A Continuing Care Retirement And Nursing

Retirement and Continue Nursing Care

A Continuing Care Retirement Communities,Types Continuing Care Retirement,Historical Perspectives,Marital Status As A Factor.

A Continuing Care Retirement Communities

    A continuing care retirement community (CCRC) is a type of facility that provides housing, meals, and other services, including nursing home care, for older adults in exchange for a one-time capital investment or entrance fee, and a monthly service fee. 

    Most CCRCs are sponsored by religious or other nonprofit organizations, but for profit organizations have entered into the retirement business as well. 

    The CCRC is usually con- structed as a village or community, and the individual remains within this community for the remainder of his or her life. All CCRCs have a written contract that residents must sign. 

Types Continuing Care Retirement

    The terms of the contract vary, and have been separated into three categories by the American Association of Homes for the Aged: 

(1) Type A homes are "all inclusive" as they offer guaranteed nursing care in the nursing facility at no increase in the residents' monthly fee

(2) Type B CCRCs do not guarantee unlimited nursing home care but have a contractual agreement to provide a specific number of days per year or lifetime of the resident in the nursing facility

(3) Type C CCRCs are based on a typical fee-for-service approach. Financial stability, particularly of Type A and Type B CCRCs, depends on high occupancy rates in the independent living apartments and maintaining the residents' optimal health and function so as to need fewer health care services.

Historical Perspectives

    The number of CCRCs has increased dramatically (50%) during the 1980s and has continued to grow. CCRCs are located throughout the United States although five states (Pennsylvania, California, Florida, Illinois, and Ohio) are home to more than one-third of the nations' CCRCs. 

    Despite the growth of CCRCs, proportionally they account for a smaller percentage of senior housing than previously. This is due to the dramatic increase in assisted living facilities.

Marital Status As A Factor 

    Generally older adults who live in CCRCS are those who were never married, or married without children, are well educated, and health conscious (Krauskopf, Brown, To- karz, & Bogutz, 1993; Petit, 1994, Resnick, 1989, 1998a). 

    Initially CCRCs were for affluent older adults; however, CCRCs are becoming more affordable and attracting those with more moderate incomes (Kitchen & Rouche, 1990). 

    The decision to move into a CCRC requires a good deal of planning and adjustment for older adults, especially if they are relocating to another city or state, and/or moving from a large home to a smaller apartment.

    The initial research in CCRCs focused on the adjustment to the community and the impact this had on the older adult. Resnick (1989), using a qualitative approach, described the challenges of adjustment to a CCRC and identified groups of individuals who were particularly at risk for relocation stress: 

(a) those who had experienced a recent loss

(b) those with a decline in mental status

 (c) the young-old (60 to 70 years) age group 

    Anticipating problems and letting residents know that they might have certain feelings helped residents in the adjustment process. 

    The study also identified the need for frequent follow-up in the first 6 months to a year following the move-in as many residents did not begin to grieve over their losses until they fully completed the work of the move. Petit (1994) implemented the findings of this work as she developed the role of the wellness nurse in a CCRC.

The majority of the nursing research done in CCRCS has been on the health practices and health promotion of these individuals (Adams, 1996; Crowley, 1996; Resnick, 1998a; Resnick, Palmer, Jenkins, &c Spell- bring, 2000; Resnick, 2003). 

    Generally, these are descriptive surveys in which residents are asked about specific health behaviors such as getting vaccinations, monitoring cholesterol land dietary fat intake, exercise activity, alcohol and nicotine use, and participation in health screenings including mammograms, Pap tests, stools for occult blood, or prostate examinations. 

    The majority of residents in the CCRCs studied did get yearly flu vaccines and a pneumonia vaccine, and approximately 61% had an up-to-date tetanus booster. A smaller percentage (approximately 30%) monitored their diets. 

    About 50% of those living in CCRCs drink alcohol regularly, only a small percent use nicotine (11%), and under 50% exercise regularly. Approximately 40% to 50% of the residents get yearly mamograms, 31% to 37% get Pap tests, 65% to 80% get prostate examinations, approximately 60% have stools checked for blood yearly, and a little over 50% monitor their skin for abnormal growths regularly. 

    Overall, there is better participation in health promoting activities of older adults living in CCRCS when compared to older adults in the community (Blustein & Weiss, 1998; Smith et al., 1999). 

    The findings, however, suggest that even in this population continued education is needed to encourage personal decision making related to health promotion activities. The findings can also be used to develop interventions to improve specific health behaviors.

    In a series of analyses examining the relationships between health behaviors among residents of CCRCs, age was the only variable that was significantly related to health behaviors and accounted for 7% of the variance. 

     increased age the residents participated in fewer health-promoting or preventive behaviors. Age, gender, physical and mental health, self-efficacy expectations, outcome expectations, and stage of change related to exercise directly and/or indirectly influenced exercise behavior in the residents (Resnick, 1998a; Resnick et al., 2000; Resnick & Nigg. 2003). 

    The influence of these variables on exercise behavior was supported in a qualitative study (Resnick & Spellbring, 2000) which focused on what helped older adults in a CCRC adhere to a regular walking program and what decreased their willingness to adhere. 

    Crowley (1996) also considered the health behaviors of older adults in a CCRC and the outcomes of a wellness program which encouraged regular exercise. A total of 21% of the 225 residents exercised, and case reports identified positive outcomes such as weight loss and improved recovery following a fracture. 

    Resnick (1999) explored the incidences and predictors of falls in a CCRC and found that the number of falls was the only variable associated with having an injurious fall. Resnick (1998b, 1999) also used a combined qualitative and quantitative approach to explore what increased or decreased residents' willingness to participate in and actual performance of activities of daily of living, such as bathing, dressing, and ambulating. 

    Personality (i.e., determination), beliefs in their ability, the unpleasant sensations associated with the activity, goals, and fears, such as the fear of falling, were identified as common themes that influenced performance of functional activities. 

    Based on quantitative findings, motivation (self-efficacy expectations, outcome expectations, and the personality component of motivation) as well as physical condition (standing balance and lower extremity contractures) were the most important predictors of functional performance in these individuals. 

    Although not extensively studied, Russell (1996) considered the care-seeking behavior of older adults living in a CCRC. This was a qualitative study using ethnographic field research that incorporated semi-structured interviews, participant observation, and focus group interviews. 

    The care seeking process was described as sequential phases and stages that evolved over time. Resnick (2003) tested the impact of an individualized approach to health promotion in these sites, and Resnick and Andrews (2002) tested an educational intervention to help older adults make end-of-life treatment preferences. 

    Some work has also been done to test exercise interventions in these settings (Resnick, Wagner & House, 2003; Vaitkevicius et al., 2002).

    CCRCs continue to be a viable living environment for older adults. In order for these facilities to keep costs down and remain lucrative it is imperative that there be a focus on maintaining health and function. 

    Continued research needs to build on the preliminary findings from exploratory studies and begin to develop and test interventions that will help older adults in CCRCs maintain their health and function. For example, many CCRCs have "wellness programs" which are nursing driven. The outcomes of these programs need to be considered both from a health perspective as well as a fiscal perspective. 

    Other important areas of research within CCRCs that nursing should consider include care processes around relocation to different levels of care, end-of-life issues, injury prevention, health care utilization patterns and the impact this has on nursing care services.