Cbe Liorarp at tt>e Dttn'sion of J£>eaitb affairs dntoeusitp of jQortfj Carolina Cfjis book leas presented Charles M. Cannerson and Lydia S. Holley A Study of Patients in Licensed Nursing Homes of North Carolina By CHARLES M. CAMERON JR. and LYDIA S. HOLLEY DIVISION OF HEALTH AFFAIRS LIBRARY RECEIVED DEC 20 '62 DIVISION OF UEAI3M AEBAIBS LIBRABS. DEPARTMENT OF PUBLIC HEALTH ADMINISTRATION SCHOOL OF PUBLIC HEALTH UNIVERSITY OF NORTH CAROLINA CHAPEL HILL 1962 Digitized by the Internet Archive in 2011 with funding from North Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project http://www.archive.org/details/reportofstudyofpOOcame THE REPORT OF A STUDY OF PATIENTS IN LICENSED NURSING HOMES OF NORTH CAROLINA With Reference to Needs and Services in the Field of Physical Therapy DIVISION OF HEALTH AFFAIRS LIBRARY By Charles M. Cameron Jr., M.D. , M.P.H. Project Director and Lydia S. Holley, P.T., M.P.H. Assistant Professor Department of Public Health Administration School of Public Health University of North Carolina Chapel Hill 1962 This project was made possible by a grant from the Nursing Home Section, Division of Personal Health, North Carolina State Board of Health, Raleigh, North Carolina. Grateful acknowledgement of this support Is made to J. W. R. Norton, M.D., State Health Director; James M. Donnelly, M.D., Director, Division of Personal Health, D. Frank Milam, M.D., Chief, Chronic Disease Section, and to the personnel of the Nursing Home Section. K^> K \ ACKNOWLEDGEMENTS The successful completion of a project of this nature Is achieved only with the cooperation, assistance, and effort of many Individuals who provide time, energy, and encouragement. Without the cooperation of the operators of the Licensed Nursing Homes In North Carolina, acting singly and through the North Carolina Nursing Home Association, the data collection would not have been possible. Miss Margaret Moore and Miss Charlene Nelson, Section of Physical Therapy, School of Medicine, University of North Carolina played an Important role in the development and Implementation of the project. Dr. Bernard Greenberg and Dr. Bradley Wells of the Department of Blostatistics, School of Public Health, University of North Carolina were of great assistance. Consultation and suggestions of major value were provided by Miss Anne Parrish, Physical Therapy Consultant, North Carolina State Board of Health. The local health departments of North Carolina were generous In their support and efforts throughout this activity. TABLE OF CONTENTS Foreword Page Chapter 1. Background and Development of the Nursing Home Study. 1 Chapter 2. Selected Characteristics of Nursing Home Patients . . * 11 Chapter 3. Physical Status of Nursing Home Patients in North Carolina 19 Chapter 4. Functional Achievements of the Patient Population 33 Chapter 5. The Nursing Home Itself 45 Chapter 6. Physical Therapy Goals and Needs 51 Chapter 7. Conclusions and Recommendations 71 Appendix , 79 FOREWORD Foremost among the health problems facing this nation today are the chronic, long term illnesses which account for the major portion of deaths, a significant amount of the total illness, and an overwhelm- ing share of disability and crippling. In addttion to a direct burden on the individual sufferers of these diseases and disorders, a significant toll is being paid by society as a whole to defray the costs of research and in support of the nursing homes, rehabilitation facilities and other community services needed to assist in the management of long term illness. Although the goal of medical science Is to devise methods of averting the occurrence of these diseases entirely, significant efforts must go toward the restoration, rehabilitation, and continued care of the current and future victims of chronic disease. Current concepts stress that more Is Involved than the provision of good daily care to the chronically III patient, and that appropriate emphasis In general hospitals, In nursing homes, and in home care pro- grams must be directed toward those restorative techniques which prevent the extension of existing disease and promote maximum independence of the patient In such basic functions as eating, bathing, dressing, ambulation and the like. The application of the knowledge, skills, and abilities of the professional field of physical therapy Is an essential to the provision of restorative health services. Knowledge of where, how, when, to whom, and through what administrative patterns these services should be provided is necessary to the economical utilization of scarce community health resources and to the achievement of the best available care for the chronically ill patients of North Carolina. Chapel Hill C.M.C L.S.H. August 1, 1962 CHAPTER I BACKGROUND AND DEVELOPMENT OF THE NURSING HOME STUDY BACKGROUND AND DEVELOPMENT OF THE NURSING HOME STUDY Long term Illness has been characterized as Including those diseases, defects and disabilities which require professional medical care over a prolonged period of time and which, in addition, may require that the patient receive specialized services in chronic disease hospitals, rehabilitation facilities, nursing homes and other types of community health facilities. For many reasons, interest has been focused upon the licensed nursing homes of North Carolina during the past 18 to 24 months. Particular concern on the part of the public health agencies of the state was stimulated by the transfer of responsibility for the licensure of nursing homes from the Medical Care Com- mission to the North Carolina State Board of Health by the 1961 General Assembly of North Carolina. The assignment of responsibility for the licensure and supervision of these facilities to a department of public health Is Justifiable In light of the current concepts concerning the care required by the aged and the Infirm. With traditional emphasis on prevention of disease, public health personnel now are equally concerned regarding the prevention of complications and disability which may arise from the primary disease or health defect of the patient. The public health viewpoint also features appropriate awareness of the Importance of restorative services for the chronically ill — restorative services to assist the patient In returning to hts pre-dlsease functional level or to at least permit him maximum independence in the basic essential activities of daily living even though he may remain homebound or in an Institutional setting. Another characteristic of the public health approach to nursing home care Is the conviction that the level of patient care available is not only a function of the physical plant and Its operation, but also Is Influenced by the knowledge, skill, and abilities of the institutional staff In such fields as nursing, physical therapy, recreational therapy, dietetics, administrative management, and other professional areas which constitute the basic Ingredients In the delivered product known as "patient care". The formulation of administrative plans to Improve patient services In nursing homes should be under- taken with full knowledge of the characteristics of the patients to be served and the resources of the nurs- ing homes to provide these needed services. To this end the Department of Public Health Administration of the University of North Carolina School of Public Health was asked to develop for the North Carolina State Board of Health data concerning the needs of nursing homes In the state and suggestions and recom- mendations regarding mechanisms for Improvtng patient care In the area of physical therapy. Since It was already known that no nursing homes In this state regularly employed physical therapists, It seemed evident that services In this professional sphere could be implemented only to the extent that needed consultation, guidance, and assistance from qualified physical therapists Is made available to the personnel providing care In North Carolina's licensed nursing homes. Provision of physical therapy consultation differs somewhat from nursing and other fields of professional care In that: 1. The number of registered physical therapists In North Carolina is so small that personnel shortages In this field are among the most critical encountered today. 2. The uneven distribution of physical therapists means that many regions of the state are totally devoid of any resources. 3. Until recently, medical and nursing personnel were Inadequately prepared In the proper applica- tion of physical therapy skills and in utilization of physical therapists In the care of the aged and chronically III, and 4. The expanding utilization of physical therapists in rehabilitation centers, teaching centers, home care programs and other community health facilities is increasing much faster than the supply of professionally qualified physical therapists. In view of these observations, It was felt that the Improvement of patient care In nursing homes In North Carolina through application of additional knowledge from the field of physical therapy would be realized most effectively after documentation of the needs for physical therapy services of patients being cared for in the licensed nursing homes and the resources for providing these needed services. To Implement this documentation and to obtain current status of nursing home patients insofar as physical status and abilities were concerned, it was decided to have a qualified registered physical therapist evalu- ate Individually a statistically selected sample of patients in licensed nursing homes. Her primary mission was to Identify the physical therapy needs of this sample of patients currently receiving care In the licensed nursing homes of the state. While in the nursing homes, this therapist was regarded as being able to obtain two additional types of data: (1) basic Identifying data concerning the general characteristics of the patients and (2) some Im- pression as to the design, equipment, and other aspects of the home as it pertained to those patients whom she was evaluating. PHASE ONE It was determined that, due to the paucity of data concerning the pattent population In the licensed nursing homes of North Carolina, a complete census of the patients should be obtained as the Initial phase of the study. With the cooperation of the Nursing Home Association, the North Carolina State Board of Health and the local health departments of the state, this census was completed In a single day In late January 1962 and revealed that 1,093 patients were then receiving care In the 37 licensed nursing homes. In order to facilitate the rapid, accurate tabulation of identifying information on these 1,093 patients, a minimum of facts about each individual patient and about each nursing home was collected Incidental to the census. The forms used In the collection of this Information are shown on page 12. The results obtained from this census are shown on pages 13 and 14. In summary, It was determined that the typical patient at the time was 75 years of age or older, female, a bed patient all or part of the time and had been a resi- dent of the home for from one to five years. PHASE TWO To provide more detailed Information required for program planning, a 12.5 percent sample of the total patient group was selected In such a fashion as to be representative of the total group and Include some patients receiving care in each of the 37 homes. This sample, numbering 121 patients, was used for the collection of much more detailed information which forms the basis of the report. The appendix contains copies of the forms used by the physical therapist In the collection of this In- formation. The information obtained from this effort as well as the Information from the census cards was placed on punch cards for ease in tabulation and analysis. The mechanics of scheduling visits, arranging for alerting local health departments of activities In their areas, and the day-to-day details of the actual operation of this activity have been spelled out In some detail In periodic activity reports provided by the pro|ect staff to the Nursing Home Section, North Carolina State Board of Health, and are available to those who may be contemplating such an activity. 