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Summary:Factors associated with the ageing of Hong

Kong’s population has led to increasing need for longterm care. Nursing homes operated for profit providethe majority of long term care places. Residents inthese homes are characterised by chronic diseases,multiple disabilities and a high incidence of cognitiveimpairment. Therapeutic care is needed to maintainthe functional status of these frail elderly residents.There are service gaps in the existing system ofcommunity health care services. Delivery of healthcare requires a highly co-ordinated effort with a closepartnership between the hospital and nursing homebecause residents are frequently transferredbetween these two places. Strategies to improve thestandard of health care in these nursing homesinclude an active educational program for nursinghome staff, the role of community nurses to provideregular assessment and treatment, an integratedmedical record to improve documentation betweenthe home and hospi tal and emphasis onrehabilitation.

Rising demand for nursing home care in HongKong

Hong Kong has a rapidly ageing population. Atthe same time there is an epidemiological transitionwhere chronic diseases are the leading causes ofdisability and death now. Such diseases are morecommon in the elderly and the likelihood of needinghelp with activities of daily living becomes greaterwith aging. About 40% of the elderly in Hong Konghave difficulties in activities of daily living1.

These factors result in the elderly segment ofthe population consuming a disproportionateamount of health and long term care services. Datain the West show that admission rates to nursinghomes rise exponentially after the age of sixty-five.The age-specific admission rate to nursing homesincreases fourteen-fold between the ages of sixty-five and ninety 2. In the United States, 43% of personsafter the age of sixty-five will use a nursing homebefore they die while more than 20% of nursing homeresidents will spend at least five years there3.

Although Hong Kong has a predominantlyChinese population and a culture that values careof the elderly by their own family, there has been amarked change in the traditional family structureover the past two decades. There is an increasingtendency towards nuclear families which weakensfamily support for the elderly. Elderly people alsotend to have poor social support. About 10% ofelderly people live alone and 12% with their spouseonly. Therefore about 22% of elderly people live ina potentia lly weak support ing network4.Furthermore 60% of elderly people in Hong Kongreport that they do not have a close family memberor friend 5. These are well documented risk factorsfor institutionalization 6,7.

Hong Kong is also experiencing anotherdemographic transition that is described as thefeminisation of ageing 8. There are more elderlywomen than men but they are more vulnerable toisolation than men. They tend to live alone andreceive less help from relatives compared to theirmale counterparts 9. There are twice as many elderlywomen compared to men in institutional care inHong Kong10. With these social, epidemiological anddemographic trends coming together, Hong Kongcan be expected to follow the situation in the Westwhere demand for long term care is growing.

There has already been a rapid increase in thesupply of nursing home beds in Hong Kong overthe past decade. The current capacity of nursinghomes exceeds the bed capacity of the HospitalAuthority. In 1997, the number of governmentsubsidized C & A and Home for the Aged placeswas 17,487 while private nursing homes had17,700 places11. The important role of the privatenursing home industry in long term care is alsoseen in the West. In the United Kingdom, the privatesector accounts for more than two thirds ofresidential homes while 92% of nursing homes inthe United States are privately owned12.

There were 19,200 persons waiting for care-and-attention home admission and 7,600 personswaiting for infirmary placement in 1998. Such along queue for placement means that for most

GERIATRIC CARE FOR RESIDENTS OF PRIVATENURSING HOMESTC Sim M.B., B.S. (Singapore), FHKAM (Med)Senior Medical OfficerEMF Leung M.B., B.S. (H.K.), FRCP (Edin), FHKAM (Med)Chief of Service, Department of Medicine and Geriatrics,United Christian Hospital, Kwun Tong, Hong Kong

J HK Geriatr Soc 2000;10:84-89Correspondence to: Dr T C Sim

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elderly people, the need for long term care need tobe met by other means like private nursing homes.These waiting-list statistics also reflect a genuineneed for long term care that must be met. This wasshown in a study of elderly people who needed longterm care in Hong Kong. 59.3% of those waiting forinfirmary placement were already residing in privatenursing homes13. With our present economicclimate, the government is unlikely to have asustained increase in funding for long term care.There is good reason to believe that private nursinghomes will continue to be the mainstay of long termcare in future.

