TRANSITIONS BETWEEN COMMUNITY AND NURSING HOME RESIDENCE IN AN URBAN ELDERLY POPULATION
Howard R. Kelman, Ph.D.; Cynthia Thomas, Ph.D.
ABSTRACT: Over the course of a three year observation and study period, some 6% of a representative community residing urban el- derly population were admitted to nursing homes. Nearly half of this group were still living in nursing homes at the end of this observation period. One third had died after entering the nursing home, and the remaining people had returned to their own homes in the community. These three groups had significantly different mean lengths of stay in nursing homes; nearly two years for those whose stays were more per- manent, 50 days for those whose stays were short-term, and 153 days on average for those who died following admission. At baseline, the three groups also tended to have different patterns of health, functional and social characteristics. The short term stayers and those who died following admission to a nursing home differed from respondents who did not enter nursing homes-- primarily in terms of prior living arrangements and levels of social support. The permanent stayers differed from the two other nursing home sub-groups, and from community residents, in that they ten- ded to be older and more functionally and mentally impaired. How- ever, at baseline they appeared at less risk to expire than those people who later died following admission to nursing homes. Clinical and research implications based on these findings are discussed.
BACKGROUND
Issues concerning the place of nursing home care in a contin- uum of long term care services continue to occupy the attention of health care planners, administrators, clinicians, and researchers. This has been the case for a number of reasons.
First, more than 1,350,000 elderly Americans currently reside in nursing homes, and the number of nursing home beds now exceeds the number of acute care hospital beds. 2 While at any one moment in time only 5% of the population 65 years old, or older, are nursing home residents, the life-time risk of being admitted to a nursing home has been variously estimated as upwards of 40%. 3.5
Second, costs for nursing home care are substantial. They are second only to hospital care as a proportion of all expenditures for health care? Nursing home costs encompass approximately 40% of all Medicaid costs and force many otherwise income independent elderly individuals into poverty. 7
Third, the availability of and access to nursing home beds and to quality care in nursing homes is poorly and unevenly distributed. 2 Fi- nally, having to relinquish residence in the community for institutional living is an abrupt and radical transition that is seldom welcomed by elderly persons or their family members except in cases of extreme hardship or sickness among care givers and is accepted only as a last resort or when other care options are either not available or have been exhausted. 1
The magnitude and urgency of the problem of providing nurs- ing home care--particularly in an era of budgetary stringency--and its likely growth over time due to the graying of the population and in- crease in the proportion of the oldest segment of that population, 89 con- tinues to give rise to a large body of research. These efforts included information on characteristics of nursing home populations, 1°-1~ determi- nants of nursing home admissions and outcomes, 13-16 costs, policies and planning, and the treatment of medical conditions. 17-~° Much of this liter- ature is beyond the scope of this paper. Studies of diverse elderly populations ranging from those few that include broadly representative groups as well as populations of frail or disabled individuals, those living in special housing environments, or participants in special programs, have commonly identified advanced age and functional deficits as high risk factors for nursing home place- ment. Studies of elderly populations living in nursing homes indicate that the resident populations have become older, more disabled, and have high rates of hospitalization and death. 2~-27 Other studies have doc- umented significant local and regional variations in both the numbers and characteristics of referrals to nursing homes and resident popula- tions, 2s~° and have described variations in length of stay among those admitted to nursing homes? 7 Despite these and other advances in our knowledge of the nurs-ing home as a social and health care institution, and its use by elderly populations, significant gaps in the precision and range of this knowledge remain to be closed? I Little is known, for example, of the dy- namics of the transition from community to nursing home residence and, for some, return to living in the community. Our inability to pre- dict or to identify more accurately persons at high risk of nursing home placement 32 has limited our ability to provide community-based services that could substitute or prevent nursing home placement? 3-s6 Because we have infrequently studied representative community populations longitudinally, data on incidence and prevalence are also limited? ~ A longitudinal study of health, health care and aging in a repre- sentative urban population of elderly persons residing in the commu- nity provided an opportunity to explore certain of the transitional dynamics, characteristics, and outcomes of study participants who were admitted to nursing homes during the course of a three year period of observation, av In this paper we present first our findings from analyses of the occurrences of nursing home admissions followed by the results of analyses of the health and social characteristics of respondents who experienced one or more nursing home admissions.
Study Sample
Seventy -three percent of a randomly selected population of el- derly residents (age 65 or over) of a defined health area in the North Centra
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城市老年人口社区与养老院的过渡
摘要:通过3年的观察和研究，有代表性的城市老年居民中，约6%的人进入了养老院。在观察期结束时，这组人中有近一半仍住在养老院。三分之一的人在进入养老院后死亡，其余的人回到了他们在社区的家中。这三组在疗养院的平均停留时间有显著差异;住院时间较长者为近两年，住院时间较短者为50天，入院后死亡者平均为153天。
ABSTRACT: Over the course of a three year observation and study period, some 6% of a representative community residing urban elderly population were admitted to nursing homes. Nearly half of this group were still living in nursing homes at the end of this observation period. One third had died after entering the nursing home, and the remaining people had returned to their own homes in the community. These three groups had significantly different mean lengths of stay in nursing homes; nearly two years for those whose stays were more
permanent, 50 days for those whose stays were short-term, and 153 days on average for those who died following admission.