100 100 59 59 94 94 96 96 79 79 82 82 VALIDITY OF CENSUS DATA Number Percent Total Available Sample Patients Full agreement Agreement, Identification data Agreement, length of stay data Agreement, bed status data Agreement, mobility status The reliability of the formation received from the census of all patients In licensed nursing homes In North Carolina was validated by completing a second census card on those patients selected for the sample survey at the time of the Investigator's visit. The second card was then checked against that patient's Initial census card to determine the agreement on each item. Fifty-nine percent of the patients surveyed had complete agreement for all data on the census card Including age, sex, race, length of stay, bed status and mobility. Six percent of the survey patients were found to have Incorrect age grouping on the initial census card while race and sex were 100 percent accurate. Four percent had Incorrect length of stay data even when allowance was made for the time elapsed between the completion of the census card and the visit to the home. These four Items Involved Information that required no Interpretation so it must be assumed that these were simple mistakes. Seventy-nine percent of the patients had agreement in bed status on both cards and 82 percent agreed on mobility status. Both these Items are subject to two variable factors besides the obvious one of a simple misplaced check mark. These are: a difference In Interpretation of what the item means and secondly, a change in the condition of the patient. The item for bed status included four categories: (1) out of bed, except sleep and rest, (2) In bed part of time, (3) in bed most of time, (4) In bed all the time. Obviously the person checking the chart may Interpret these broad periods of time in a different manner from the investigator, particularly In the second and third categories. The time period between the filling out of the census card and the visit to the nursing home by the Investigator varied from five weeks to twelve weeks. Within this period, It is likely that the status of a number of patients could have changed as they either improved in overall condition or deteriorat- ed In physical or mental capacity. This would create a discrepancy In the agreement of the cards although they were both correctly used. The mobility status of patients on the census cards Included these categories (1) walks unassisted with cane or crutch, (2) maneuvers with wheelchair or walker, (3) walks only with attendant's help, and (4) never walks or wheels self. Although these categories were intended to provide for varying degrees of mobility, it was found that misinterpretations did occur. At least five percent of the group was classified as unknown because no category was checked on the census card. During the visits the Investigator realized that the patients in question walked completely Independently and were not classified in any category shown on the card. There were other minor misinterpretations but the greatest discrepancies between the two cards were due to a change in the functional ability of some patients. Several who had been up and around either In a wheelchair or with assistance at the time of the census were now in bed all the time. Almost an equal number had shown improvement In their mobility level, now able to perform at a higher level of mobility. The "disability" item on the census card provided the information that, by the operator or administrator's opinion, 8.7 percent of all patients In licensed nursing homes had no disability. "No disability " was de- fined as pertaining to those patients who require no regular nursing or personal care. When those patients identified as "no disability" were visited as part of the detailed study, it was found that although they were able to manage on their own to a large extent, the majority needed some service that they themselves could not provide. However, the level of nursing or personal care they require is not of the highest order and the patient's presence in the nursing home appears to depend a great deal on what other facilities and ser- vices are available in the area. All of the patients had one or more diagnoses that require medical super- vision; some required oral medication and often needed an adjusted diet. About half of these patients needed constant supervision or observation as they suffered from senility and other brain disorders and lacked the judgement to carry out an independent life. The conclusion to be drawn is that all the patients in the study were disabled in some manner to the degree of needing services that they could not wholly provide for themselves. However, the determination of the actual level of care required for each patient is beyond the scope of this study. AVAILABILITY OF SAMPLE PATIENTS Number Percent Total Patients available Patients deceased since census Patients removed to their homes Removed to another Institution Patients uncooperative Patients removed to hospital Patients away from home for day Nursing home uncooperative Other 2 2 There were 121 patients selected from the Nursing Home Census to be Included In the sample for the detailed study. The study was Initiated five weeks after the day of the census and continued until twelve weeks after the census date. During this period of time eleven (10%) of the selected sample patients de- ceased, three (2%) were discharged to their homes, and another two percent were removed to another Institution. When the Investigator visited the homes two patients (2%) of those selected refused to co- operate with the study and, therefore, were deleted from the study. Another two patients (2%) were not available for other reasons. In no case did the nursing home personnel refuse to cooperate with the study. Of the 121 patients selected for the sample survey, 100 were found to be available. These 100 patients then became the basis of the more detailed study. 121 100 100 82 11 10 3 2 3 2 2 2 UNIVERSITY OF NORTH CAROLINA SCHOOL OF PUBLIC HEALTH NURSING HOME STUDY Patient Census - Jan. 23, 1962 (12:01 A.M. to 12:00 P.M.) Name of Home Address Administrator 1. Number of beds available 2. Number of beds occupied 3. Number of Registered Nurses working 4. Number of Licensed Practical Nurses working 5. Number of aides and orderlies giving personal services All information for the Census day ONLY. UNIVERSITY OF NORTH CAROLINA SCHOOL OF PUBLIC HEALTH NURSING HOME STUDY Patient Census - Jan. 23, 1962 (12:01 A.M. to 12:00 P.M.) Patient Nc • d-5) AGE (6) □ 1. 1 - 44 □ 2. 45- 64 a 3. 65- 74 a 4. 75- 84 a 5. 85+ SEX (7) □ 1. Mali □ 2. Female RACE (8) □ 1. Whil e □ 2. Non -White LENGTH OF STAY (9) O 1 . 1 day to 1 mo. J 2. 1 mo. to 3 mos. J 3. 3 mos. to 1 yr. [_) 4. 1 yr. to 5 yrs. []5. 5 yrs. & over DISABILITY (10) □ l- Disability ~2 2. No disability Name of Patient BED STATUS (11) | | 1. Out of bed, except sleep and rest ] 2. In bed part of time Q3 3. In bed most of time ~2 4. In bed all the time MOBILITY (12) | | 1. Walks unassisted with cane or crutch J 2. Maneuvers with wheelchair or walker Q3. Walks only with attendant's help I | 4. Never walks or wheels self Front (over) Explanation Please complete one card on each patient either resident in or admitted to the nursing home between midnight January 22 and midnight January 23, 1962. Item 9 — Length of Stay - Refers to the length of time the patient has been in this nursing home during this present admission. Item 10 — Disability - "No Disability" refers to the patients who require no regular nursing or personal care. PLEASE RETURN CARDS WITHOUT DELAY TO Nursing Home Study School of Public Health University of North Carolina Chapel Hill, N. C. Back (over) SCHOOL OF PUBLIC HEALTH NURSING HOME STUDY PATIENT CENSUS ~ JANUARY 23, 1962 AGE 1 -44 45-64 65-74 75-84 85 + Unknown SEX Male Female RACE White Non-White (Indian) Number Per Cent 20 1.8 99 9.1 232 21.2 468 42.8 273 25.0 1 .1 1093 100.0 315 28.8 778 71.2 1093 100.0 1092 99.9 1 0.1 1093 100.0 LENGTH OF STAY 1 day to 1 month 1 month to 3 months 3 months to 1 year 1 year to 5 years 5 years and over Unknown 68 6.2 109 10.0 334 30.6 527 48.2 49 4.5 6 .5 1093 100.0 DISABILITY Disability No disability Unk now n 994 96 3 91.0 8.7 .3 1093 100.0 BED STATUS Out of bed, except sleep & rest 417 38.2 In bed, part of the time 225 20.6 In bed most of the time 274 25.0 In bed all of the time 174 15.9 Unknown 3 0.3 1093 100.0 MOBILITY Walks unassisted 282 25.8 Alone with wheelchair 156 14.5 Walks assisted by attendants 196 17.9 Never walks 421 38.3 Unknown 38 3.5 1093 100.0 SCHOOL OF PUBLIC HEALTH NURSING HOME STUDY Data on Licensed Nursing Homes January 23, 1962 1. Total number of beds available 1239 Number of homes reporting 37 2. Total number of beds occupied 1091 Number of homes reporting 37 3. Number of beds available for occupancy In North Carolina 148 Number of homes with vacant beds 24 4. Size of nursing home 1 to 25 beds 14 25 to 50 beds 18 50 to 75 beds 4 75 to 100 beds 1 Total: 37 5. Number of Registered Nurses In Licensed Nursing Homes 49 Nursing homes reporting no Registered Nurses 5 Number of homes reporting 31 6. Total number of Licensed Practical Nurses In Licensed Nursing Homes 73 Number of homes reporting no Licensed Practical Nurses 5 Number of homes reporting 31 7. Total number of Aides and Orderlies In Licensed Nursing Homes 365 Number of homes reporting 31 8. Total personnel giving personal care . 487 CHAPTER 2 SELECTED CHARACTERISTICS OF NURSING HOME PATIENTS To study the physical therapy needs and services of patients In the nursing homes of North Carolina, It was first necessary to gather background data to Identify these patients as to personal characteristics, facts concerning their usual residence and such re- lated Information as to give Insight Into the general pattern of admission and financial resources during their stay In the nursing home. Generally there were the "who, what, when, where, and why" questions upon which the more de- tailed data collection would be based. 