Standards of care in private nursing home inHong Kong

There are 430 nursing homes run for profit inHong Kong 8. In a newspaper interview, the residentof a Shamshuipo home said, “This man behind mespeaks only Toishanese. The other man there whohas cancer is in hospital at the moment. I havenever spoken to the two women hooked on feedingtubes and the others are just too frail to talk andlie in their beds.”

He was among 12 residents living in a 700square foot flat with two toilets, without a fire escapeand the kitchen was built in an illegal structure.There were only two female amahs, one for the dayand the other for the night14. While there can bewide variations in disability levels and standardsof care between different nursing homes, theinterview is a fair description of the typical privatenursing home in Hong Kong.

Private nursing homes in Hong Kong have his-torically poor standards of care15. Recent changesin legislation can help to improve standards infuture16. At present, however, the “revolving door”patient from the nursing home is a familiar sight.Common examples include severely disabled elderlypatients who are admitted for conditions such asdehydration, undernutrition, pneumonia orpressure sores; improved after a lengthy period ofhospital stay and discharged back to the nursinghome only to be rapidly re-admitted for the sameproblems. An audit in United Christian Hospitalshowed that 26.8% of unplanned readmissions tothe Department of Medicine and Geriatrics werefrom private nursing homes. There is an obviouslack of continuity between treatment in the hospitaland care in the nursing home. Nursing homeresidents have specific characteristics that partlyexplain why this service gap exists although HospitalAuthority already has a sophisticated structure toensure continuity of care in the community.

Characteristics of residents in private nursinghomes in Kwun Tong

1,002 residents of private nursing homes inKwun Tong was surveyed in 1998. The average ageof residents was eighty years and 68% were women.35% had contractures of the legs, 38% were bed orchair-bound and 39% had either urinary or doubleincontinence. Assessment with the Katz Index ofADL17 showed 93% had one or more impairmentsin the activities of daily living. 30.7% in a subgroupof 268 patients audited for polypharmacy wereprescribed at least five drugs. There was also a highincidence of cognitive impairment. A similar surveyof 317 residents in 1999 found that 67% hadAbbreviated Mental Test (Hong Kong version)18

scores less than six. By comparison, the prevalenceof dementia in Hong Kong’s elderly population agedseventy years or older in the community is 6.1%19.This is consistent with experience in othercountries, where cognitive impairment in long termcare facilities is much higher than the communityand ranges from 30% to 70% 20,21. (Table 1)

Table 1. Characteristics of residents in private nursing homesin Kwun Tong

Mean age (years) 80 ± SD (8.6)Male/Female (%) M 32% / F 68%Lower limb contractures (%) 350 (34.9%)Bed or chair-bound 385 (38.4%)Urinary or double incontinence 396 (39.5%)Functional dependency in at least one ADL (%) 93%Polypharmacy 30.7%AMT score < 6 67%

The survey showed that private nursing homeresidents have a high prevalence of medical diseasesand disabilities. A significant proportion of privatenursing home residents are not ambulant. Mosthave impaired cognition. There is also the addedburden of advanced age, polypharmacy, complexinteraction of acute and chronic diseases.Neuropsychiatric conditions that cause problembehaviors are common. Therefore providing care tothe nursing home resident is a challenging task.The complexity at this level requires a highlycoordinated effort.

