The Declining Quality of Elderly Healthcare
By: Glenn W. Clark / February 2, 2011
Health care is a trillion dollar industry and a social venture that involves and affects all citizens in America. This project is about the future of elderly health care. Initially, this study look into the present situation of the elderly healthcare followed by a detailed analysis of the environment (i.e. various factors that impact the elderly healthcare).
1. Health status that includes diseases, disabilities and lifestyle behaviors.
2. Access to health care services that includes the number of available resources like hospitals, clinics, health care providers, nursing homes etc.
3. Social factors that includes living arrangements, cultural, social and religious values.
4. Economic status that includes the income, insurances and the assets of elderly population.
All of these factors are needed to be taken in account when assessing the elderly care needs in the future as the future is built on the basis of present. In this part of the project we will discuss trends and health care expenditures and who pays for health care; demographic trends for the population as a whole and for the elderly; the impact of an aging population and immigration on health care resources; trends and life styles in chronic diseases; forces driving health care utilization, including medical breakthroughs, growing consumer demands, and governmental and institutional policies; trends in the supply of health care resources and the allocation of financial resources to the health care services.
Define your particular focus in terms of what your chosen industry’s present form is, its market, and a short summary history of its birth, growth and development
INTRODUCTION
Healthcare is a trillion dollar industry and a social venture that involves and affects all citizens in America. This project is about the future of senior citizens or elderly healthcare. The healthcare needs of the elderly are influenced by a number of factors including health status (diseases and illnesses, disabilities, lifestyle behaviors), access to healthcare services (availability, discrimination), social factors (living arrangements, cultural and religious values, education), and economic status (income, insurance, assets etc).
The future is built on the present – slowly, and with visible patterns that we call trends. As such the future of elderly healthcare can be viewed as an extension of the present, incorporating many new developments. These new developments can be studied in the form of socio-cultural changes that is occurring and impacting the elderly healthcare. Elderly people rely mainly on their social network. They need to stay connected to families and friends. Society can play a greater role to keep this network alive. Our social and cultural system is rapidly changing and it is impacting the elderly population. Economy has impacts on everything and so elderly healthcare is a major concern. Government spending on Medicare and Medicaid has increased and due to the current economic downturn, these spending may be lowered putting the future of elderly healthcare is at great risk. Besides social-cultural and economic changes, political changes have great impacts on the elderly healthcare. After nearly twenty years of political posturing and many failed attempts by a multitude of political figures and four presidents, the United States has witnessed a bitter year of debates and loose bipartisanship. Recently, Mr. Obama was able to sign into legislation a comprehensive agreement to overhaul the country’s health care system and cemented his place in history. This piece of legislation inevitably will all but guarantee access to medical insurance for tens of millions of Americans. Upon review of the new bill, it promises to issue an executive order "to ensure that federal funds are not used for abortion services and a provision for the care of our elderly populations was an additional add-on”. This bill attempts to effect every individual in the United States and the most affected will be the aging baby boomers. This legislation will create a new bureaucratic department (The National Coordinator of Health Information Technology). The sole function of this unit will be to monitor the treatment of the elderly to ensure that your doctor is doing only the minimal amount of treatment and at the same time conforming to the federal governments predetermined standards of care. Unfortunately, the standards of care vary from case to case and the doctors and healthcare providers will only be able to do what they deem appropriate and cost effective. Rapid technological changes have impacted elderly health care. Technology provides better home, self-care, and more access to care, and reduce costs. Elderly can get up to date information on health, utilize latest health testing and monitoring tools, and automated and easy to use equipments to help stay healthy.