在基线时，这三组人的健康、功能和社会特征也有不同的模式。短期留宿者和进入养老院后死亡的人与没有进入养老院的受访者不同——主要是在先前的生活安排和社会支持水平方面。永久留宿者不同于其他两个疗养院的亚组，也不同于社区居民，他们的年龄更大，功能和智力也更差。然而，在基线上，他们死亡的风险比那些后来在疗养院去世的人要低。
At baseline, the three groups also tended to have different patterns of health, functional and social characteristics. The short term stayers and those who died following admission to a nursing home differed from respondents who did not enter nursing homes-- primarily in terms of prior living arrangements and levels of social support. The permanent stayers differed from the two other nursing home sub-groups, and from community residents, in that they tended to be older and more functionally and mentally impaired. How- ever, at baseline they appeared at less risk to expire than those people who later died following admission to nursing homes.
在此基础上讨论了临床和研究意义。
Clinical and research implications based on these findings are discussed.
背景
BACKGROUND
有关疗养院护理在长期护理服务中的地位的问题继续引起卫生保健规划人员、管理人员、临床医生和研究人员的注意。这种情况有很多原因。
Issues concerning the place of nursing home care in a continuum of long term care services continue to occupy the attention of health care planners, administrators, clinicians, and researchers. This has been the case for a number of reasons.
首先，目前有超过1,350,000名美国老年人居住在养老院，养老院的床位数量已经超过了急症护理医院的床位数量。尽管65岁或65岁以上的人口中只有5%是疗养院的居民，但据各种估计，进入疗养院的终生风险高达40%以上。
First, more than 1,350,000 elderly Americans currently reside in nursing homes, and the number of nursing home beds now exceeds the number of acute care hospital beds. 2 While at any one moment in time only 5% of the population 65 years old, or older, are nursing home residents, the life-time risk of being admitted to a nursing home has been variously estimated as upwards of 40%.
第二，养老院的费用是巨大的。他们在医疗支出中所占比例仅次于医院吗?养老院的费用约占医疗补助费用的40%，迫使许多原本收入独立的老年人陷入贫困。
Second, costs for nursing home care are substantial. They are second only to hospital care as a proportion of all expenditures for health care? Nursing home costs encompass approximately 40% of all Medicaid costs and force many otherwise income independent elderly individuals into poverty. 7
第三，养老院床位和优质护理的可得性和可得性都很差，分布不均。2 Fi -基因表达,不得不放弃住宅社区的制度生活是突然和激进转型很少受到老年人的欢迎或他们的家庭成员除了在极端困难的情况下或疾病护理人员,只能作为最后的手段或其他保健选项不可用或筋疲力尽。
Third, the availability of and access to nursing home beds and to quality care in nursing homes is poorly and unevenly distributed. Finally, having to relinquish residence in the community for institutional living is an abrupt and radical transition that is seldom welcomed by elderly persons or their family members except in cases of extreme hardship or sickness among care givers and is accepted only as a last resort or when other care options are either not available or have been exhausted.
的大小和紧迫性的问题提供养老院护理,尤其是在预算紧缩的时代,及其可能的增长随着时间的推移,由于人口老龄化和平衡,人口的比例最古老的部分,继续产生大量的研究。这些努力包括关于疗养院人口特征、疗养院入院的决定因素和结果、费用、政策和规划以及医疗条件治疗的信息。这些文献的大部分都超出了本文的范围。
The magnitude and urgency of the problem of providing nursing home care--particularly in an era of budgetary stringency--and its likely growth over time due to the graying of the population and in- crease in the proportion of the oldest segment of that population, continues to give rise to a large body of research. These efforts included information on characteristics of nursing home populations, determinants of nursing home admissions and outcomes, costs, policies and planning, and the treatment of medical conditions. Much of this literature is beyond the scope of this paper.
多样化的老年人群的研究从那些包括广泛代表性的几组以及虚弱或残疾人的人口,生活在特殊的居住环境,或参与特殊项目,通常认为高龄和功能性赤字高危险因素,养老院的地方。对生活在养老院的老年人口的研究表明，居住在养老院的人口变得更老、更残疾、住院率和死亡率都很高。其他研究表明，在转介至养老院和住院人口的数量和特征上，存在显著的地方和区域差异，并描述了入住养老院的患者在住院时间上的差异。
Studies of diverse elderly populations ranging from those few that include broadly representative groups as well as populations of frail or disabled individuals, those living in special housing environments, or participants in special programs, have commonly identified advanced age and functional deficits as high risk factors for nursing home place-ment. Studies of elderly populations living in nursing homes indicate that the resident populations have become older, more disabled, and have high rates of hospitalization and death. Other studies have documented significant local and regional variations in both the numbers and characteristics of referrals to nursing homes and resident populations, and have described variations in length of stay among those admitted to nursing homes?
尽管我们对托儿所作为一种社会和卫生保健机构的知识以及老年人对其的使用有这些和其他方面的进步，但在这一知识优势的精确度和范围方面仍有很大的差距有待填补。例如，我对从社区到养老院的过渡以及一些人重返社区生活的过程知之甚少。我们无法预先诊断或更准确地识别出养老院安置风险较高的人，这限制了我们提供社区服务的能力，而社区服务可以替代或预防养老院安置?由于我们很少纵向研究具有代表性的社区人口，因此关于发病率和患病率的数据也很有限。
Despite these and other advances in our knowledge of the nursing home as a social and health care institution, and its use by elderly populations, significant gaps in the precision and range of this knowledge remain to be closed? I Little is known, for example, of the
dynamics of the transition from community to nur
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