11 TABLE 1 AGE BY SEX Years Total Male Female No. % No, , % No. % Total 100 100 38 38 62 62 1 - 44 1 100 1 100 _ _ 45- 64 12 100 6 50 6 50 65- 69 6 100 2 33 4 67 70 - 74 15 100 5 33 10 67 75- 79 21 100 10 48 11 52 80 - 84 22 100 9 41 13 59 85 - 89 14 100 4 29 10 71 90 -t 9 100 1 12 8 88 TABLE 2 SEX BY AGE Years Total Male Female No. % No . % No. %_ Total 100 100 38 100 62 100 1 - ■44 1 1 1 3 — — 45- •64 12 12 6 16 6 10 65- •69 6 6 2 5 4 6 70 - ■74 15 15 5 13 10 16 75- ■79 21 21 10 26 11 18 80 - •84 22 22 9 24 13 21 85- ■89 14 14 4 10 10 16 90 H 9 9 1 3 8 13 The population of the licensed nursing homes In North Carolina was found to be comprised of 38 per- cent males and 62 percent females indicating that two out of three patients in these homes are women. The age distribution of patients in North Carolina nursing homes was found to be essentially compati- ble with the age distribution of patients in nursing homes elsewhere in the United States, that is, pre- dominantly a very old age group. Eighty-seven percent of the patients were past the age of 65 with twelve percent between 45 and 64 years of age and only one percent under 45. In the older age groupings, 66 percent of the patients were over 75 years of age with 23 percent over the age of 85. The oldest patient In the survey was 102 years old. The nursing home population in North Carolina again parallels the national pattern in that among the older age group the larger portion is comprised of women. Although the findings did not demonstrate a consistent proportionate shift, it was found that of those under 65, one half were men while of those 85 and older, only one fourth were men. From age 70, only 29 percent of the patients are men, and by the 90th year only one out of nine nursing home patients is a man. Table 2 shows another method of reviewing the age-sex population of the nursing homes and demon- strates that among the male population, 19 percent are under 65 years of age while only 10 percent of the women are in this age group. Conversely, among those seventy-five and over are 63 percent of all the men and 68 percent of all the women. Even more striking is the finding that the 85 and over group includes 13 percent of all the men but 29 percent of all the women. 12 RACE At the time of this activity, the patient load in licensed nursing homes in North Carolina was com- posed entirely of white persons. Data from the census of nursing homes completed in January 1962 revealed only one non-white (an Indian) in residence at that time. TABLE 3 USUAL COUNTY OF RESIDENCE N umber Percent Total 100 100 Same as nursing home 59 59 Adjacent to nursing home 23 23 Elsewhere within state 10 10 Out of state 8 8 Nursing homes in North Carolina generally draw upon the immediate locality for their patient loads as shown by the finding that 59 percent of the patients were receiving care in their home county and 23 percent were from counties immediately adjacent to the ones in which the institutions were located. Only eight percent of the patients were classed as being from out of the state. It might be noted here that the 37 licensed nursing homes surveyed at this time were located In 25 of the 100 county units in North Carolina, with two-thirds of these establishments In the middle third or Piedmont section of the state. Therefore the distribution of licensed nursing home facilities is not uniform throughout the state. TABLE 4 MARITAL STATUS AND RESIDENCE OF SPOUSE Number Percent 17 17 4 4 66 66 Total 100 100_ Single, divorced and widowed 87 87 Single Divorced Widowed Married 13 13 Spouse same nursing home Spouse own home Spouse relative's home Spouse boarding home Spouse another institution From the sample population of nursing home patients surveyed, It was determined that 87 percent of the patients were presently without a living mate. Seventeen percent had never been married while four percent were divorced and 66 percent were widowed. Of the thirteen percent who were currently married, only one-half of the spouses maintained their own home. This information is significant when proposals to rehabilitate patients to return to their homes are studied since only six percent of the patients have a home and companion. These facts also help ex- plain why some patients remain in nursing homes when they no longer require the professional services of such a facility. 13 1 1 6 6 3 3 2 2 1 1 TABLE 5 MAJOR REASON FOR ADMISSION Number Percent Total 100 100 Unable to live alone Family unable to care for Financial reasons Unhappy In previous nursing home Special facilities needed Other reasons 34 46 3 3 1 13 34 46 3 3 1 13 The reason for admission to a nursing home Is frequently a complicated one Involving the type of care required, age, marital status, family resources, and facilities available. However, In each case the ma|or reason for admission was noted for the survey. It was judged that forty-six percent of the patients were admitted because family members (spouses, children, siblings) were not able to provide the needed care. Thirty-four percent had lived alone or with a paid companion until It was no longer possible to maintain an Independent household and Institutional care was sought. There were direct financial reasons for three per- cent of the admissions, and a like percentage where the patient or family had been unhappy with a previous nursing home facility and a move was made. Thirteen percent of the patients did not fall clearly Into any of these categories. Although financial considerations might well be a contributing factor In most cases, other factors are of greater significance as indicated by the small percentage where financial considerations were the major reason for admission. TABLE 6 ONSET OF DISABILITY Total 1 day to 1 month 1 month to 6 months 6 months to 1 year 1 year to 2 years 2 years to 5 years 5 years to 10 years 10 years and over Unknown Number 100 Percent 100 1 1 3 3 15 15 40 40 22 22 18 18 1 1 It was difficult to obtain valid information as to the period of time during which the disability or chronic illness had prevented the full or usual activities of the patient. However, from the patient's re- cord, the operator's knowledge, and the patient's verbal history, 80 percent were judged to have been disabled for over two years, 40 percent over five years and 18 percent over ten years. Only four percent of the patients had been limited in their full activities for a year or less. There were no patients in the survey who had been In a home less than one month as the selected sample was obtained from a nursing home census taken at least one month previous to any data collection. It Is evident from these findings that nursing home patients in North Carolina are predominantly In the chronic disease category by virtue of the length of time of disability regardless of other factors. 14 TABLE 7 LENGTH OF STAY Number Percent Total 1 month to 3 months 3 months to 6 months 6 months to 1 year 1 year to 2 years 2 years to 3 years 3 years to 5 years 5 years to 10 years 10 years and over 100 100 1 1 26 26 15 15 18 18 17 17 14 14 7 7 2 2 A breakdown of the data on length of stay of nursing home patients reveals that over one-fourth (27%) of the patients had resided In the present nursing home from one to six months with an additional 15 percent having been there from six months to one year. Almost equal numbers of patients had resided In the nursing home from one to two years (18) and two to three years (17). Those residing three to five years comprised fourteen percent of the total group. Only nine percent of the patients had been residents of the present home for over five years. Nation- wide studies of the nursing home populations have demonstrated higher percentages In this category. This may be explained by the fact that the majority of the licensed nursing homes in North Carolina have been In operation a relatively short time with 20 of the 37 homes being less than five years old. Death rates for patients In nursing homes would also tend to limit extended periods of residency. Other tables show that the population is one heavily weighed with the older age groups and with chronically ill persons, both high risk populations. TABLE 8 IMMEDIATE PRIOR RESIDENCE Total Number 100 Percent 100 Private dwelling Own home Relative's home Other 43 20 20 3 43 20 20 3 Hospital General Mental 37 36 1 37 36 1 Long-term care facility 19 Licensed nursing home 5 Other (Home for Aged, etc.) 14 19 5 14 Unkr The Immediate prior residence of the patients studied revealed that two main sources, almost equal In number, contributed the majority of the patients: private dwellings In 43 percent of the cases and hos- pitals in 37 percent. There were 19 percent who had come to the home directly from another long-term care facility, such as a licensed nursing home (5%) or a home for the aged (14%). Of those patients who came directly from a private dwelling, equal numbers were previously in their own homes and in relatives' homes. ]'j TABLE 9 PATIENT COSTS FOR NURSING HOME CARE Cost Per Month Number Percent Total 100 100 $100 to $149 24 24 $150 to $199 36 36 $200 to $249 29 29 $250 to $299 5 5 $300 to $349 6 6 $350 and over - - The median range of charges per month for room, board, and basic nursing care In licensed nursing homes In North Carolina was $150 to $199 per month. Thirty-six percent of the patients were paying costs in this range which was the largest percentage In any of the groupings. The maximum payment for these basic services was approximately $350 per month with the minimum being $1 10. There were 24 percent of the patients whose care averaged less than $150 per month. Forty percent of the patients' payments ranged over $200 per month. One should bear In mind that the majority of nursing home patients in licensed facilities In North Carolina are paying $7 per day or less for care. TABLE 10 SOURCE OF PAYMENT Major Source Number Percent Of Patients Of Patients Total 100 100 Personal or family 63 63 Public assistance 26 26 Social Security 6 6 Veterans vendor 3 3 Insurance - - Workman's Compensation - - Vocational Rehabilitation - - Other 2 2 All Sources Number Percent Of Sources Of Sources Total 132 100 Personal or family 80 60 Social Security 17 13 Public assistance 26 20 Other 9 7 Valid data with regard to source of payment for Individual patients was difficult to ascertain. The most accurate data could be obtained regarding those receiving benefits from the public assistance welfare program. It was generally determined that 63 percent of the patients were utilizing personal or family resources to meet the major cost of their nursing home care. Twenty-six percent derived the major portion of their payments from public welfare assistance. Social Security funds were known to be the major source of pay- ment for six percent; however, this represents "underreporting" since the nursing home administrators may not be aware of a patient's receipt of