter about get­ting older.

Re­fus­ing home health­care af­ter a hos­pi­tal­iza­tion puts pa­tients at risk of a dif­fi­cult, in­com­plete or slower-than-an­tic­i­pated re­cov­ery. With­out th­ese ser­vices, older adults’ odds of be­ing read­mit­ted to the hos­pi­tal within 30 or 60 days dou­ble, ac­cord­ing to one study.

Why, then, do se­niors, re­sist get­ting this as­sis­tance?

“There are a lot of mis­per­cep­tions about what home health­care is,” said Carol Levine, di­rec­tor of the US United Hos­pi­tal Fund’s Fam­i­lies and Health Care Pro­ject, a spon­sor of the new re­port.

In the United States, un­der Medi­care, home health­care ser­vices are avail­able to older adults who are home-bound and need intermittent skilled care from a nurse, a phys­i­cal ther­a­pist or a speech ther­a­pist, among other med­i­cal providers.

Typ­i­cally, th­ese ser­vices last four to six weeks af­ter a hos­pi­tal­iza­tion, with a nurse vis­it­ing sev­eral times a week. Some pa­tients re­ceive them for much longer.

Many se­niors and care­givers con­fuse home health­care with “home care” de­liv­ered by aides who help peo­ple shower or get dressed or who cook, clean and serve as a com­pan­ion.

The two types of ser­vices are not the same: Home health­care is de­liv­ered by med­i­cal pro­fes­sion­als; home care is not.

This was the mis­take Win­s­tel’s father made. He thought he was be­ing of­fered an aide who would come to his apart­ment ev­ery day for sev­eral hours. “I don’t want a babysit­ter,” he com­plained to Win­s­tel, chief op­er­at­ing of­fi­cer of the Care­giver Ac­tion Net­work.

Like many other se­niors, this older man was proud of liv­ing on his own and didn’t want to be­come de­pen­dent on any­one.

“Older adults are quite con­cerned about their in­de­pen­dence, and they worry that this might be the first step in some­one try­ing to take that away,” said Dr Les­lie Kernisan, a San Francisco geri­a­tri­cian and creator of the web­site Bet­ter Health While Ag­ing.

Other rea­sons for re­fusals: Se­niors see their homes as sanc­tums, and they don’t want strangers in­vad­ing their pri­vacy. They think they’ve been get­ting along just fine and have unrealistic ex­pec­ta­tions of what re­cov­er­ing from a hos­pi­tal­iza­tion will en­tail.

Or there are cir­cum­stances at home – per­haps hoard­ing, per­haps phys­i­cal ne­glect – that an older adult doesn’t want some­one to see.

Or the pa­tient’s cog­ni­tion is com­pro­mised and he doesn’t un­der­stand his needs or lim­i­ta­tions. Or cost is a con­cern.

Robert Rosati, vice pres­i­dent of re­search and qual­ity at Vis­it­ing Nurse As­so­ci­a­tion Health Group, New Jer­sey’s largest pri­vate home health­care provider, said about 6% of se­niors who have agreed to re­ceive home health­care from his or­gan­i­sa­tion af­ter a hos­pi­tal­iza­tion end up re­fus­ing ser­vices.

Of­ten, a break­down in com­mu­ni­ca­tion is re­spon­si­ble. Pa­tients haven’t been told, in clear and con­crete terms, which ser­vices would be pro­vided, by whom, for how long, how much it would cost and what the ex­pected ben­e­fit would be.

So, they don’t un­der­stand what they’re get­ting into, prompt­ing re­sis­tance, Rosati said.

Kathy Bowles, di­rec­tor of the Cen­ter for Home Care Pol­icy & Re­search at the Vis­it­ing Nurse Ser­vice of New York, sug­gests a plain-lan­guage, pos­i­tive way to con­vey this in­for­ma­tion. For ex­am­ple: “A nurse will check your med­i­ca­tions and make sure they’re all in or­der. She’ll as­sess if you need phys­i­cal ther­apy to help you re­gain your strength. And she’ll teach you and fam­ily mem­bers how to care for you once home care is over.”

“A lot of re­sis­tance arises from pride,” said Bowles, also a pro­fes­sor of nurs­ing ex­cel­lence at the Univer­sity of Penn­syl­va­nia. “The con­ver­sa­tion has to change from ‘Look, we think you re­ally need help’, to ‘We want to help you take care of your­self’,”

Em­pha­siz­ing that a physi­cian has rec­om­mended home health­care can also be help­ful. “In my ex­pe­ri­ence, if a doc­tor says ‘I’d like a nurse to come see you and check that you’re feel­ing bet­ter’, peo­ple are fairly re­spon­sive,” Kernisan said.

In­stead of ar­gu­ing with an older adult who says “I don’t want any as­sis­tance”, try to fol­low up by ask­ing, “Tell me more. What are you con­cerned about?” Kernisan sug­gested. “Peo­ple re­ally want to feel lis­tened to and val­i­dated, not lec­tured to.”

This isn’t to sug­gest that per­suad­ing an older adult to ac­cept un­wanted help is easy. It’s not.

Last year, Win­s­tel’s father had a med­i­cal de­vice im­planted in his spine to re­lieve pain from spinal steno­sis – an out­pa­tient pro­ce­dure. Once again, he de­clined post­op­er­a­tive help.

Two days later, Win­s­tel got a phone call from her dad, who had col­lapsed and couldn’t get up from the floor.

Win­s­tel said she’d call 911. “No, I don’t want some­one com­ing in and find­ing me like this,” her father in­sisted. “You have to come.”

Later, at the hos­pi­tal, doc­tors di­ag­nosed an ad­verse re­ac­tion to med­i­ca­tion and a sur­gi­cal site in­fec­tion on her father’s back.

“He lives alone. He can’t reach back there. He wasn’t car­ing for the wound prop­erly,” Win­s­tel ex­plained.

Ex­ten­sive, heated con­ver­sa­tions fol­lowed, dur­ing which her father in­sisted he was never go­ing to change. “For him, liv­ing in­de­pen­dently car­ries risks, and he’s will­ing to ac­cept those risks,” Win­s­tel said.

She hopes the new re­port on se­niors re­fus­ing home health­care will jump-start a con­ver­sa­tion about how to bring care­givers into the process and how rec­om­men­da­tions should be con­veyed.

“As the daugh­ter of some­one who has re­fused care, un­der­stand­ing that this is some­thing lots of peo­ple go through makes me feel a lit­tle less crazy,” Win­s­tel said. – Kaiser Health News/Tribune News Ser­vice

As many as 28% of pa­tients of­fered home health­care when they’re be­ing dis­charged from a hos­pi­tal – mostly older adults – say ‘no’ to those ser­vices, ac­cord­ing to a new re­port.

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