Service gaps and unmet needsAt present, the residents of private nursing

homes actually use an impressive array of formalhealth care services. Apart from the nursing homestaff and private medical practitioner, otherservice providers include the acute hospital forinpatient care and outpatient clinics, day hospital,

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community nursing service, community reha-bilitation team, community geriatric assessmentteam and Department of Health elderly healthteams and general outpatient clinics. There are,however, gaps among this existing range of serviceproviders because we do not have a coherentapproach towards care of this group of elderlypatients with chronic disabling conditions. Theymay be confused and unable to give an accuratehistory. They are often unable to participateeffectively in making decisions for their own medicalcare, especially when acute illness intervenes.Therefore a piecemeal approach where the nursinghome resident is referred between various services,with none having overall responsibility, results inlack of continuity of care. Some suffer unnecessarymorbidity when they cannot gain access to theservices that they require.

The nursing home resident has basic needs likefood, shelter, assistance with activities of daily livingand nursing care. Another need often overlookedis transportation. Many of these disabled elderlyresidents need assistance to attend medicalappointments. Transport services like Rehabusand Hospital Authority NEATS can only partly fillthis need. These residents often need anaccompanying person to help with the logistics ofthe outpatient clinic and to fill prescriptions at thepharmacy. They are also needed to provide keyinformation when the resident has impairedcognition. Nursing home residents often have todepend on the home’s staff for this functionbecause they lack adequate social networks. Whenthe nursing home staff cannot fulfill this function,compliance with medical treatment can bedisrupted and the health of the resident iscompromised. It is not uncommon for disabledresidents to default medical follow-up for thisreason. This makes the capability to provide on-site medical care in nursing homes important.

Private nursing homes do not providecomprehensive medical care. However they arereceiving people with severe illnesses from ourhospitals. Therefore there is an urgent need toimprove the standard of nursing homes if patientsare to be discharged safely after a short length ofstay in hospital and maintained in a reasonablestate of health in the homes. Without effective post-acute care, the nursing home resident is at highrisk for either extended lengths of stay in hospitalor for transfer back and forth between the nursinghome and acute hospital.

Apart from the problems of the residents, weshould also look at the problems of the private

nursing homes themselves. It has been famouslysaid “a nursing home is a facility that has few or nonurses and can hardly qualify as a home”22. Thereis a shortage of trained staff. The environment lacksprivacy and has inadequate facilities for social andrecreational activities. Individual treatment plansare often lacking. Rehabilitation is rare althoughmany residents need some form of maintenancetherapy. One major reason for the poorer standardsof private nursing homes compared to government-funded ones is their lower cost. Profitability is anatural consideration in any profit making businessand private nursing homes provide less becausethey usually charge less.

The need for health care in nursing homesThere are many factors that contribute to the

present state of private nursing homes. Thisresults in the elderly resident having many needsthat are not addressed in the nursing homeenvironment. Despite the constraints describedabove, public expectations for the care of ournursing home residents are high. There is ahypothesized link between unmet need forassistance and increased use of acute hospitalservices (see Figure 1)23. We need to improve thestandard of care in private nursing homes or theresidents will use the hospital emergencydepartment by default. Leaving aside the nursinghome cost versus quality conundrum, we can stillimprove the standard of care with effective geriatricoutreach services to these homes.

Fundamental to improving the standard of carein private nursing homes is a clear concept of thegoals of nursing home care. Nursing home careshould fulfill the goals as listed in Table 224. Mostof these goals are similar to our care for the elderlyin geriatric medicine and focus on functionalindependence, quality of life, comfort and dignity ofthe residents. Medical staff who cares for nursing

Elevated levels ofacute care use

Figure 1. Hypothesized Causal Chain 23

Unmet need

Adverse events

Negative health

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home residents must keep these goals in perspectivewhile addressing the usual aims of medical treatmentsuch as prevention and cure of acute illnesses.

Table 2. Goals of nursing home care24

1. Safe and supportive environment for the chronically ill.2. Provide rehabilitation to ensure best functional and cognitive

status.3. Professional nursing care to delay progression of chronic

medical illness.4. Prevent acute and iatrogenic medical disease.5. Dignity and comfort for chronically / terminally ill residents

and their carers.6. Allow autonomy and decision making concerning end of

life issues.