O.A.S.I. benefits. Veterans Administration vendor payments for 16 care were the major source of payment for three percent of the patients and two percent were supported by other funds not listed, such as railroad pensions. There were no cases where it was known that health or medical insurance, workman's compensation or vocational rehabilitation made any contribution toward the maintenance of these patients In nursing homes. From the known data, 132 sources of payment were identified for the 100 patients, 60 percent of these being personal or family payments. Public assistance made up 20 percent of the total known sources with Social Security responsible for 13 percent. Seven percent of the sources of payment were from various other mechanisms. It was established that seventeen percent of the patients were known to receive some Social Security benefits and that seven percent of all the patients were receiving both Social Security and public welfare aid, indicating a very low level of Social Security benefit. SUMMARY The nursing home population in North Carolina Is heavily weighed in terms of the older, white, fe- male, widowed patients. The ma|orIty of these patients reside in nursing homes within the immediate locality of their usual dwelling and have entered the home because their families or they themselves have not been able to provide the needed care in their usual habitation. Patients have come to the nursing home directly from a private dwelling or a general hospital In over 80 percent of the cases with approxi- mately equal percentages from each location. The length of stay In North Carolina nursing homes Is not excessively long, 40 percent of the patients having resided In the same home for less than one year and only nine percent for over five years. However, over 40 percent of the patients have been disabled or restricted In their usual activities for over five years with only four percent disabled under one year. By far the greatest source of payment for nursing home care in North Carolina Is derived from personal or family sources with welfare assistance and Social Security benefits supplying about one-third of the patients' payments. The "average" range of payment per month for these services Is $150 to $199, with the majority of the nursing home patients paying less than $7 per day for care. 17 CHAPTER 3 PHYSICAL STATUS OF NURSING HOME PATIENTS IN NORTH CAROLINA Having collected Information regarding the Identifying characteristics and background of the nursing home patients, attention was given to obtain- ing data which would classify the patients according to their present physical condition. This Information was recorded from the attending physician's patient history, notes and orders, the knowledge of the most qualified professional personnel In the home and the observations and tests conducted by the Investigator. Data Included Items on diagnosis, function of the body systems and special sense organs, mental status, medical supervision and general patient care required. 19 TABLE 1 1 DIAGNOSIS PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS Number Percent Number Percent Total 100 100 100 100 Heart disease 7 7 35 35 Cerebral vascular accident 17 17 11 11 Other cardlo-vascular disease 5 5 5 5 Senility (with and without cerebral arteriosclerosis) 23 23 10 10 Fracture 9 9 5 5 Arthritis 7 7 6 6 Degenerative central nervous system disease 13 13 3 3 Mental disorders 7 7 2 2 Neoplasm 4 4 1 1 Other 8 8 17 17 Unknown 4 4 By definition, the primary diagnosis Is that medical condition most disabling, or, in this study, the medical condition which led to admission to the nursing home. The Information with regard to diagnosis was obtained from the physician's admission history and subsequent records, from the professional knowledge of the nurse tn charge, and by Inference from the medications ordered by the physician. Heart disease, cerebral vascular accidents and other cardlo-vascular diseases accounted for 29 per- cent of the primary diagnoses with an additional 23 percent due to senility usually associated with cerebral arteriosclerosis. This indicates that cardiovascular conditions were the basis for over one-half the ad- missions to the nursing homes in this state. Central nervous system diseases were the next most frequent category followed In order by fractures, arthritis, mental disorders, and neoplasms. Eight percent of the primary diagnoses were due to "other" conditions with blindness being the most prominent one. The secondary diagnosis, defined as the next most disabling condition, is chiefly remarkable in the percentage of patients recorded with heart disease (35%). The secondary diagnosis follows the same general pattern as the primary; cardiovascular conditions (51%) with senility (10%) were by far the leading diagnos- tic causes of secondary disability In the nursing home patients. It is to be noted that diabetes was not found to be the primary disability for any patient but the disease was present In six percent of the patients. 20 TABLE 12 PRIMARY DIAGNOSIS BY AGE Total Heart CVA Other CV Senil- ity Frac- tures Arthri- tis CNS Mental Disord. Co icer Other No. % No .% No. % No.% No. % No. % No . % No. % No. % No . % No. % Total 100 100 7 100 17 100 5 100 23 100 9 100 7 100 13 100 7 100 T 100 8 100 1-44 1 1 1 8 45-64 12 12 - - 1 6 - 1 4 - 1 14 4 31 3 43 - - 2 25 65-69 6 6 - - 1 6 - 2 9 - - - 2 15 - 1 25 - 70-74 15 15 - - A 24 - 3 13 - 1 14 5 38 1 14 - - 1 13 75-79 21 21 3 43 8 47 2 40 3 13 2 22 1 14 1 8 - 1 25 - 80-84 22 22 T 30 1 6 3 60 6 26 1 11, 2 29 - - 3 43 2 50 2 25 85-89 14 14 1 14 1 6 - 5 22 5 55 2 29 90+ 9 9 1 14 1 6 - 3 13 1 22 3 37 When the primary diagnoses of the patients In licensed nursing homes in North Carolina are examined by age groupings, certain characteristics become apparent. The older age groups are heavily weighed with patients having fractures, heart and other cardiovascular diseases. The single diagnosis that occurs pre- dominantly In the younger age groups is degenerative central nervous system disease with over 50 percent of these patients under 70 years of age and all the patients with this primary diagnosis under 80. While cerebral vascular accidents involve a wide age range, 71 percent of these patients are between 70 and 80 years of age. Senility, predominantly attributed to cerebral arteriosclerosis, is the primary diagnosis for an age range of patients from the 45-64 group through the 90 + group. As would be expected, the ma|ortty of these cases are in the oldest ages (61 percent being over 80 years of age.) Arthritis as the primary diagnosis Is found In almost all age ranges. Although no distinction was made between rheumatoid and osteoarthritis with 58 percent of the patients over 80 years of age one would suspect osteoarthritis cs the usual type. Mental disorder as a primary diagnosis Is demonstrated in two age groupings, 45-64 and 80-84. Those in the older age group who were diagnosed as having mental disorders showed few signs of physical deterio- ration. Cancer patients are in the mid-range being from 65 through 84 years of age. "Other primary diagnosis" shows no distinct age pattern. 21 TABLE 13 APPARENT NUTRITIONAL STATUS Number Percent 53 53 29 29 18 18 Total 100 100 Average Markedly thin Markedly obese The nutritional status of slightly over half of the patients in nursing homes as judged by observation of height, body type and general appearance was "average". The status of approximately one-third was "markedly thin" or underweight and the remaining 18 percent were classed as obese. TABLE 14 SKIN CONDITION Number of Patients No apparent lesions 78 Pressure areas 4 Decubltl 5 Other 15 Evaluation of the skin of the survey patients revealed that 78 had no apparent lesions. Four showed evidences of pressure areas while five had one or more areas of body surface which had broken down as a decubitus ulcer. Fifteen of the patients had other skin conditions ranging from trophic changes typical of rheumatoid arthritis to ulcerations from peripheral vascular diseases. It was possible for a patient to fall into more than one of these categories and allowance was made in the questionnaire for this occurrence. Consider- ing the age range of the patients, their patterns of mobility and the problems of incontinence, the overall skin condition of the patients in nursing homes was remarkably good, and would not appear to be a major problem with regard to the potential for rehabilitation services. 22 TABLE 15 CONTINENCE BOWEL BLADDER Numb er Percent Number Percent Total 100 100 100 100 Voluntarily controlled Occasionally lacks control Never voluntarily controlled 58 58 52 52 13 13 18 18 29 29 30 30 The status of patients with regard to their bladder and bowel continence is of particular concern to all those dealing with long-term patients. It was found that half of the survey patients had complete control of bladder and bowel, 30 percent were incontinent of bladder and bowel with 13 to 18 percent occasionally lacking control of one or the other. Those in the latter category sometimes realized the need too late to acquire the proper facilities or help, or were soiled at night or In periods of emotional stress. Eleven per- cent of the patients were catherized routinely and were included with the "never voluntarily controlled" group. TABLE 16 DENTITION Total Number 100 Percent 100 Natural Edentulous 24 76 24 76 Dentures not used 35 35 Dentures used 41 41 In this survey of nursing home patients, 24 percent were found to have dentition adequate to masticate food. Seventy-six percent were essentially edentulous with 4] percent having and using dentures while 35 percent had no effective method of chewing food. It was noted that there were patients who had dentures but did not use them, either from their own volition or a lack of opportunity. 23 TABLE 17 VISION Number Percent Total 100 100 No apparent Impairment 7 7 Moderate Impairment 66 66 Glasses not used 22 22 Glasses used 44 44 Severe impairment 25 25 Glasses not used 1/ 17 Glasses used 8 8 Unknown 2 2 Only seven patients (7%) were without apparent visual Impairment. Sixty-six percent presented moderate impairment which did not greatly affect the care of the patient. A total of 25 percent had visual impairments severe enough to Interfere to a marked degree with the activities and care of the patient. Fifty-two percent of the total patients wore glasses with varying degrees of correction of visual Impairment. It was noted that several totally blind patients were able to function at an Independent level within the protected atmosphere of the home but apparently could not maintain this level in other circumstances. With the amount of visual Impairment Indicated from this data, It Is logical to establish this handicap as one of the major factors limiting the Independence of this population group. TABLE 18 HEARING — ■,— .■■■■■—-,-.,- — -, ..