Settings for Care for Older People

Most older people receive medical care in their primary care doctor's office. 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. Some doctors' offices offer treatments, such as physical therapy.

Hospitals provide the most comprehensive medical care. For older people in particular, staying in a hospital increases the risk of problems such as infections, pressure sores, confusion, and incontinence. Because of these risks, older people should be hospitalized only if they are very ill. Older people may enter the hospital through the emergency department or 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 therapists

• Occupational therapists

• Social workers

• Medical technicians

• Nurses' aides

• 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.

Observation care is care within a hospital for people who are not well enough to go home but are not ill enough to meet the requirements for actual hospital admission. With observation care, practitioners can do tests and give treatments for a day or two before deciding whether people need to be admitted. Such people are observed briefly in an emergency department, a special observation unit, or a regular hospital room, even though they are not actually admitted to the hospital. The difference between admission and observation is important because Medicare considers observation care an outpatient service. Thus, Medicare does not cover rehabilitation services after observation care.

Surgical centers are places where same-day surgery or other procedures may be done. Such procedures include those 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 without hospitals have surgical centers. Then, people can have procedures in their own community without needing to travel to a more distant hospital.

After discharge from the hospital, people with a severe disability may need to continue their recovery in a rehabilitation facility. A rehabilitation facility may be located in a hospital or a nursing home or be a separate facility. These facilities provide skilled nursing care and physical, occupational, and speech therapies. Usually, people need to have been admitted to a hospital for 3 days to be eligible for Medicare to pay for the rehabilitation facility. A waiver of the 3-day hospital stay requirement is available in some cases, including with some Medicare Advantage plans.

When people are admitted to a rehabilitation facility, an interdisciplinary team tries to anticipate how long their stay will be. For older people, the stay may range from a few days 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 may be able to stay at home and get rehabilitation therapy as an outpatient at a rehabilitation facility.

People who are frail or who have recently been discharged from a hospital or rehabilitation facility often need care in their home. This care is often provided by family members and/or friends. But when such help is not available or when older people need more help than family members and friends can provide, older people may be eligible to receive home health care services from a home health care agency. These agencies send registered nurses, therapists, home health aides, and/or social workers depending on the person's needs and insurance coverage.

Currently, the number of practitioners who will visit people in their home is increasing. Care is provided by teams consisting of doctors, nurse practitioners, pharmacists, and social workers. A visit in the home can be very helpful because it is more convenient for older people, and it enables practitioners to see how people are doing in their usual living environment.

End-of-life (hospice) care may also be provided in the home.

In the United States, one source of support services and health care in the community is a senior center. These centers provide social, recreational, and educational activities, and some serve meals—an important service for people who cannot prepare their own.

Day care centers are another community-based service. Day care centers charge for services. However, they can provide a break for caregivers during the day so that caregivers can, for example, keep their job. Some day care centers also provide some health care. For example, these centers may have a nurse and/or nursing assistants on duty. The nurse can check blood pressure, make sure people are taking their medications as instructed, and provide health information. Nursing assistants can help make sure that older people's toileting needs are taken care of and that they are fed as needed during the day. When there are medical concerns, the nurse may contact the person's primary care practitioner or family members. Some day care 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 delivery 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.

People can obtain information about community services, including senior centers, 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 using the internet.

Post-acute care is care immediately after hospital discharge for people who need more care than they can get at home but do not clearly need long-term care. Post-acute care facilities provide a variety of health services including skilled nursing care and physical and occupational rehabilitation to help people regain their strength and function. Most people ultimately return to their home. However, some do not recover all of their function and may require long-term care.

The prospect of needing long-term care services concerns many older people. The likelihood of needing long-term care increases greatly as people age because older people are more likely to develop chronic disorders and to have problems functioning. How long care is needed varies from weeks to years to indefinitely.

Long-term care is focused on helping people maintain function. It helps them do the activities necessary to care for themselves and to live as independently as possible. These activities include basic daily activities (such as eating, dressing, bathing, grooming, and walking) and other activities (such as shopping, balancing a checkbook, doing laundry, and housecleaning). Long-term care includes help with health care such as taking vital signs, monitoring weight, and giving medicine. Most long-term care facilities also provide social and recreational activities.

Many people have their first experience with post-acute and long-term care after a hospital stay. During an illness or after an injury, many older people lose some or all of the ability to care for themselves. Thus, although they may be well enough to leave the hospital, they may need to go to a post-acute and long-term care facility for rehabilitation and recovery. This move can be physically and psychologically demanding. People have to adjust to many new faces and to new routines for sleeping, bathing, dressing, eating, and other daily activities. The move happens quickly, with little time to adjust.

Most people associate long-term care with a change in residence:

• To the home of a family member

• To a retirement community

• To an assisted-living community

• To a board-and-care facility

• To a life-care community

• To a nursing home

Older people may be particularly concerned about moving to an institution. People live in institutions for a variety of social and economic reasons. The most common reasons are physical problems and/or problems with mental function (cognition) plus lack of adequate social support.

What type of arrangement is possible depends partly on a person's needs (medical, functional, social, and emotional), preferences, and financial and social resources such as long-term care insurance, availability of state waiver programs, and family members’ willingness and ability to help. One person may be able to live at home with the help of a spouse. Another person with similar problems but without family support may need to go to a nursing home. Learning about the many types of long-term care facilities can help people choose the right time and place for long-term care. Each type of long-term care facility provides different services and levels of health care.

After the type of arrangement is determined, a particular facility must be carefully chosen. Even within each type, facilities differ considerably in environment, services (including health care), activities, living arrangements, and rules. Sometimes the difference is simply a matter of what people can afford, but even within a price range, quality varies.

When people have a progressive, incurable disorder and death is expected in the near future, hospice care provides the treatments and services needed to control symptoms, ease pain, and help people and their family members prepare for the death. Hospice care may be provided in a

• Person's home

• Nursing home

• Hospice facility

The hospice care team usually involves a primary care practitioner, nurse, social worker, and others who are trained to care for dying people. Pharmacists, counselors, physical therapists, ethicists, and trained volunteers may also be involved.

Hospice personnel are needed to make sure that all of the person's physical and psychologic needs are met as well as the needs of the family and caregivers. 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 recognize the physical signs that death is near, understand what to do when the person dies, and help them cope with the loss.