One of the most dramatic changes in the last decades in the world of health care education has been the incredible advance in technology. Information and communication technologies such as personal computers, video products such as videocassettes and videodiscs, and communication devices such as modems and facsimile machines, have changed the world. Increased performance and speed have been matched by declining costs, thus enabling more and more schools to have access to these new technologies (Fallows & Bhanot, 2002). According to Olade (2004), future changes in elderly health care using observed phenomena and evidences is an example of education which refers to formalized experiences designed to enlarge the knowledge or skills of nursing educators or practitioners. Through experiences and evidences, the ability to learn actual clinical practice and the orientation in health care protocols and policies in handling patients’ needs will be achieved. This method is also termed as Evidence-based practice. Evidence-based practice involves a combination of many disciplines, including aspects of multidisciplinary sciences to promote the restoration and maintenance of health in elderly clients. Much literature has been published on this topic in recent years, an evolving subject and concept for specific practices that promote more effective, safer and more efficient ways of caring . Maintaining and improving high satisfaction among elderly health care practitioner is an important area to discover (Fallows & Bhanot, 2002). To achieve this, health care workforce to continually strive for excellence, be responsible and flexible enough, have the confidence to face the challenges, and inspire everyone with a shared vision.
ENVIRONMENTAL SCAN
This section presents an environmental scan in terms of socio-cultural, economic, political, technological, and educational changes and its impacts on the elderly healthcare. This entire work is grouped into three sections:
1. Socio-cultural and Economic changes
2. Political and Technological changes
3. Educational changes
These position papers explains relevant changes from the perspective of the elderly thus examining the key trends affecting the elderly healthcare and form the groundwork for looking into the future by taking all this information into account as the foundation upon which the future of healthcare for the elderly will emerge.
SOCIO-CULTURAL AND ECONOMIC CHANGES
This section uncovers key driving forces that impact elderly healthcare.
These driving forces include:
1. Demographics
2. Health Status and Life Style
3. Healthcare facilities
4. Healthcare workforce
5. financial resources
1.1 Demographics:
The more consumers there are the greater the demands for product and services (more people to feed, clothes, houses and treat for illnesses. According to US census bureau, this year when the leading edge of the baby boom cohort starts to hit 65 years of age, the relative size of the elderly population will begin to increase more dramatically. According to US Census Bureau projections, the relative size of the older population in 2015 will reach 14 percent. In 2030, the percentage is projected to be almost 20% of the total population. Additionally, the number of people 65 and older in the United States accounted for 13 percent of the total population. Between 2007 and 2008, this age group increased by 927,305 people. Also to note, projected population of people 65 and older in 2050. People in this age group would comprise 20 percent of the total population at that time. (U.S. Census Bureau, 2009)
Immigrants:
Another high growth category of Americans is the immigrant population. Some people think that Immigration is the life blood of this nation. They are wrong. This myth has been perpetuated since the arrival of the pilgrims into the actions of twentieth century European and Asian immigrants of today. In 2008 over forty three million foreign born residents (12% of the population) were living in the US. (Kaiser Commission on Medicaid and the uninsured, 2003) most of these immigrants (73%) entered the US legally and almost one third of these are naturalized citizens. The rate of legal immigration in 2008 was estimated to be just over 1.5 million people (Social security administration board of trustees, 2008).
The expansion of the US population through immigration has significant negative impact on health care. Studies show that certain groups are more prone to illnesses and diseases and they grow in numbers thus the demand on health care system increases.
Life expectancy
Life expectancy at birth and at age sixty five differs according to gender, race and ethnic status and it continuously increases over the next decades. Life expectancy increased by nearly 30 years over the entire century. In the year 2025, projected life expectancy for men and women at birth will be 76.5 years and 81.5 years, respectively. The slow ascent is projected to continue, and by 2050 life expectancy at birth is expected to be 79.0 years for men and 83.5 years for women. To learn more about trends in life expectancy and mortality go to the module titled “Trends in Life Expectancy and Mortality.”
One key aspect of this discussion is “ life expectancy is only part of the story of aging in America”. It is large cohorts of aging persons (such as the baby boom generation) in combination with longer life expectancies that make the graying of America a truly great demographic phenomenon. The next section provides one way of assessing the magnitude of these combined forces.
Growing consumer demands
The demand of health care services have been increasing steadily due to an expanding population base, the increasing proportion of the elderly, increasing incidence of chronic diseases, medical breakthroughs, increasing availability and use of pharmaceutical drugs, and the availability of financial resources ( primarily health insurance and government support. As more consumers with health insurance become aware of new treatments and drugs they require them from their physicians. Patients are also becoming aware of what constitutes good care and so becoming more demanding of services. They become less healthy through life style choices,, consumers look for fast medical cure for obesity, hyper tension, diabetes, and other chronic conditions.