-■,. ■ ■ — - . Total Number 100 Percent 100 No apparent impairment 51 51 Moderate Impairment 37 37 Hearing aid not used Hearing aid used Severe impairment 33 4 10 33 4 10 Hearing aid not used Hearing aid used Unknown 6 4 2 6 4 2 Hearing impairment was noted far less than visual impairment with 51 percent demonstrating no ap- parent handicap. Of the remaining patients, 37 percent had impairment which did not interfere with or excessively prolong their care while 10 percent had Impairment which did interfere. Only eight percent used hearing aids although others had discarded them due to discomfort, lack of benefit or lack of mental ability to use them satisfactorily. It Is to be noted in reviewing these results that half of the patients do demonstrate some hearing loss which means that those in attendance tend to raise the volume of their voices to all patients and thus mask minor individual impairments. 24 TABLE 19 ABILITY TO COMMUNICATE VERBALLY Number Percent Total 100 100 No apparent impairment 53 53 Moderate impairment 28 28 Severe Impairment 17 17 Unknown 2 2 The ability to verbally communicate was without apparent limitation in 53 percent of the cases. Another 28 percent were able to produce some meaningful speech but with moderate Impairment In ex- pression. There were 17 percent who were judged to have severe difficulty In producing meaningful sounds often caused by the total absence of speech mechanisms. Although problems of communication between those patients with the more severe Impairments and attendants were observed In the nursing homes, the prolonged length of stay of most patients has enabled those giving personal care to Interpret and understand to a certain degree the Individualized manner of communication of the patients so involved. TABLE 20 ORIENTATION Number Percent Total 100 100 Rarely confused 42 42 Sometimes confused 40 40 Always confused 18 18 Although there were no comatose patients in the study group, the degree of mental orientation to their surroundings varied to a marked degree. Over half (58%) were considered to be always, sometimes or partially confused. The number of those "sometimes confused" would probably be higher If periods of observation had been longer. The 18 percent "always confused" was based on a consistent lack of knowl- edge as to time, space, location or people. Orientation has a direct bearing on the patient's potential for restorative services. This is a particularly difficult problem in patients who are "sometimes confused" since the nursing home personnel cannot rely on any consistent level of understanding or performance. 25 TABLE 21 ATTITUDE Number Percent Total 100 100_ Usually cooperative 60 60 Sometimes cooperative 36 36 Rarely cooperative 2 2 Unknown 2 2 The cooperation of the patient was judged by the Investigator's personal experience with the patient combined with the opinions of the personnel attending the patient. Thirty-six percent varied In their response and were considered as being uncooperative at fairly regular periods. Only two percent were "rarely cooperative" or hostile. Uncooperative behavior is a symptom of a number of the diagnostic catagories which predominate in this group of patients and does not necessarily Imply personality defects. TABLE 22 ABILITY TO FOLLOW DIRECTIONS Number Percent Total 100 100 Adequate 63 63 Poor 31 31 Impossible 6 6 Of the patients surveyed, 63 percent were able to follow adequately simple directions with 31 percent showing a poor ability to carry out such requests. Only six percent were judged as unable to follow any directions from either a physical or mental point of view. However, it must be realized that the ability to follow directions incorporates several factors including the willingness to try. The attitude and co- operation shown by Table 24 seems to indicate that the factor of willingness may be more important than the physical and mental capacity of the Individual. 26 TABLE 23 MEMORY FOR RECENT EVENTS Number Percent Total 100 100 Adequate Poor No Unknown 49 49 38 38 10 10 3 3 Less than 50 percent of the nursing home patients were judged to have adequate remembrance of occurrences within a period of a few hours. Ten percent were thought to have no memory for recent events with 38 percent demonstrating a varying or poor abtllty to recall events that happened In a relatively re- cent time period. This pattern of the ability to recall relates to the previous information on the ability to follow direc- tions. With constant supervision a patient may be able to follow specific directions for actions but his "carry-over" to un-supervlsed performance may be minimal If the directions cannot be remembered. These two characteristics have a great bearing on the expectations for restorative care services. In considering the mental status of patients in the nursing homes one should recall that the mental deficiencies demonstrated are often symptomatic of a disease process rather than personality traits. As such, they may or may not be amenable to treatment, but in any case should be recognized as part of the disease, not an unrelated behavioral pattern. Also, the various factors which make up an Individual's mental status are interrelated to a degree that it Is difficult to Isolate any one characteristic or to make other than subjective judgement. 27 TABLE 24 RANGE OF JOINT MOTION Total Number 100 Percent 100 Functional range in all extremities Lack of functional range, 1 extremity Lack of functional range, 2 extremities Lack of functional range, 3 extremities Lack of functional range, 4 extremities Unknown 51 51 7 7 19 19 11 11 10 10 2 2 The general functional range of motion of the extremities of each nursing home patient in the survey was deterr..ined to give an Indication of the physical condition of each patient. The patient was first tested in a fairly detailed manner ( see Appendix) and later these findings were categorized and a single score was given for the extremity as a whole. The range of motion tested was for passive movement, that is the ability of the examiner to carry the extremity through the functional ranges of motion of each joint. It was found that 51 percent had functional range of motion in the joints of all four extremities. Only seven percent were lacking In functional range of one extremity only, increasing to 19 percent who lacked functional range of motion in two extremities. Eleven percent were lacking in functional range in three extremities and ten percent in four extremities. Two percent of the patients classed as unknown since their condition prevented such examination. In analyzing the disability that is caused by a lack of functional range, those without handicap In all extremities were least disabled, those with one or two extremities lacking in range were the intermediate or moderate group, here consisting of 26 percent, while those lacking in three or four extremities were the dependent or most involved group, 2 1 percent of the total . 2H TABLE 25 VOLUNTARY STRENGTH Number Percent 52 52 5 5 17 17 2 2 22 22 2 2 Total 100 100_ Functional voluntary power In all extremities Lack of functional power, 1 extremity Lack of functional power, 2 extremities Lack of functional power, 3 extremities Lack of functional power, 4 extremities Unknown Functional voluntarily controlled muscle strength of nursing home patients was tested to give another Indication of their physical condition and how their function In other areas was affected. There are no completely objective methods to determine normal ranges of muscle strength for these age groupings, there- fore, the term "functional " was used as a criteria of measurement. It was found that 52 percent of these patients had at least functional power In all four extremities. Only five percent showed a lack of functional power in one extremity, Increasing to 17 percent with weak- ness in two extremities. There were two percent who lacked functional power In three extremities while 22 percent of the total group demonstrated weakness In four extremities. There were two percent of the patients whose condition did not warrant testing. It Is striking that the largest percentages of those handicapped experienced this In two and four extremities. The four extremity weakness Is best explained by the fact that a number of patients were bed- ridden with resultant loss of power In all extremities. The number of hemiplegics gives a ready explanation for the two-extremity loss of power. Combination of the one and two extremity lack of function (22%) was regarded as "moderate Involve- ment, " and the three and four (24%) as the "severely Involved. " 29 TABLE 26 MEDICAL DOCTOR LAST SEEN Total Number 100 Percent 100 1 day to 1 month 43 43 1 month to 6 months 49 49 6 months to 1 year 5 5 1 year to 2 years 3 3 2 years and over " Forty-three percent of the patients had been seen by a physician within one month of the time the data was collected, 49 percent had been seen in from one to six months and of the remaining group, only three percent had not been seen within the preceding one year period. Medical care In the majority of homes was provided by private local physicians although three homes reported that a medical staff Is employed. Other homes have a physician designated as available to handle emergency situations which may arise at times when personal physicians are not available. It should be noted that some patients are seen on a regularly scheduled basis by their personal physicians, others only as their physical condition may warrant. There was evidence that telephone consultations between the nursing home personnel and the physician occurred frequently. The patients supported by the welfare department were more likely to see physicians only in critical situations or at the time of the yearly physical examination for welfare re-certlflcation, according to Information provided by nursing home operators. This group also was more likely to have the service of several different physicians over a period of time as the welfare payments do not routinely cover the cost of physician services and the nursing home operators use the most readily available medical service as the need arises. TABLE 27 PHYSICAL THERAPY TREATMENT Total Number 100 Percent 100 Not during admission Sometime during admission, not now Now, by P. H. therapist Now, by non-P. H. therapist 97 2 1 97 2 1 Of the survey patients only three percent had received physical therapy treatments by a qualified physical therapist during their residence in the nursing home. Only one patient was currently being seen by a physical therapist, this being one of those employed by the North Carolina State Board of Health. However, the visits were on an Irregular basis. Although it was impossible to obtain definitive information with regard to physical therapy services provided to the survey patients prior to their admission to the nursing home, approximately ten percent were known to have received such care for the disability by which they were currently handicapped. 