Download The Case for Going Home

Specialization in Health Management for Older Persons
2013-2014
CASE STUDY #2
The Case for Going Home: Changing Living Environments for Older Adults
Welcome students. The challenge continues and we once again present you with a case study in
which your group must provide a vision and innovative solutions based on international
experiences and evidence-based approaches. In developing solutions, we invite you to use
evidence and build synergies and linkages between all of you health professionals,
administrators, researchers and clinicians.
You have two hours to review the case, discuss the case with your group members and develop
a presentation. Each group will have 10 minutes to present, followed by 10 minutes of
discussion. Following group presentations and an overall discussion session, participants will
receive a lecture on Adapting Living Environments for Older Adults by Dr. Alan DeLaTorre.
Again, we ask that you share your responses, learning from evidence-based examples and
international best practice without forgetting that the challenge of health managers of
emerging countries in the Caribbean is to adapt and not directly adopt actions or solutions that
have been developed in other countries. We invite you to find a solution to the proposed
problem as a health manager: planning, implementing, evaluating and frequently adjusting
resources available to solve the problems of the elderly in health care.
Specialization in Health Management for Older Persons
2013-2014
“The Case for Returning Home”
Mr. W., age 69, had a severe left hemisphere stroke with resulting Broca aphasia 3 months ago.
He has nearly completed 3 months of intensive inpatient rehabilitation at a geriatric care facility
and is ambulatory with the use of a quad cane for balance. He still favors his left side and has
some difficulty with fine motor function in his right hand. He is able to complete most of his
daily activities effectively at the rehabilitation facility, which is a well-designed, supportive
environment, with highly trained health professionals.
He is a highly motivated, outgoing, cognitively intact individual with many friends in the
community. His spouse is still in reasonable health, but she has had heart bypass surgery, is
being treated for high blood pressure and arthritis, and cannot be depended on to assist with
any weight-bearing tasks. The couple lives in a 1960s split-level home in a rural community
where Mr. W. operated a successful small business. He has three married daughters – two living
in others towns and one living next door with her husband and two daughters. Mr. W. wants to
go home. But home is not equipped to support his needs like the rehabilitation center.
_____________________________________________________________________________________
This health crisis in Mr. W.’s life represents a host of challenges that could potentially lead to
quite different outcomes. Initially, after the stroke, his family physician indicated that
placement in a nursing home was likely, since most people with such extensive damage have
not regained the ability to walk, talk, or feed themselves. The speech therapist agreed with the
family physician and indicated that the aphasia was so severe that only limited language use
could be expected. Fortunately, the attending physician at the hospital had been through a
geriatric rehabilitation rotation in medical school and had seen a physiatrist-led (i.e., physician
specializing in physical medicine, rehabilitation and resorting optimal function) team of allied
health professionals in an adapted environment “work miracles” with highly impaired but
motivated individuals – so she wrote the orders for rehabilitation. That Mr. W. made such a
significant recovery in rehab – regaining the ability to walk, perform daily routines, and
communicate (even though hesitantly), with the hope of returning to his home and community
– indicates that there is still much to learn about maintaining independence and health in the
face of apparently clear medical conditions but with differing medical opinions about potential
functional improvements. While the family physician saw Mr. W. as a disabled person with
nursing care needs whose wife could not be expected to take care of him, the attending
physician sought to return Mr. W.’s capacity to the highest level possible.
This case sets the stage for a perspective that sees the crucial role of not only the health care
providers but also for the community and family, in understanding the complex components
affecting health, aging, and independent living. Research on people with functional limitations
who remain in home and community settings have shown the importance of considering the
whole person – physical, social and personal aspects – in the context of his or her physical
environment.
Specialization in Health Management for Older Persons
2013-2014
As a Health Manager:

Review the research on maintaining functioning in older adults and improving or
stabilizing functioning in older impaired adults in terms of both the risks and the
resources of the living environment. Use the case of Mr. W. to illustrate the complexity
of managing “aging in place”.