Market forces also affect the health care environment that includes:
1: Availability and influence of providers (hospitals, doctors, nurses, insurance companies, drug companies).
2: Competition among providers
3: Pricing and profit incentives.
4: Government subsidies (Medicare reimbursements, research funds, hospital grants)
5: Regulation of providers, pricing, and distributions.
6: Government policies and programs (Medicare, Medicaid, supplemental medical insurance)
7: Access to and affordability of health care.
1.2 Health status and life style
Additional factors adversely affecting elderly health care services is the state of health i.e. illnesses, diseases, fitness etc. Many factors go into creating the state of health of elderly population. These factors include genetics, family history,, life style behavior, environmental conditions, educational opportunities, and access to health care ( financial, transportation and insurance).
The centre for disease control has estimated that direct medical costs associated with physical and activity is nearly $ 76.6 billion, while the direct and indirect cost of smoking are $ 75 billion (CDC and prevention, 2005).
“The shift towards chronic illnesses stemming from lifestyle behaviors influence up to 50% of our health status” (Institute for the future, 2003). The recent studies show that chronic diseases inevitably leads to disabilities and limitations in daily living activities, forcing patients to require home cares and/or rehabilitation, and many cases, to be institutionalized and assisted living facilities or nursing homes.
1.3 Healthcare Facilities
Hospital Occupancy
As of 2005 there were 7569 hospitals in the country which employed 1.5 million (US census bureau, 2005). Community hospitals which account for 85% of all hospital total to 4919.
Hospitals provide inpatient services that include accommodations for routine care, intensive and coronary care, and surgical care, obstetrics and new born nurseries, and behavioral health emergencies, crisis stabilization. Community hospitals bed capacity has declined from 436 beds per 100,000 population in 1975 to 280 beds in 2005 (the Henry J. Kaiser foundation, 2006), due to reduce length of stays and the use of outpatient procedures. Currently hospital beds are sufficient to meet demand accept in high growth areas with economic problems. With population growth especially in areas serving the immigrants and elderly population, hospitals are under pressure to accommodate more patients.
Hospital Outpatient Services:
Outpatient services are increasing faster than inpatient services. (In 2008 the number of outpatient visits was 98.2 million).
Emergency Services
A visit to hospitals in emergency departments has been increasing while the supply of emergency departments has been declining. Visits to hospital emergency rooms amounted to 115.2 million (forty per one hundred person in 2008)
Nursing Homes
Nursing homes have been around long time, but over the past 10 to 15 years utilization on per capita bases has been declined. Some of the reasons in this decline include lower level of disabilities among the elderly, expansion of home care and availability of alternative options such as assisted living (Dennison, 2004). Nursing homes now serve a much older population, 46% of all nursing homes residents were over age 85 (national centre for health statistics).
Assisted Living Facilities
As the elderly age and their ability to provide for their daily needs such as activities declines, their choices regarding living arrangements have become driven by economics. Both are reflective in terms of what their family can afford V what their families can provide. Analysts argue that institutional options are often close to those who can neither afford the expense of long term care nor wish to spend down their resources in order to benefit from public funding of care (Mutchier & Burr, 1999).
1.4 Analysis of healthcare work force
The majority of health care services are delivered by health care professionals. The availability of which varies by profession, but certain common trends can be found. In January 2006 the centre for health work force studies released a report on the impact of the aging population on the health work force. The outcome the report concluded that health care professionals received limited or marginal training on care to the elderly; healthcare professionals themselves are aging rapidly and supplies are declining; and many health professionals lack diversity and serving minority groups is less than desirable.
Physician
Physicians and surgeons work in office based practices (50%), hospitals -25% and other settings-25% (Bureau of labor statistics, 2010).
The aging of the population will increase demand to 3.1 per 1000 persons (National Centre for Health Workforce Analysis, 2003).
