Pushing Through: How Older Adult Caregivers Manage Wound Care.

Older adults are taking on caregiving roles and are performing complex care procedures, such as wound care, in the home setting yet there is a dearth of knowledge about how older adult caregivers manage the performance of wound care on a day-to-day basis. The theoretical framework developed in this research describes this process of managing the caregiving role. Interviews with 18 caregivers aged 65 years and older who were performing wound care in the home for a care recipient yielded a theoretical framework from their narratives using a qualitative grounded theory analysis. The resultant theoretical framework, Pushing Through, consisted of five phases: (a) accepting the role, (b) lacking confidence, (c) creating a system, (d) trusting in self, and (e) owning the outcomes. An understanding of the older adult caregiver's process creates opportunities for healthcare professionals to develop and implement evidence-based interventions.

Older Adult Caregivers' Perspectives on Wound Care Resources: A Qualitative Study.

With an aging population, increasing numbers of older adults are assuming a caregiving role, including performing complex care procedures, such as wound care. Access to and use of resources are associated with better physical and mental health for caregivers. A thematic analysis of qualitative interviews with adult caregivers aged ≥65 years performing wound care identified seven resources supportive of the caregiver role, including: (a) access to expert guidance from health care professionals; (b) written instructions; (c) relationships with health care professionals for obtaining wound care supplies; (d) need for additional medical equipment; (e) financial resources; (f) coverage for caregiver personal time; and (g) select persons for caregiver social and emotional support. Given that older adults are increasingly cast into caregiver roles in the home setting, providing resources to sustain care recipients and their caregivers is critical. [Research in Gerontological Nursing, 16(4), 194-201.].

State-level Medicaid 1915(c) home and community-based services waiver support for caregivers.

BACKGROUND: Informal caregivers encounter emotional distress, worsening personal health, and financial strain. The Medicaid 1915(c) Home and Community-Based Services (HCBS) waiver programs provide an array of services including support for caregivers. PURPOSE: This policy analysis examined Medicaid waiver services offered to persons 65 and older among the 50 states and District of Columbia (DC). METHODS: Data were obtained from Medicaid waiver applications for adults age 65 and older available at Medicaid.gov. Data elements included number of waiver programs and services for supporting caregivers. Descriptive statistics were applied. FINDINGS: Forty-three states including DC (84%) offered a Medicaid waiver for older adults; seven states (14%) offer two waiver programs; eight states (16%) had no Medicaid waiver. Payment to a relative or legal guardian caregiver was the most common service offered in 39 (76%) states. Other services included in-home respite care and adult day health care (35 states; 67%), out-of-home respite care (32 states; 63%), skilled nursing (28 states; 55%), paid spousal caregivers (18 states; 35%), caregiver training (15 states; 29%), and adult day care for socialization (7 states, 14%). DISCUSSION: This study identifies wide variability in caregiver support across state-based Medicaid waivers. Future research should evaluate effectiveness of the waiver programs in supporting caregivers and inform evidence-based policy advocacy for supporting caregivers.

Relationship between occurrence of falls and fall-risk scores in an acute care setting using the Hendrich II fall risk model.

INTRODUCTION: Falls are a common clinical problem in the acute care setting, and fall-related injuries can include fractures, subdural hematomas, excessive bleeding, and even death (Hitcho et al., 2004). Several instruments are used clinically to estimate a patient's risk of falling. The STRATIFY (Oliver, Britton, Seed, Martin, & Hopper, 1997), the Morse Fall Scale (Morse, Black, Oberle, & Donahue, 1989), and the Hendrich II Fall Risk Model (Hendrich, Bender, & Nyhuis, 2003) are three instruments widely used in clinical practice by nurses. To be clinically useful, a fall risk assessment instrument should be easy to use with only a small number of items, perform consistently across target populations, and have evidence-based scoring and good inter-rater reliability. Oliver (2008), author of the STRATIFY tool, questioned the merits of any instrument used to assess fall risk in hospital inpatients in the absence of interventions to modify the risk factors. Too often, patient assessment and assignment of a score become required tasks and resulting data do not drive interventions. PURPOSE: The purpose of this study was to explore the relationship between scores on the Hendrich II Fall Risk Model (HIIFRM) and fall occurrence as recorded in the medical record for patients diagnosed with diabetes mellitus, stroke, or heart failure in an acute care inpatient setting. METHOD: To determine if a relationship existed between the occurrence of a fall and the HIIFRM score, the study used a random sample of patients who fell during admission and a matched control group of patients who did not fall. Fall cases were identified based on an admission Medical Severity-Diagnosis Related Group (MS-DRG) (Schmidt & Stegman, 2008) of stroke or secondary International Classification of Diseases (9th revision) (ICD-9) code (Hart, Stegman, & Ford, 2009) of heart failure or diabetes. Non-faller matched controls were selected at random from the same admission MS-DRG or secondary ICD-9 code as the fall case and matched for admission month/year. DISCUSSION: This study found HIIFRM scores to be related significantly to falls in the sample of patients with diabetes, but not in the sample of patients with heart failure. Although the HIIFRM demonstrated statistically significant mean differences in scores between patients who fell and those who did not, clinically the instrument failed to identify 44% of patients who did fall as being at high risk for falling. Given the negative consequences associated with falling, not identifying 44% of high-risk patients can have significant clinical implications. CONCLUSIONS: In this study, HIIFRM scores were related to falls among inpatients in an acute care hospital who had a diabetes diagnosis, but not a heart failure diagnosis. The differ ences between patient groups based on medical diagnoses suggest the instrument does not perform equally across patient groups, nursing skill levels, or clinical units. Though the findings are statistically significant, the clinical concemrn remains that a large percentage of patients who fell were scored as low risk using the HIIFRM instrument. At some level, every patient admitted to an acute care hospital is at risk for falls. Patients sick enough to be in the hospital have underlying disease, are receiving physiologically altering medications and treatments, and are likely experiencing pain, fatigue, anxiety, sleep disturbance, and other symptoms that interfere with cognitive and physical functioning. The key to preventing falls among hospitalized patients may lie in addressing how the hospital environment creates risk. Nurses should continue to improve the ability to assess fall risk and implement interventions that modify or eliminate risk when possible.