Care model for more than just medical condition needed in long-term care
Eleanor Feldman Barbera, Ph.D.
Of the most efficient countries for healthcare, the United States ranks second in healthcare costs per capita but 46th in efficiency (out of the 48 countries ranked!). The move from a biomedical to a biopsychosocial model of healthcare might be able to change that.
Consider the following scenario: Estelle's fall at home sent her to the hospital. She was diagnosed with a hip fracture and diabetes and transferred to the nursing home for short-term rehab. A biomedical model would treat both conditions and send her home again. A biopsychosocial model would also address her need to make dietary changes, her fears of falling again, the alcoholism that contributed to both her diabetes and her fall, and her noncompliance with the rehab staff.
From biomedical to biopsychosocial
In her American Psychological Association presidential address, psychologist Suzanne Bennett Johnson discussed the change from a biomedical model of care to a biopsychosocial model of healthcare. The biomedical model of care that has “dominated Western medicine … for over 100 years” focuses solely on biologic factors to understand illness. It's resulted in cures for infectious illnesses such as tuberculosis, pneumonia, and influenza, and increased life expectancy from 49 years in 1901 to 77 years in 2001. The biomedical model has been a great success in many respects.
As Johnson points out, however, “while infectious disease was the leading cause of death in 1900, today most Americans die of chronic disease: heart disease, cancer, chronic lower respiratory diseases, and stroke.”
Underlying these diseases are behaviors such as smoking, poor dietary habits, sedentary behavior, and substance abuse. In addition, she notes, “as many as 40% of medical patients are co-morbid for a mental health disorder and as many as 75% of seriously mentally ill patients are co-morbid for a physical health disorder.”
Implications for LTC
Clearly, in order to reduce chronic disease in this country (and to decrease medical costs), we need to address the behaviors – the psychological and social factors — underlying the diseases. But we work with elders, you might say, the damage caused by years of poor self-care has already been done! Perhaps.
But as a psychologist talking with seniors over the years, I've found that many of my lovely old dogs were ready for new tricks. We need to intervene, however, in certain key ways:
- Make the most of The Critical Period: I can't emphasize enough the importance of engaging new residents in all levels of LTC in healthy behaviors. Most people have a few points in their lives when their environment changes — they go to college, they get married, they start a new job, they move to a long-term care setting. These shifts in surroundings offer the best chance for accompanying behavioral changes. Get your residents immediately involved in new, beneficial activities such as exercise, healthy eating, smoking cessation groups, and Alcoholics Anonymous meetings (you've got alcoholics in your community, trust me). Engage your new residents from Day One before they have the chance to settle into their old patterns.
- Offer psychological services: Since a large number of our residents have both mental and physical health disorders, we must treat the mental health disorders in addition to the physical disorders in order to provide adequate care. In addition, most of the nursing home residents I've met are traumatized to some extent by the medical procedures they've undergone and are reacting to the stress of nursing home admission and its accompanying losses. The most psychologically healthy among us could use some extra support upon entry into long-term care in order to prevent a worsening of mental health issues.
- Educate about physical illnesses: Proper management of chronic diseases has a huge impact on the course of the illness and the need for rehospitalization. LTC providers sometimes take an unnecessarily paternalistic approach to illness, assuming responsibility for medicating the condition without offering the guidance needed for the resident to manage the underlying causes. I've spoken to many, many residents who know the name of their disease but nothing about it, such as how to control the symptoms or where to get more information. The lack of knowledge causes them anxiety. We, as long-term care providers, can offer multiple information forums (at the time of initial diagnosis, pamphlets for later reading, illness-related subscriptions such as Diabetes Forecast magazine, etc.) to assist our residents in understanding and managing their conditions.
- Prepare for transitions of care: The propensity for medical complications and “transfer trauma,” especially during transfers between facilities, has received more attention recently due to the high costs (physical, emotional, and financial) associated with them. We can partner with our residents and their families to facilitate care transitions by giving them information about what to expect at the next level of care and what to look out for in terms of medical or emotional complications (and then listening to them when they report symptoms). For residents moving to lower levels of care and assuming more responsibility for treatment, we can use a team approach to teach them about the management of their chronic conditions. For example, we can employ a nurse/psychologist team where the nurse teaches residents to take their blood sugar levels and the psychologist identifies and works through potential barriers to performing this essential task (squeamishness, the challenge of setting up a consistent new behavior, denial, resistance on the part of family members, etc.). A transition in care is often a new Critical Period where there's the potential for greater behavioral change.
The good news is that long-term care providers who offer a person-centered approach are already using a biopsychosocial model, treating the whole person instead of just their medical condition.
Eleanor Feldman Barbera, PhD, the author of The Savvy Resident's Guide, is an accomplished speaker and consultant with over 16 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.