Demand for physicians’ services is highly sensitive to changes to consumer preferences, health care reimbursement policies and legislation for example if changes to health coverage result in consumer facing out of pocket costs, they may demand fewer physician services. Demand for physician services may also be tempered by patients relying more on other health care providers. Such as physicians’ assistants, optometrists, nurse anesthetists and nurse practitioners for home health care services (Bureau of labor statistics, 2010). Physicians providing charity care and treating Medicaid patients declined between 1997 and 2001)
.
Physician Assistants
Physicians’ assistants are most needed in inner cities and rural areas where there are fewer doctors per capita. In 2002 there were sixty three thousand (Bushnell, 2004).
Nurses
Currently there is a shortage of registered nurses. The shortage is due to the retirement of a large number of nurses who are not being replaced with equal numbers of nursing graduates due to the lack of ability of nursing schools to accommodate the number of applicants (Reuter’s health, 2003). Current projections show the nation could be short of 800,000 nurses in the coming years to replace retiring nurses the number of nurses would have to increase by 40% annually (Reuter’s health, 2003)
1.5 Financial resources:
Healthcare services are exchanged for money in the form of direct transaction or are made through the third party (insurance company, charity or government). All products and services are provided by private, nonprofit, or government organizations through sales, grants and donations or tax revenues and by individuals through income (earned, saved)
Allocation of Financial Resources:
A huge amount of individual, employer and government financial resources is allocated to health care. The centers for Medicare and Medicaid services publish the national health expenditures, which measures spending for health care in the US by type of service delivered (hospital care, physician services, nursing home cares) and source of funding for those services( private health insurance, Medicare, Medicaid, out of pocket spending, etc) (Center for Medicare & Medicaid Services, 2004). CMS report indicated that national health expenditures had increased from $1.4 trillion in2001 to @1.6 trillion in 2002 (9.3 percent increase). This growth has exceeded the rate of growth of the economy as a whole by nearly 6 percent, which means we are spending more than we are making. Healthcare expenditure in 2003 accounted for 15.0 Percent of the Gross National Product. What it was 30 years ago and much higher than Canada.
The government pays nearly half of the healthcare bill. Government spending on health in 2002 amounted to 46 percent of all health expenditures, with 17 percent paid under the Medicare program, 16 percent under Medicaid, and 13 percent under other government programs (Center for Medicare and Medicaid Services, 2004)
Insurance:
Most American with health insurance is able to get the entire standard healthcare they need and want. National Bureau of Economic Research (NBER) found the following:
- The majority (81%) of us wage earners have health insurance
- In 1996 only 68% of the self employed under age 63 had health insurance
- An estimated 31 million people were noninsured in 1996
The geographic and ethnic distribution of America’s uninsured is uneven and varies widely. This unevenness correlates with multiple factors including employment pattern, poverty, the organization of Medicare systems, and political differences among states. The number of Americans without health insurance coverage rose from 43.6 million in 2002 to 45.0 million in 2003 (15.6 percent of the population) (US census Bureau, 2005). Caution must be exercised in considering the number of uninsured in America. The uninsured do have some source of care: Public hospitals, community health centers, local clinics, and some primary health care physicians. American without insurance are eligible for Medicare (Seniors) or Medicaid (poor) to go to hospital emergency rooms for treatment (hospital cannot refuse them). Even illegal immigrants can find treatment. The financing of health care is a complex and critical issue, since the majority of services are funded through either government or private insurance programs. With more employers opting out of providing insurance (especially to retirees and low paid employees), the burden is shifting more to individuals and, for those who cannot pay, to the public welfare system or bankruptcy court. This problem is compounded by the increasing burden on the Medicare System as our population continues to age.
FUTURE CONCERNS OF THE ELDERLY
When the elderly think about the future, they are concerned with three main issues:
1. Social issues:
2. What kind of life, life style, and social life will they have?
What kind of quality of life?
For how long they will be able to maintain their independence?
Where they will live (alone, with family/friends, or institutionalized)?
Where they will be safe?
2. Health issues:
How healthy will they be when they grow older?
How long they will live?
What kind of illness will afflict them and when?
Will they find the quality care they need when the time comes?
3. Economic/Financial issues:
How they will pay for living expenses and health care when they no longer have the income from steady full-time employment?
Will they have to work part-time?
Will they have to go back to work full-time?