Geriatric outreach services to nursing homesallow hospital-based geriatricians a uniqueopportunity to integrate the home’s resources intothe hospital’s continuum of care. To form aneffective partnership with the nursing home, thegeriatrician must be familiar with the home’s staffstructure and routine. This can differ greatly fromthe hospital environment that we are familiar with.For example, aides that provide hands-on care maynot be under the administrative control of thenursing staff. Instead they often answer to the homemanager or owner, who may not be a trained healthprofessional. These aides may have received limitededucation and even less training in health care.They may not be conversant in Cantonese and jobturnover is high. Hence, apart from patient factors,the delivery of health care can be significantlyinfluenced by the structure of the nursing homestaff. Awareness of the different priorities of thehome managers, nurses and care aides can helpavoid conflicts that result in the patient receivingsub-standard care.

Strategies to improve the standard of care innursing homes1. Training for carers:

Private nursing homes have difficulty attractingqualified nurses because of the unpleasant jobnature, long hours and poor pay. Shortage ofproperly trained staff leads to poor quality of carein the home. There should be an active program ofin-service training for the care staff. Apart fromformal lectures, this also includes partnering withthe care aides and providing them with knowledgeand solutions to the problems that they face withparticular residents.

An important area of education is staff attitudestowards care of residents. Private nursing homescommonly focus on custodial care of their residents.

The residents have food and shelter in a reasonablysafe and clean environment. The goals of nursinghome care as listed in Table 1 are often neglected.Nursing home staff may perform most tasks for theresidents, irrespective of individual ability. Moststaff take over functions like bathing, dressing, useincontinence pads in place of the toilet andwheelchairs instead of encouraging ambulation.These helping activities reduce opportunities forresidents to practise the skills needed for activitiesof daily living. In turn, this fosters the concept thatelderly residents are not capable of basic self-care.It has been shown that compared to encouragementor minimal assistance, an actively “helping”intervention can reduce the elderly subject’sability to perform a task25. Nursing homes thatemphasize such custodial care can potentiallyincrease disability in those residents they areserving. In contrast, the concept of therapeutic carerequires a range of recreational and rehabilitativeactivities to maintain their functional status for aslong as possible. In caring for such frail elderlyresidents, it is useful for staff to see therapeuticactivity as being anything you do. Routine taskslike activities of daily living, baths, meals or familyvisits can be used to maintain skills, promoteself-esteem and promote social interaction.Motivation is an important factor in the elderlyperson’s ability to perform such activities andinterventions to improve motivation should bedeveloped by carers26.

The outreach team has a responsibility towardscontinuing education of the nursing home staff,particularly the care aides. Care aides have atremendous influence on the quality and type ofcare provided to residents. They have no formaltraining and respond intuitively to changes in theresident's condition. Experienced aides, however,can grasp the meaning of a situation for their clientsor recognize the need for a particular action.Through close personal contact, they know theresidents well and can provide a familiar andsupportive environment that is very important forthoes with impaired cognition. Carers, however,often experience strss in coping with problembehaviours. Staff burnout is a major hazard whenthere are high proportions of cognitively impairedresidents. A survey of staff needs in dementia unitsin Canada found that management of their ownstress levels was among the training topics thathad greatest demand27. There is a need forcont inu ing s ta f f t ra in ing and genu ineencouragement.

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2. Professional nursing care for private nursinghomes:

Another strategy that can help improve nursinghome care is the role of community nurses as partof the geriatric outreach team. They can teachformal skills necessary for nursing medicallycomplex patients. Community nurses can alsopositively influence the nursing home staff in non-medical aspects of resident care. Where there aresubacutely ill residents who require closemonitoring, the community nurse’s contribution inassessment of the resident at home is particularlyimportant as the geriatrician cannot see theresidents daily. They can perform on-siteassessment to detect new problems early. Thisallows appropriate referral to the geriatrician andrapid identification of residents who need hospitalcare. The capacity to provide close monitering on-site also allows a variety of medical conditions tobe treated in the home instead of transfer to acutehospital. With close observation, nurses can keepfebrile illnesses like upper respiratory tractinfections or uncomplicated cystitis in the nursinghome. The new routines and strange environmentencountered after transfer to an acute hospitalcan be a disruptive experience to nursing homeresidents, particularly those with impairedcognition. Risk of iatrogenic problems like pressuresores and deconditioning are high. In selected cases,geriatric outreach teams working in partnershipwith nursing home staff can offer treatment in thehome without detracting from the quality of careprovded.