30 MEDICATIONS Only five percent of patients In licensed nursing homes took no regular medications. Three percent were allowed to have such drugs as aspirin and nitroglycerin to be taken at their own discretion. Informa- tion available showed that approximately 20 percent of the patients regularly or occasionally required hypodermic injections, frequently recorded as "vitamin preparations." The most frequently ordered medications were tranquilizers and vitamins. Specific drugs for cardio- vascular disease and hypertension were ordered in approximately a third of the cases. Laxatives were mentioned as in regular usage in many homes, some provided in the form of fruits and other nutritional supplements. Barbiturates, sleeping pills, anti-spasmotic and antl-convulsant drugs were ordered in a small percent- age of cases. For diabetics oral medications were more frequently used than insulin injections. Many of the operators commented concerning the prominent role played by tranquilizers, psychic energizers and other similar medications in maintaining patients tn the nursing home environment. PHYSICIAN'S INSTRUCTION REGARDING PHYSICAL CARE In an effort to determine the types of special care ordered by physicians, information about certain aspects of care was obtained. It was established that in 37 percent of the cases, the physician had given minimal instructions with regard to the degree of activity expected of the patient. This included specifi- cations on the frequency and time limits the patient was to be out of bed, the limitations on ambulation and the equipment to be used in ambulation. The more typical orders in this category read "up when able, " "up in chair daily, " "use walker, " and "do what he Is able. " Only two percent of the patients had instructions regarding the use of appliances, such as braces, footboards, trapezes, or bed boards. Five percent had specified the use of such physical agents as heating lamps, hot packs, or specific exercises. There were 61 percent of the patients who had no medical instructions covering these aspects of phy- sical care. DIET Dietary requirements of the nursing home patients are determined not only by the physical status of the patient but also by the condition of the mouth, dentition and the mental status. Nursing home adminis- trators in the majority of the homes described the "regular" house diet as "low salt" with almost fifty per- cent of the patients reported as requiring complete or partial salt restriction. Another six percent of patients required diabetic diets while an additional eight percent needed other special diets such as low fat, high caloric, low calcium, or bland diets. There were many variations in the consistency of food consumed by the patients but such special instructions rarely were mentioned in physician's orders. Twenty percent were found to need soft or ground foods with another twenty percent requiring food in a liquid, blended or puree form. Tube feeding was necessary in only one case. The figures presented are underestimates since a number of the homes habitu- ally serve food of less solid consistency than normal. In these homes however it is not considered a "special diet". At times it was difficult to determine if the food service varied according to the patient need or to the ease or convenience of the nursing home staff. 31 SUMMARY The data collected regarding the present physical condition of the nursing home patients under study demonstrated that cardiovascular disease plays the leading role in disability and nursing home admission, both as the primary and secondary diagnosis. The primary diagn^ is does not appear as a major determinant of the physical therapy goals for self- care and mobility or the physical therapy skills required. Obseity was found far less often than a normal or subnormal nutritional state among patients observed. The general condition of the skin of patients in nursing homes was remarkably well-preserved considering the age, Involvement and the fact that nearly one-half the patients lacked complete control of their elimination processes. Visual impairment was an almost universal finding with one-fourth of the patients severely handicapped in this special sense. Poor hearing was judged a less disabling factor in number and severity. The ability to communicate verbally was limited to some degree in nearly one-half of the patients in the survey. The physical condition as demonstrated by the range of joint motion and voluntary muscle strength was found to be limited to some degree In approximately half the patients. Of the characteristics used to evaluate the mental status, orientation was found to be the largest disabling element with over one-half of the patients functioning at less than "normal" expectations. This finding, combined with other Indices of mental deterioration, Indicated that the general mental status of patients In nursing homes was a major disabling factor, affecting the function of the patient in many other categories. Physician attendance to the patients in licensed nursing homes was reported as 93 percent of the patients having been seen by a medical doctor within six months. Compared to other studies of nursing home care, this Indicates a high order of medical supervision. However, professional consultation for re- habilitation services as Indicated by services of a physical therapist are limited to the degree of one patient In the study receiving physical therapy treatment at irregular intervals. Oral medications and some level of "special" diet are indicated services for individual patients almost universally. However, the physician's Instruction with regard to physical care and activity were found to be comparatively inexplicit or In many cases nonexistant. In general, the findings concerning the present physical condition of patients in North Carolina's licensed nursing homes denoted a population with many complex limitations of function, Indicating the need for significant amount of medical, nursing and personal care. 3? CHAPTER 4 FUNCTIONAL ACHIEVEMENTS OF THE PATIENT POPULATION The previous chapters have given information concerning specific characteristics of the patients under study. This chapter defines the level at which patients are functioning in those essential activities of dally living. This gives a picture of the dependence or independence with which the patients are actually accomplishing such activities as feeding, bathing, dressing and ambulation. 33 FUNCTIONAL ACHIEVEMENTS OF THE PATIENT POPULATION A functional activity test was given to the selected patients in this study of the physical therapy needs of nursing home patients. This is commonly known as an "A.D.L." (activities of daily living) test to deter- mine at what level the patient is presently functioning in the performance of duties which are commonly necessary each day in carrying out normal living. The examination procedure was broken into several parts with a variety of items under each to be evaluated. Headings wer. 90+ Race ( )1. ( )8. White Non-white 7. Sex ( ) 1. Male ( )2. Female Marital Status and Residence of Spouse ) 1. Single ) 2. Married; spouse same nursing home ) 3. Married; spouse own home ) 4. Married; spouse relative's home ) 5. Married; spouse boarding home ) 6. Married; spouse another institution ) 7. Married; spouse residence unknown )8. Widowed ) 8. Divorced ) y. Unknown Length of Stay in This Home ) 1. 1 day to 1 mo. ) 2. 1 mo. to 3 mos. ) 3. 3 mos. to 1 yr. ) 4. 1 yr. to 5 yrs. ) 5. 5 yrs. St over 12. 15. 14. Payment per Month ) 1. $100 to $149 ) 2. $150 to $199 >3 $200 to $249 ) 4. $250 to $299 ) 5. $300 to $349 ) 6. $350 & over 18. M.D. Last Seen ( ) 1. 1 day to 1 mo. ( ) 2. 1 mo. to 6 mos. ( ) 3. 6 mos. to 1 yr. ( ) 4. 1 yr. to 2 yrs. ( ) 5. 2 yrs & over ( ) y. Unknown 19. mmediate Prior Residence ) 1. Own home ) 2. Relative's home ) 3. Other private dwelling ) 4. General hospital ) 5. Mental hospital ) 6. Licensed nursing home ) 7. Other facility ) 8. Unknown Major Source of Payment ) 1. Personal or family ) 2. Medical insurance ) 3. Social security ) 4. Public assistance ) 5. V.A. Pension ) 6. Compensation )7. O.V.R. ) 8. Other (specify) ) y. Unknown Physical Therapy Treatment ) 0. Not during admission ) 1. Sorne time during admission, not now. ) 2. Now, by PH. therapist ) 3. Now, by non-P.H. therapist ) y. Unknown 13. 20. Usual County of Residence ) 1. Same as nursing home ) 2. Adjacent to nursing home ) 3. Elsewhere within state )4. Out of state ) y. Unknown 10. Onset of Disability ) 1. 1 day to 1 mo. 1 mo. to 6 mos. 8 mos. to 1 yr. 1 yr. to 2 yrs. 2 yrs. to 5 yrs. ) 6 5 yrs. to 10 yrs. ) 7. 10 yrs. & over 16. 17. )2. )3. )4. )5. Reasoi i for Admission (If not 6 in Item 12) ( )1. Unable to live alone ( )2. Family unable to care for ( )3. Financial considerations ( )4. Other (specify) (If 6 in Item 12) ( )S. Unhappy in previous ( )6. Less expensive ( )7. Special facilities ( )B. Closer to usual home ( )8. Unknown All Sources of Payment ( )1. Personal or family ( )2. Social Security ( )4. Public Assistance ( )8. Other ( ) TOTAL P.T. Treatment Frequency ( )0. Not now ( )1. More than 1 per week ( )2. 1 per week ( )3. 1 per 2 weeks ( )4. 1 per month ( )5. Irregularly 80 NURSING HOME STUDY U.N.C. School of Public Health Patient No. PATIENT CARE 21. Medications 22. Diet ( ) 0. None taken ( )1. Regular ( ) 1. Taken under supervision ( )2. Special, non-tube (specify) ( ) 2. Taken without supervision (specify type) ( ) 3. Special, tube (specify) ( ) y. Unknown ( ) TOTAL PHYSICAL CONDITION 24. 25. Diagnoses 26. 28. Dentition 20. ( ) 1. Natural ( ) 2. Edentulous, does not use dentures ( ) 3. Dentures used Special Sensei 31. Vision 32. ( ) 1. No apparent impairment ( ) 2. Moderate impairment, glasses not used. ( ) 3. Moderate impairment, glasses used. ( ) 4. Severe impairment, glasses not used. ( ) I. Severe impairment, glasses used. ( ) y. Unknown 34. Continence, Bladder ( ) I. Usually voluntarily controlled ( ) 2. Occasionally lacks control ( ) 3. Never voluntarily controlled Communication 36. Expressive ( ) 1. Speech ( ) 2. Gestures, not speech ( )3. None Menial Status 38. 