These three reasons of concerns are inseparable - a change in any aspect of one area can have a dramatic effect on another area.
Inter-relationship of factors affecting the Elderly:
Foundational Factors Intermediary factors Outcomes
Family
Community Social Life
Residence
Education Independence
Social Status
Social Security
employment Financial assets
Income Financial Status
Healthcare findings
Globalization
Medical Technology
Healthcare
Life Style Diseases
Disability
Longevity Health Status
Quality of Life
Life expectancy
Genetics Age
Sex
Ethnicity
These primary concerns act together to influence the lives that the elderly will have and the healthcare needs they will encounter in the future. Policy makers need to take into account the needs of the elderly not just today but in the future, especially since today’s policies influences the future along with the event that American will encounter as they grow older and became the elderly of 2050.
Independence:
Quality of life is a product of one’s financial status, life style, health status, environment, and social support. As many Americans age, they gradually lose their independence, mobility, health, friends, and income, resulting in a decline in their quality of life. Their access to resources in their environments decreases as they becomes less mobile (can no longer drive a car, walk to public transportation, or find someone to drive them places). Without transportation, they cannot sustain employment, do volunteer work, get to social or cultural events, or visit friends and family. They become more home bound, socially isolated and depend on care givers.
As the elderly grow older and their health declines they become less able to care for themselves (financially or in terms of daily living activities), and become even more dependent on others including care givers and family members, to provide assistance with daily living activities.
In 2003 73% of older men lived with their spouse while only half (50%) of older women did (federal interagency forum on aging related statistics, 2004). About 30.8 %( 10.5miilion) of all non institutionalized older persons in 2003 lived alone. (7.8 million Women and 2.7 million men). They represented 39.7% of older women and 18.8% of older men (national council of aging, 2005).
Another types of living arrangement for the elderly is the assisted living facility. The national center for assisted living reports that:
- Approximately 800,000 people in US lived in assisted living communities
- With one third of them males and two-third females
- The typical resident is an 80 year old woman, who can walk on her own but required help in performing 2-3 activities of daily living (Sunrise, Senior Living, 2006)
Another important concern for Americans as they age is their standing in the community and their ability to continue to participate in activities that contribute to their well being. Unlike some cultures, where the elderly gain status in the community as they age, the US culture tends to degrade the social status of individual as they age. To combat this, organizations that represent the elderly (such as AARP) work aggressively to promote the elderly and advocate for their needs.
When individual retire they are separated from the social group they spend the most time with – namely, their co worker. If they have a spouse, they tend to spend more time with that person. This behavior could, in turn, further isolate them from other potential social contacts. Those who live in retirement community, benefit from the recreational and social activities that take place in the community. Access to recreational community is also important in terms of opportunities for physical exercise, which is critical for maintaining health and combating obesity, osteoporosis, and physical disabilities.
Financial status:
The majority of American spend what they can earn (or more) and save little (the personal savings rate as a percentage of disposable personal income in 2004 was 1.2 percent (compared with 11.2 percent in 1982) (Reinsdorf, 2005). While they are employed, individuals can acquire material goods and afford the interest on accumulated debts (credit cards, loans, mortgage, etc). But for many American as they age or retire or take part time or low-paying positions, their ability to pay basic living expenses and increasing medical expenses exceeds their financial assets, which include social security, other pensions, part time income, and assets (savings, dividends)
A secure retirement foundation on today’s America has to be built on four strong pillars: social security, savings and pensions combined, earning from continued work, and health insurance” (William D. Novelli, 2001). Those who are elderly and have ample financial assets (Savings, investments, property, etc.) have a good chance of maintain good quality life. They can pay for house hold living expense, various recreational activities, private transportation to social and cultural events, expensive medical procedures and prescription drugs, the services of professional care givers, and assisted living facilities. Those with fewer financial assets must depend on part time jobs (if they can get then), pensions (social security and, in some cases, private pensions), and Medicare insurance. Those who live I poverty are even more confined, having to subsist on social security, Medicare/Medicaid, welfare, and some time donations from family and nonprofit organizations
Income:
The elderly agree depended on income, at any age group, to pay for everyday expenses, including healthcare, since most elderly are retirees, they depend on non employment source of income, including interest on investment, sales of assets, and pensions. The median income for elderly household was $19448 in 1996 (National bipartisan commission on the future of Medicare, 1998). In 2001, the median income was $14152 ($19668 for males and $11313 for females). The state of working America 1998 -99 published by the economic policy institute “found that despite of 2.6 percent increase in real wages since 1996, median wages were still below their level in 1989 and typical family had to work more just to maintain it standard of living” (Beans, 1999).