3. Documentation of medical problems andmedications:

Nursing home residents have often havemultiple medical problems and may not be able torelate their medical histories accurately. Properdocumentation is a key strategy for improving thestandard of medical care in the nursing home. Themedical database of diagnoses, progress notes offollow-up visits in the home, acute hospital recordsand medications should be kept together. Such anintegrated record facilitates medical decision-making both in the nursing home, especially in thepost-acute phase after discharge from hospital, andvice versa. It also avoids interruptions in the medicalrecord at a time when there are changes in thepatient’s status. For example, this occurs duringthe acute illness that necessitates transfer fromhome to hospital and in the recovery phase whenthe patient can be discharged back to the home.Continuity of care between the acute hospital and

nursing home is also strengthened with the use ofa simplified record of nursing issues to be followedup by nursing home staff. The Chinese script shouldbe used in these nursing records for effectivecommunication with the nursing home staff.

4. Rehabilitation assessment and training:Rehabilitation should be an integral part of the

treatment of nursing home residents. This isparticularly important for patients dischargedfrom hospital. Elderly patients are at high riskfor deterioration in function after hospitaldischarge28,29. In consultation with a multi-disciplinary team, provisions can be made forrehabilitative activities in the nursing home or inother facilities like the geriatric day hospital.Residents able to perform activities of daily livingand small chores in the home should be encouragedto do so. Bed-bound patients should have protocolsfor frequent turning to prevent pressure sores andregu la r assessment fo r asp ira t ion andundernutrition. Homes often lack the space andfacilities for proper recreational activities. Residentswho are less disabled, however, do benefit fromgroup activities and recreational therapists can bea valuable resource for this purpose.

ConclusionPrivate nursing homes have an established role

in the care of a highly specific population of elderlypeople with chronic disabilities. It is a challenge toprovide a coherent approach towards long term carefor this group of frail elderly people. Existingcommunity resources are inadequate for theircomplex needs. Reliance on our traditional hospital-based services is not an effective way to deliverhealthcare to these elderly people. Outreachservices led by geriatricians can provide theleadership to integrate these homes into our healthcare system. We can form effective partnershipswith the nursing home staff to improve quality ofmedical care for elderly people residing in theseprivate nursing homes. Every effort should be madeto develop this new system of healthcare delivery.

References1. Leung MF, Lo MBN. Social and health status of elderly people in

Hong Kong. In: SK Lam (ed). The health of the elderly in HongKong. Hong Kong: Hong Kong University Press, 1997:43-62.

2. Freedman VA. Family structure and the risk of nursing homeadmission. Jour of Geronto: Soc Sci 1996;51B (2) S61-S69.

3. Kemper P, Murtaugh CM. Lifetime Use of Nursing Home Care. NEng J Med 1991;324(9):595-600.

4. Leung EMF. Housing and environmental issues for elderly people- a health and functional perspective. In: Phillips DR, Yeh AGO

89

(eds). Environment and ageing: environmental policy, planning anddesign for elderly people in Hong Kong. Hong Kong: Centre ofUrban Planning and Environmental Management, University ofHong Kong, 1999:37-51.

5. Chi I. Social support among Chinese elderly in four Asian cities.HK Jour Geronto 1996;10(Supplement):369-372.

6. Lagergren M. Transferring to an institution - an analysis of factorsbehind the transfer to institutional long term care. Can J on Aging1996;15(3):427-441.