38. Consciousness ( ) 1. Conscious ( ) 2. Periodically comatose ( ) 3. Comatose 41. Ability to Follow Directions ( ) 1. Adequate ( )2. Poor ( ) 3. Impossible ( ) y. Unknown (specify) Skin ( )0. No apparent lesions ( )1. Pressure areas ( )2. Decubiti ( )4. Other (specify) ( ) TOTAL Pain ( )0. No Complaint ( )1. Occasional, at rest ( )2. On activity ( )4. Continuous ( ) TOTAL Hearing ( )1. No apparent impairment ( )2. Moderate impairment, hearing aid not used. ( )3. Moderate impairment, hearing aid used. ( )4. Severe impairment, hearing aid not used. ( )8. Severe impairment, hearing aid used. ( )y- Unknown 23. Instruction about Physical Care ( ) 0. None ( ) 1. Degree of activity (specify) ( ) 2. Appliance (specify) ( ) 4. Physical agents (specify) ( ) TOTAL 27. Apparent Nutritional Status ( ) 1. Average ( ) 2. Markedly thin ( ) 3. Markedly obese 30. Dominant Hand ( ) 1. Right ( )2. Left ( ) y. Unknown 33. Speech, verbal ( ) 1. No apparent impair ( ) 2. Moderate impair. ( ) 3. Severe impair. ( ) y. Unknown 35. Continence, Bowel ( ) 1. Usually voluntarily controlled ( ) 2. Occasionally lacks control ( ) 3. Never voluntarily controlled Orientation ( ) 1. Rarely confused ( ) 2. Sometimes confused ( ) 3. Always confused ( ) y. Unknown 37. Receptive ( ) 1. Speech ( ) 2. Gestures, not speech ( )3. None 40. Attitude ( ) 1. Usually cooperative ( ) 2. Sometimes cooperative ( ) 3. Rarely cooperative ( ) y. Unknown 42. Memory for Recent Events ( ) 1. Adequate ( ) 2. Poor ( ) 3. No ( ) y. Unknown 81 ACTIVITIES OF DAILY LIVING aj. Bed Activities ( ) 1. Independent ( ) 2. Assisted ( ) 3. Dependent 46. Dressing ( ) 1. Independent ( ) 2. Assisted ( ) 3. Dependent 49. Ambulation ( ) 0. Not ambulatory ( ) 1. Ambulatory without aids, independent ( ) 2. Ambulatory without aids, assisted ( ) 3. Ambulatory with cane/crutch, independent ( ) 4. Ambulatory with cane/crutch, assisted ( ) S. Ambulatory with walker, independent ( ) 6. Ambulatory with walker, assisted. ( ) 7. Other (specify) NURSING HOME STUDY U.N.C. School of Public Health 44. Personal Care ( ) I. Independent ( ) 2. Assisted ( ) 3. Dependent 47. Hand Activities ( ) 1. Independent ( ) 2. Assisted ( ) 3. Dependent Patient No. 45. Feeding ( ) I. Independent ( ) 2. Assisted ( ) 3. Dependent 48. Wheelchair Activities ( ) 0. Not used ( ) I. Used, independent ( ) 2. Used, assisted ( ) 3. Used, dependent SO. Appliances Used in Ambulation ( ) 0. None used ( ) 1. Long leg brace (rt-lf) ( ) 2. Short leg brace (rt-lf) ( ) 3. Prosthesis (type) ( ) 4. Combination of above (specify) FACILITIES 51. 54. Entrance 52. Elevation ( ) 1. Adequate ) 0. Not applicable ( ) 2. Needed, steps changed ) 1. Adequate ( ) 3. Needed, ground level ) 2. Needed, ramp ( ) 4. Needed, ramp ) 3. Needed, stairs ) 4. Needed, elevator Bed, Type in Use; Type Needed 55. ] 3ed Appliances ( ) 1. Hospital; adequate ) 1. Adequate ( ) 2. Regular; adequate ) 2. Needed, 1 appl. ( ) 3. Hospital; regular needed ) 3. Needed, 2 appls. ( ) 4. Regular; hospital needed ) 4. Needed, 3 appls. ( ) 6. Hi-Lo used ) 5. Needed, 4 appls. ( ) 6. Other combination 53. (specify) 57. Equipment, misc. Doorways ( ) I. Adequate 58. To Room ( ) 2. Needed, 1 item ( ) 1. Adequate ( ) 3. Needed, 2 items ( ) 2. Inadequate, type ( ) 4. Needed, 3 items ( ) 3. Inadequate, width ( ) 4. Inadequate, sill 60. To Dining Room 61. To Recreation Room ( ) 0. Not applicable ( ) 0. Not applicable ( ) 1. Adequate ( ) 1. Adequate ( ) t. Inadequate, type ( ) 2. Inadequate, type ( ) 3. Inadequate, width ( ) 3. Inadequate, width ( ) 4. Inadequate, sill ( ) 4. Inadequate, sill Inknown 59. 62. Grab Bars ( )l. Adequate ( )2. Needed, by stairs ( )3. Needed by ramp ( )4. Needed in corridor ( )S. Needed by toilet ( )6. Needed by shower/ tub 56. Equipment, Transportation ) 1. Adequate ) 2. Needed, patient lifter ) 3. Needed, cane/crutch ) 4. Needed, parallel bars ) S. Needed, walker ) 6. Needed, wheelchair ) 7. Needed, wheelchair and patient lifter ( ) 8. Needed, other (specify) To Bathroom ( )0. Not applicable ( )1. Adequate ( )2. Inadequate, type ( )3. Inadequate, width ( )4. Inadequate, sill To Outside ( )1. Adequate ( )2. Inadequate, type ( )3. Inadequate, width ( )4. Inadequate, sill 82 NURSING HOME STUDY U.N.C. School of Public Health Patient No. SHORT-TERM PHYSICAL THERAPY GOALS 63. Self-Care ( ) 0. No feasible goal ( ) 1. Improvement to independent care ( ) 2. Improvement, supervision required ( ) 3. Improvement, assistance required periodically ( ) 4. Improvement, assistance required routinely ( ) 5. Maintain present level 64. Mobility ( ) 0. No feasible goal ( ) 1. Independent ambulation and elevation ( ) 2. Independent ambulation, level surface ( ) 3. Ambulation with assistance ( ) 4. To chair, with assistance ( ) 5. Lifted to & from chair ( ) 6. Maintain present level of mobility. 65. Factors Limiting Self-Care at Present ( ) 0. None apparent ( ) 1. Physical facility not adequate ( ) 2. Nursing home staff not adequate In knowledge of restorative techniques In interest in restorative techniques In time to apply restorative techniques ( ) 4. Patient's condition Not in physical condition to tolerate activities Not in mental condition to participate in activities Length of time disability present without attempts at restorative care CI TOTAL STAFF TRAINING IN RESTORATIVE TECHNIQUES 66. R.N.'s. ( )C ( )1. ( )2. ( )4. No No training Demonstration or Workshop Formal training 67. L.P.N.'s No ( ) 0. No training ( ) 1. Demonstration or inservice ( ) 2. Workshop ( ) 4. Formal training ( ) TOTAL ( ) TOTAL PHYSICAL THERAPY SKILLS INDICATED •9. Heat, Cold & Hydrotherapy )C )I. )2. )3. )4- )5. )6. )T. )8. )9. None Cold Infrared Hot moist packs Moistaire Paraffin baths Diathermy Ultrasonics Whirlpool Hubbard tank 70. Therapeutic Exercise I ( ) 0. None ( ) I. Positioning ( )2. Postural ( ) 4. Range of motion ( ) TOTAL 71. Ther. Ex. II 72. Ther. Ex. Ill ( ) 0. None ( ) 1. Neuromuscular re-ed. ( ) 2. Breathing ( ) 4. Other (not in I, II, III) (specify) ( )0. None ( )l. Active ( )2. Resistive — P.R.E. ( )4. General Conditioning ( ) TOTAL 68. Aides & Orderlies No ( ) 0. No training ( ) 1. Demonstration or inservice ( )2. Workshop (~1 TOTAL 74. Miscellaneous ( ) 0. None ( ) 1. Massage ( )2. E.M.S. ( )4. Other (specify) ( ) TOTAL ( ) TOTAL 75. 76. AGREEMENT with CENSUS CARD ( ) 0. Not full agreement ( ) 1. Agreement, ident. data 73. Transfer, ADL, Gait Training ( ) 2. Agreement, length of stay ( ) 0. None data ( ) I. Transfer activities ( ) 4. Agreement, bed status data Bed ( ) 8. Agreement, mobility status Chair ("I TOTAL Wheelchair / v, T°'. let . r«"i 77. AVAILABILITY OF SAMPLE ( ) 2. Activities of D.L. PATIENT Feedin^ ( } °" Patient available „ , ■"""■■ ( ) 1. Deceased since census Personal Hygiene . . - „ , . H . JB ( ) 2. Removed home / * , /-. •. mi ( ) '• Removed to hospital ( ) 4. Gait Training . i . _ ', . «i- 4 i. j ( ) 4. Removed to another uisti- Without aids t .■ n ii . L tution Parallel bars . . . . . , , _, , . . ( ) 5. Away from home day of Cane/crutches . .. Walker V1Slt _ . ( ) 6. Patient uncooperative _ ' ( ) 7. Nursing Home would not " am P •: allow Prosthesis ( ) „_ other ( ) TOTAL (specify) 83 Patient No. CODE I = A = = ACTIVITIES OF DAILY LIVING check appropriate column performed independently performed with some assistance unable to perform any part alone APPLIANCES ( )0,none used ( )long leg brace/e, rt — If. ( ) short leg brace/s, rt. — If. ( ) prosthesis ( Combination CODE P = A = N = FACILITIES check appropriate column present or used by this patient adequate for this patient revision or installation needed *3- BED ( )1. ( )2. ( )3 I A Moving Rolling .Reach bedside table I Sit up Manage covers ■ 'ERSONAL CARE ( )l. ( )2. ( )3 Comb/brush hair Brush teeth/care dentures Wash & dry Manage urinal/bedpan/toilet Take shower/tub bath ■EEDING ( )l. ( )2. ( )3. Use fork/spoon Drink from glass /cup lit E Cut bread IRESSING ( )1. ( )2. ( )3. Manage night clothes, robe Undress, street clothes Dress, street clothes [AND ACTIVITIES ( )l.( )2.( )3. 'Manage call signal Operate TV Use tobacco Open & remove letter Writing kt V its i. fHEELCHAIR ( )0,not used Used: ( )1. ( )2. ( )3- Propel Bed to chair & back Open, through, close door Transfer to toilet & back >. IMBULATION ( )0,not ambul. ( Without aids,( ) walker ( )cane/crutch, ( )other On & off bed Open, through, close door 5C On & off toilet Up & do\m stairs Outside ). Nursing Home Study UNC, SPH 51. ENTRANCE P A N Steps Ramo Ground level 52. ELEVATION Ramp Stairs Elevators 53- GRAB BARS & RAILS Outside steps Outside ramp Inside steps Inside ramp Corridors used By toilet By shower/tub 5*. BED, type Hospital Regular Hi-Lo 55- APPLIANCES Bed Board Bed rails Bedside table Footboard Trapeze Pull-up rope 56. EQUIPMENT, transportation Patient lifter Cane/crutch Parallel bars Walker Wheelchair Other 57. OTHER EQUIPMENT Lounge chair Seat in tub Seat in shower Low lavatory Low mirror Bridge board Adaptive devices Other DOORWAYS Adeq If not adequate Type Width Sill 58. To room 59- To bathroom 60. To dining room 61. To recreat.robm 62. To outside 84 Nursing Home Study U.N.C. School of Public Health Numb er Date Left STRENGTH, RANGE OF MOTION AND SPASTICITY TEST MOVEMENT Right R.O.M. Sp. Strg. Strg. Sp. R.O.M. Neck flexion Neck extension Trunk flexion Trunk extension Shoulder flexion Shoulder extension Shoulder abduction Shoulder adduction Shoulder Int. rotation Shoulder ext. rotation Elbow flexion Elbow extension Forearm supination Forearm pronation Wrist flexion Wrist extension Finger flexion Finger extension Thumb flexion Thumb extension Thumb abduction Thumb opposition Hip flexion Hip extension Hip abduction Hip adduction Hip int. rotation Hip ext. rotation Knee flexion Knee extension Ankle dorsi flex, (kn.ext.) Ankle dorsi flex. (hip, kn. flex) Ankle plantar flexion Ankle inversion Ankle eversion Toe flexion Toe extension CODE: R.O.M. = range of motion, passive 1 = full or functional range 2 = less than major part 3 = minimal to no range. Insert in degrees the approximate position. Sp. = spasticity or spasm 1 = no spasticity 2 = moderate spasticity 3 = severe spasticity Strg. = Strength, voluntary power 1 = functional or above 2 = below functional 3 = not present 85 Appendix B NURSING HOME STUDY UNC SCHOOL OF PUBLIC HEALTH INTERPRETATION OF QUESTIONNAIRE Number on questionnaire 1,2,3,4. Patient number: Census and sampling number, assigned according to Nursing Home in which the patient resides. 5. Age: According to age groupings indicated. 6. Race: Non-white includes Negro, Indian, Mexican, Oriental, and others. 7. Sex: Male or female. 8. Usual County of Residence: county which patient considers as "home" or legal residence, not including nursing home or other institutions. 9. Marital Status and Residence of Spouse: 1. Single = never married 2-7. Married = living spouse 8. Wtdowed = once married but spouse deceased 9. Divorced = legally separated or divorced 3. "Own" home indicated residence spouse shared with patient. 6. "Spouse In another Institution" would include another nursing home. 10. Onset of disability: Length of time since disability prevented full or usual activities. 11. Length of Stay: Time patient resided in present nursing home during the present admission. Patient may have departed for a visit or been hospitalized but not discharged from home. 12. Immediate Prior Residence: Dwelling from which patient transferred to this nursing home. 3. "Other private dwelling " includes residing with non-relative, with or without payment. 13. Reason for Admission: Major factor that precipitated admission to this nursing home. If in Item 12, number 6 (Licenses Nursing Home) was checked, answer selected from numbers 5 through 9. Number 9 may apply to either group. 14. Payment per month: Range of charge for basic room, board, and nursing services monthly. Does not Include extra payment for medications, physicians' visits, etc. 15. Major Source of Payment: The person, group, or agency making largest financial contribution toward this payment monthly. 16,17. All Sources of Payment: Pensions and other forms of insurance payments (other than medical insurance) included in "personal and family". This item is primarily to determine the number receiving social security and/or public assistance payments. 