Source of income:
In general, as people grow older, their incomes decline while their dependence on SS increases (national bipartisan commission on the future of Medicare, 1998)
Poverty: In 1997 the poverty level for an elderly individual was $7698 and for a couple was $9709 (National Bipartisan Commission on the future of Medicare, 1998). Poverty rate among the elderly have stabilized at 10 percent since 1999, with 3.4 million elderly persons below the poverty level in 2001 (administration on aging, 2002).
Older women are more likely than older men to be poor (12 percent vs. 7 percent); those not living with relatives were much more likely to poor (20 percent) than were older persons living with families (6 percent); and the worst situation is to be an older Hispanic woman living alone or with non relatives (50.5 percent)
Social security:
The importance of social security for the elderly cannot be overemphasized, social security accounts for more than half of retirement income (90 percent or more for a quarter of the elderly) and keeps 40 percent of the elderly out of poverty (AARP, 2002), Lower-income older retirees receive more than three-fourth of their income from social Security. By contrast, middle-income older retirees receive about half and younger retirees about one-third of their incomes from social security. Among the high income group, both older and younger retirees receive less than one-fifth of their incomes from social security (AARP, 2002).
GOVERNMENTAL AND INSTITUTIONAL POLICIES
Many elderly depends on social security as their main income. If social security remains as it is with the current level of employment tax and social security benefits there will be insufficient funds available to pay for the committed benefits for a larger number of retirees in the year 2017. Congress has began the process of considering various alternatives reforms to social security if the elderly ends up with lower pensions in the future it will jeopardize their ability to pay for health care, thereby reducing the demand for elective health care services and placing additional financial burdens on the tax payers.
The demand for the health care services is also influenced by the policies of the government and of institutions such as insurance companies, employers, and health care providers. For example funding practices influences the health care environment. When the government increases its health care costs reimbursements to providers, there is an incentive for providers to refer more patience to doctors, to order an increasing number of diagnostic tests, or to increase referrals for elective surgeries. These actions drive up the demand for health care services.
1. POLITICAL AND TECHNOLOGICAL CHANGES
The most recent healthcare legislation and its impacts on elderly healthcare. Besides political changes, this section goes into a detailed discussion of technological changes in terms of medical innovations and information systems and support for elderly healthcare
2.1 The Healthcare overhaul in United States
After nearly twenty years of political posturing and many failed attempts by a multitude of political figures and four presidents, the United States has witnessed a bitter year of debates and loose bipartisanship. Mr. Obama was able to sign into legislation a comprehensive agreement to overhaul the country’s health care system and cemented his place in history. This inevitably will all but guarantee access to medical insurance for tens of millions of Americans. The bill promised to issue an executive order "to ensure that federal funds are not used for abortion services." A provision for the care of our elderly populations was an additional add-on. Some of the proposed benefits indicate that the bill’s health rules will affect every individual in the United States (445, 454, 479) and the most affected will be the aging baby boomers. One of the most alarming facts of this current legislation is, medical treatments will be tracked electronically by a federal system. Having electronic medical records at your fingertips, easily transferred to a hospital, is beneficial and it will help avoid duplicate tests and errors. But, upon closer examination, the bill goes further than prior intrusive legislation ever has. The legislation will create a new bureaucratic department. (The National Coordinator of Health Information Technology) The sole function of this unit will be to monitor the treatment of the elderly to ensure that your doctor is doing only the minimal amount of treatment and at the same time conforming to the federal governments predetermined standards of care. Unfortunately, the standards of care vary from case to case and the doctors and healthcare providers will only be able to do what they deem appropriate and cost effective. The goal is to reduce costs and streamline your doctor’s decisions (442, 446). Analysis shows that these provisions are virtually identical to what Tom Daschle (DEM) prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Mr. Daschle,” doctors have to give up autonomy and learn to operate less like solo practitioners.”