7. Glazebrook K, Rockwood K. A case control study of the risks forinstitutionalisation of elderly people in Nova Scotia. Canadian Jon Aging 1994;13(1):104-117.

8. Bonita R. Women, ageing and health. Achieving health across thelife span. World Health Organisation. Geneva. 1998.

9. Chi I, Chow N. Housing and family care for the elderly in HongKong. Ageing International 1997;Winter/Spring:65-77.

10. Woo J, Ho SC, Lau J, Yuen YK. Age and marital status are majorfactors associated with institutionalisation in elderly Hong KongChinese. J Epidemiology and Community Health 1994;48:306-309.

11. Social Welfare Department 1996-1997 Departmental Report12. Rhoades J, Potter DEB, Krauss N. Nursing homes - structure and

selected characteristics, 1996. Rockville (MD): Agency for HealthCare Policy and Research; 1998. MEPS Research Findings No. 4.AHCPR Pub. No. 98-0006.

13. Ngan R, Leung EMF, Kwan A, Yeung D, Chong A. (1996). A Studyof the Long Term Care Needs, Patterns and Impact of the Elderlyin Hong Kong. Research Report. Department of Applied SocialStudies: City University of Hong Kong

14. Wan C. The others are too frail to talk. South China Morning PostMay 31 1999.

15. Cheng ST, Chan ACM. The future of the elderly homes in HongKong: an ecological analysis. HK Jour Geronto 1993,7(2):29-33.

16. Social Welfare Department. Residential Care Homes (ElderlyPersons) Ordinance. Hong Kong : Hong Kong GovernmentPrinters1995.

17. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studiesof illness in the aged. The Index of ADL: A standardised measure

of biological and psychosocial function. J Am Med Asso 1963,185:914-9

18. Chu LW, Pei CKW, Ho MH, Chan PT. Validation of theAbbreviated Mental Test (Hong Kong version) in the elderly medicalpatient. HK Med Jour 1995;1:207-211.

19. Chiu HF, Lam LC, Chi I et al. Prevalence of dementia in Chineseelderly in Hong Kong. Neurology 1998;50(4):1002-9

20. McEwan KL, Maxwell D. Basic facts and figures about dementiapatients in institutions. In Gutman G (ed). Shelter and care ofpersons with dementia. Gerontology Research Centre, Simon FraserUniversity 1992:3-17.

21. National Center for Health Statistics(1994). Characteristics ofnursing home residents. In National Center for Health StatisticsPHS 81-1721. National nursing home survey. Washington DC: USGovernment Printing Office

22. Butler RN. Why survive? New York: Harper and Row Publishers,1975.

23. Allen SM, Mor V. Unmet need in the community. In: Isaacs SL,Knickman JR (eds). To improve health and health care,1997. TheRobert Wood Johnson Foundation Anthology. San Francisco:Jossey-Bass Inc., Publishers, 1997:132-160.

24. Wong CP, Yu TKK, Leung JYY et al. Experience sharing of privatenursing home (PNH) program in Hong Kong East Region. GeriatricQuarterly Update July 1998:3-4.

25. Avorn J, Langer E. Induced Disability in nursing home patients: acontrolled trial. J Am Geriatr Soc. 1982;30:397-400.

26. Resnick B. Motivating older adults to perform functional activities.J Gerontological Nursing 1998;24(11):23-30.

27. Gutman GM, Killam J. Characteristics of six special care units inBritish Columbia. In: Gutman G (ed). Shelter and care of personswith dementia.. Vancouver: Gerontology Research Centre, SimonFraser University 1992:19-41.

28. Sager MA, Franke T, Inoute S et al. Functional outcomes of acutemedical illness and hospitalization in older persons. Arch InternMed 1996;156:645-652.

29. Woo J, Cheung A. A survey of elderly people discharged fromhospital. J HK Med Asso. 1993;45(4):291-297.

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