18. M.D. Last Seen: Period since professional visit to or from private personal physician. 19. Physical Therapy Treatment: Individual treatment by a qualified physical therapist (Registered by North Carolina State Examining Committee of Physical Therapists) relating to present disabilities. 'P. H. Therapist" indicates therapist employed by state or local health departments. 86 20. P. T. Treatment Frequency: Time Interval for scheduled Individual treatments. 21. Medications: 1. "Supervision" means either administration, Instruction, ln|ect!on, or application by Registered Nurse or Licensed Practical Nurse. 2. "Without supervision" Indicates patient Is responsible for taking his own medication. Specify by name or type the medications taken routinely. More than one selection may apply to same patient. Indicate if by M. D. order. 22. Diet: Check only one group. If "special", specify type ordered or required, such as soft, low sodium, low fat, diabetic, etc. If M. D. ordered diet, give this information. 23. Instructions about Physical Care: These instructions should be written or reported verbal orders by physician or other qualified personnel (Physical Therapist). More than one selection may apply. Briefly specify Instructions given. 1. "Degree of Activity" would Include specifications on time out of bed each day and the length of time, and limitation on quantity and type of movement (example: "length of hall in walker"), 2. "Appliances" would include braces, footboards, bedrails, bed board and other similar pieces. 3. "Physical Agents" include not packs, electric pads, not soaks, and specific exercise. PHYSICAL CONDITION 24,25. Diagnoses: List below. 24. The primary diagnosis for which patient was admitted to the nursing home or without which the service of the nursing home would not be necessary. 25. The secondary diagnosis for which the patient was admitted to the nursing home, or the one without which the services of the nursing home would not be as necessary, or the condition which complicates the primary diagnosis. Diagnoses 1. Heart Disease 2. Hemiplegia (mainly from C. V. A.) 3. Other circulatory disease 4. Senility, mainly from cerebral arteriosclerosis 5. Fracture 6. Arthritis 7. Paralysis (expect hemiplegia) or degenerative disease of central nervous system 8. Mental disorder 9. Neoplasma 10. Diabetes 0. Any other primary diagnosis Y. No diagnosis 26. Skin: More than one may apply. 4. (Specify "other" conditions noted.) 27. Apparent Nutritional Status: Judged by observation of relation of height, body type, and general appearance. 87 28. Dentition: 1 . "Natural " = adequate number of own teeth to mpsticate food. 2. "Edentulous, does not use dentures" = lack of own teeth, may have dental prosthesis but does not use routinely. 3. "Dentures used" = full dental prosthesis worn routinely. 29. Pain: More than one may apply. 4. "Continuous" includes those relieved temporarily by drugs. 30. "Dominant hand" = the hand that has been dominant as a life pattern. 31,32,33. "No apparent Impairment" = no deficiency recognized by the staff, patient, or researcher. "Moderate impairment" = patient and/or staff aware of some deficiency but it does not Interfere greatly with the care of the patient. "Severe Impairment" = deficiency to a degree that It Interferes with or excessively prolongs care of the patient. 33. "Speech, verbal ": ability to perform motor speech, according to degree of disability. 34, 35. Continence: 1. "Usually voluntarily controlled" - patient able to take care of his own needs or to call for aid In adequate time. 2. "Occasionally lacks control " = patient realizes need too late to obtain help or utensil, occasionally soiling at night or under stress. 3. "Never voluntarily controlled" = patient soils self continually or has Indwelling catheter or colostomy. 36,37. Communication: If there is expressive or receptive comprehension by speech, that Is the desired selection. If no expression or comprehension by speech, but uses or understands hand gestures, select number 2. 38. Consciousness: 1. "Conscious" = aware of stimulus to senses. 3. "Comatose" = loss of consciousness or awareness of stimuli. 39. Orientation: Patient's knowledge as to time, space, location, and people. 40. Attitude: General emotional tone of behavior, especially with regard to cooperation. 41. Ability to follow Directions: Judged on mental and physical ability rather than willingness. 42. Memory for Recent Events: Retention of Information during relatively short period researcher Is with patient. 88 ACTIVITIES OF DAILY LIVING - Coded from Information on yellow sheet of questionnaire. These tests are for what the patient DOES, not what the patient possibly COULD DO. Yellow Sheet explanation: A line through an item indicates that it does not apply to the patient. (/) = and/or. I = "performed independently" = patient able to begin and complete activity safely without human assistance, in a length of time reasonable for age group. A = "performed with some assistance" = constant verbal instruction or manual help necessary. O = as stated. 43. Bed Activities: In coding, use first three items. All "I's = "I", all "O's" = "O", otherwise = "A". Moving = shift from one side of bed to other, up and down. Rolling = roll on either side, not necessarily to prone and back. Reach bedside table = table on correct side for patient, able to reach objects. Sit-up = sit up on side of bed, legs over side of bed. Manage covers = able to pull up or discard light covers. 44. Personal Care: Coded on first four items. All "I's" = "I", all "O's" = "O", othewlse = "A". "Wash and dry" = at lavatory or in bed when materials supplied. Back excluded. "Manage urinal/bedpan" = take care of needs if utensils within reach. Care of catheter. 45. Feeding: Coded on first two items. Both "I's" = "I", both "O's" = "O", otherwise = "A". 46. Dressing: Use grade on last item. "Night clothes" = gown, pajamas, and slippers "Street clothes" = underclothes plus dress of slacks/skirt and shirt. Exclude tying shoe laces. 47. Hand Activities: If "I" in all that apply = "I", If "O" In all that apply = "O", other = "A". Signal = light, bell, button, etc. Operate TV = manual operation, not approach to. Use tobacco = activities of smoking, chewing, dipping. 48. Wheelchair: Coded from first three Items. 0. "Not used" = patient does not occupy wheelchair. 1. "Used - I" = patient gets In and out and propels chair without assistance. 2. "Used - A" = patient required assistance getting in and out and propelling chair. 3. "Used - O" = patient can not help self In getting to chair or propelling, lifted irv/out. 49. Ambulation: 0. "Not ambulatory" = does not stand on feet or take step. 1, 2. "Aids" = mechanical aids, such as walker, chair, crutch, cane. 3, 5. "Ambulatory Independent" = getting from bed or chair to standing position and walking without manual assistance. 50. Appliances Used In Ambulation: Specify type and extremity. 89 FACILITIES Questionnaire coded from yellow work sheer. All items are evaluated only for the patient under consideration. Use CODE on yellow sheet for Interpretation. 51. Entrance: Assumes that steps will always be present. 52. Elevation: From one level to another within building where patients have access to these levels. Could be full story or raise or drop of a few inches. 53. Grab Bars 54. Bed Type In Use or Needed: First word is for present usage, second for type needed. 5. Hi-Loused: either manual or mechanical varylng-height beds. 55. Appliances: See yellow work sheet for individual Items 56. Equipment for mobility. See worksheet for Individual items 57. Miscellaneous Equipment: Refer to worksheet for individual Items 58. 59, 60, 61, 62. Doorways: Evaluated by adequacy, If Inadequate, what makes It inadequate for this patient? Strike through if room Is not present. 2. "Type" = type of door or ease of function. SHORT-TERM PHYSICAL THERAPY GOALS 63. Self-care: O. "No feasible goal " = physical therapy skills are not indicated due to present condition or prognosis of patient. 1 - 4. "Improvement. . . " = that goal for patient would include a progression In ability to take care of self-care needs. 5. "Maintain present level" = no higher functioning anticipated but Includes those patients already fully independent. 64. Mobility: 0. "No feasible goal " = physical therapy skills are not indicated due to condition of the patient. 1 - 5. Indicates some improvement In level of mobility anticipated. 6. As stated. 65. Factors Limiting Self-care at Present: Check items which seem to be the predominate ones. More than one may be indicated. STAFF TRAINING IN RESTORATIVE TECHNIQUES 66. 67, 68. "Restorative techniques" include 1. Physiological positioning with emphasis on specific reasoning in certain conditions. 2. Range of motion activities Including normal range of joint motion with limits and precautions defined. 90 3. Transfer activities, particularly: Movement in bed, methods of sitting up, bed to chair, basic ambulation. 4. Activities of self-care, such as bathing, dressing, and feeding. "Formal training" Is basic preparation of R. N.'s and L. P. N.'s. Professional demonstration would be by physician, physical therapist, or R. N. trained in rehabilitative procedures. PHYSICAL THERAPY SKILLS INDICATED Factors in indicating skills: Goals for nursing home patients are maintenance of present level of self-care or increased ability in self-care toward greater independence. Patient's present mental and physical status as well as medical prognosis are factors in the determination. 69, 70, 71, 72, 73, 74. More than one item may be checked. Specify within Items as Indicated. 75, 76. Agreement with Census Card. During visit, a duplicate patient census card made on each survey patient. These Items checked against the original card. 0. "Not full agreement" = all items on second census card do not agree with all Items on first card. 1. "Agreement, Identification data" = age, sex, and race items are alike on both cards. 2. "Agreement, length of stay data" = this item alike on both cards. 4. "Agreement, bed status data" = this item alike on both cards. 8. "Agreement, Mobility Status" = this Item alike on both cards. 77. Availability of Sample Patient. If patient is available, "O" checked. Otherwise, check Indicated reason for non-availability. 78. Range of Motion (from green sheet in questionnaire). 0. Functional range In all extremities. 1. Lack of functional range, 1 extremity. 2. Lack of functional range, 2 extremities. 3. Lack of functional range, 3 extremities. 4. Lack of functional range, 4 extremities. 79. Strength, voluntary 0. Functional voluntary power. 1. Lack of functional power, 1 extremity. 2. Lack of functional power, 2 extremities. 3. Lack of functional power, 3 extremities. 4. Lack of functional power, 4 extremities. 91 H00008599 V WT 27 AN8 C182 1962 WT 27 AN8 C182 1962 Cameron. The report of a study of patients in licensed nursing homes of No. Car. ISSUED TO G -S ('_, _ Swz^*f COg^t : ! LI : 27 01 5 BfcfK Hi TH P m Ui*H 7S P T I ISS