Use the information gathered in the Personal Living Profile (Appendix A) to recommend
changes that would contribute to improved functioning and provide a safe and
supportive environment. Include sources demonstrating that all recommendations are
evidence-based.
REVIEW OF RELEVANT LITERATURE
In responding to the points above, you may find helpful and relevant literature to support your
case under the following topics:
 The effects of environment on living independently in later life
 Functional abilities of the person
 Hazards in the home environment
 Care network
 Self-care behaviors of the patient
 Personal aspects of home and the community
Specialization in Health Management for Older Persons
2013-2014
APPENDIX A: PERSONAL LIVING PROFILE
Mr. and Mrs. W. completed the Personal Living Profile, which was developed to incorporate
personal traits and meaning, history of modifications, and environmental affordance
opportunities in a very brief profile that can be used with ADL/IADL evaluations to identify the
most critical and potentially successful areas for modification in the living environment. The
Personal Environmental Summary (PES) was completed as an additional tool for the health care
provider to use after reviewing the PLP that was completed by Mr. and Mrs. W. This summary
gives the health care provider a framework for making notes on each of the major dimensions
of the person’s life.
Once Mr. and Mrs. W. completed the Personal Living Profile, important behavioral patterns,
attitudinal assets or barriers, and specific aspects of the living environment needing attention
could more easily be identified. The data from this profile showed that some safety measures
were already present, but no specific accessibility-oriented home modifications had been
made. There was a high willingness to do whatever it took to return Mr. W. to his home. A
physical therapist from rehabilitation center was assigned to do an on-site home assessment
with Mrs. W. and the adult daughter.
This assessment of Mr. W.’s home environment was an important step, preferably before his
release from the rehabilitation facility. For example, adding an extra railing along the staircase
was would allow Mr. W. to climb the stairs independently when he arrived home. Next, it was
important for the therapist to observe Mr. W. functioning in his own environment, in order to
accurately determine his use of environmental modifications and identify additional
modifications that would improve his functioning. Modifications can be made in ways that
retain a home-like character, which is important to Mr. W. and to others who also use areas in
the home.
_______________
In each of the PLP sections below, Mr. W.’s daily behavior patterns are considered in light of his
recent functional changes and challenges:
Sleeping: Mr. W. no longer has as much muscle and fat tissue as when he was younger and
sleeping on his firm mattress is no longer as comfortable as it once was. At the same time, he
needs a firm under layer to support his back, in part because his back muscles are no longer as
strong as they were. Mrs. W. also notes that Mr. W. wakes several times during the night to go
to the toilet, and it is harder for him to get out of bed safely
Bathing, Grooming, Dressing: Mr. W. is still able to bathe and dress himself, but he would
prefer to be able to sit in the shower and also for some aspects of dressing himself. He stands
upright for other grooming activities such as shaving and brushing hair and teeth. He leans
against the cabinet, though, because of some weakness in his right leg.
Specialization in Health Management for Older Persons
2013-2014
Cooking and Eating: Mr. W. has always been involved in some aspects of food preparation,
including preparing the holiday turkey, cooking fish and seafood, and grilling meats.
Accomplishing such tasks contributes greatly to his self-esteem. Mr. W. does have difficulty
cutting meat with a knife and fork using both hands. Also, it is oftentimes hard to walk safely
from the house to patio to use the BBQ grill while holding a plate of meat. The sliding door is
harder to open and his feet get caught in the rug in the living room.
Medications: Managing medications for compliance is very important to an older adult’s health.
Mr. W. takes three medications – Betoptic (betoxolol) for glaucoma, Flomax (tamsulosin) for
urinary urgency at night, and Lopurin (allopurinol) for gout – as well as a multivitamin. Now that
he has so many different medications, he has a hard time remembering when to take each pill.
Leisure Activities and Hobbies: Mr. W. Was an avid golfer. His stroke affected his ability to drive
long shots, but his putting has remained quite good. Golf was an important physical and social
activity with friends. With the partial aphasia, Mr. W. often hesitates in finding the right word,
and then gets frustrated. He is acutely aware of becoming a burden to his friends, and because
he was never the most patient golfer when the group ahead was slow, he now refuses to play
the game. This represents a loss in his social world, as many of his friends are unsure how to
communicate with him. He will, however, putt balls in the yard with his granddaughters, which
gives him satisfaction. Mr. W. would like to continue participating in social activities, but is
unsure how to with his limitations.
Activities Away from Home: During the first year following his stroke Mr. W. was dependent
upon his spouse, daughter, and friends for transportation. Because of their rural location, there
were no services such as a store, library or post office he would walk to.
External Environment: The external environment is an important setting for physical activity by
many older adults, who may associate the outdoors with exercise. There is great variation in
the type and extent of outdoor space available; it may include the area around the home, the
nearby walkable neighborhood, and workout stations or other amenities in the community. The
quality, extent, and location of these environmental features have been found to substantially
influence levels of outdoor activity. To fully support outdoor activities and avoid falls, these
areas should ideally be reached by smooth and level walking surfaces, and should provide
comfortable, safe seating at frequent intervals. However, Mr. W. lives on a farm. There are no
sidewalks, and the walking trails are just the ones made by the cattle, very unsuitable for an
older person with many mobility problems to navigate safely. Also, the home patio area is one
step down from a large carport, used in the summer as a living area with a carpet and furniture.
This step was not clearly visible and did not have a handrail.