Keeping doctors informed of the newest medical findings is important, but enforcing uniformity goes too far:
Penalties for non compliance
The losers’ of the new system will be the Hospitals, Doctors and the elderly. This group of citizens is not intentional abusers but is unaware of the new system and will face severe penalties for non-compliance. What is meant by a “Meaningful user” isn’t defined in the bill. That task will be left to the HHS secretary, who will be empowered to impose penalties for non-compliance in accordance with sections 511, 518, 540-541.
We have to ask “What penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment?” The vague language is intentional. In Tom Daschle book, he proposes an appointed body with vast powers to make the “tough” decisions elected politicians won’t make. This argument is echoed in the Article “The Case For Killing Granny” (Newsweek, September 2009) The article points out that “almost 1/3 of the money spent by Medicare goes to patients in the last two years of life” How sad for a powerful nation such as the United States to propose such a sick idea as this. This group of Americans sacrificed in there early years and now our government wants to turn its back on them. Morally this is wrong.
The political mud bath and the stimulus bill adds another bureaucratic level to the health care system and calls it the Federal Coordinating Council for Comparative Effectiveness Research (190-192). The goal, Daschle’s book explained, is to slow the development and use of new medications and technologies because they are driving up costs. He praises Europeans for being more willing to accept “hopeless diagnoses” and “forgo experimental treatments,” and he chastises Americans for expecting too much from the health-care system.
Elderly Hardest Hit
Daschle says health-care reform “will not be pain free.” Seniors should be more accepting of the conditions that come with age instead of treating them. That means the elderly will bear the brunt of the younger generations lack of management skills..
Medicare now pays for treatments deemed safe and effective. The stimulus bill would change that and apply a cost- effectiveness standard set by the Federal Council (464).The Federal Council is modeled after a U.K. board discussed in Daschle’s book. This board approves or rejects treatments using formulas that divide the cost of the treatment by the number of years the patient is likely to Live. These numbers are determined by actuary tables developed by insurance companies. Treatments for younger patients are more often approved than treatments for diseases that affect the elderly, such as osteoporosis and dementia.
In 2006, a team of U.K. health board care givers decreed that elderly patients with macular degeneration had to wait until they went blind in one eye before they could get a costly new drug to save the other eye. It took almost three years of public protests before the board reversed its decision. In this instance we need to apply the principals of Social Networking to correct the wrongs.
Hidden Provisions:
Once the Obama administration’s economic stimulus bill passes the Senate in its current form and sustains the test of time, seniors in the U.S. will face similar rationing. Defenders of the system say that the groups most likely to benefit will be the younger generations but they to will sacrifice later.
The stimulus bill will affect every part of health care, from medical and nursing education, to how patients are treated and how much hospitals get paid. The bill allocates more funding for this bureaucracy than for the Army, Navy, Marines, and Air Force combined (90-92, 174-177, 181).
Hiding health care legislation in a stimulus bill is intentional. Daschle supported the Clinton administration’s health-care overhaul in 1994, and attributed its failure to debate and delay. A year ago, Daschle wrote that the next president should act quickly before critics mount an opposition. “If that means attaching a health-care plan to the federal budget, so be it,” he said. “The issue is too important to be stalled by Senate protocol.”
1.2 CTUHR and elderly healthcare
CTUHR’s mission will be to provide information on the decline of elderly care and our analysis is based on the current healthcare being offered in the United States. The suggestion uses the Chronic Care Model (CCM) and will attempt to demonstrate how to forge a close, personal relationship between a patient and his or her caregiver who working together can develop a personalized and proactive care plan which will improve the quality of health care. Given that the majority of patients served by the CTUHR model will have multiple, interacting conditions, the interdisciplinary team approach has demonstrated the ability to improve the quality of care and improve health outcomes by addressing not only the patients’ medical needs, but also their psychological, social, and spiritual needs. CTUHR staff drives patient-centered care by focusing on what patients want (in terms of their health and social well-being) in their later years, rather than having the physician solely determine what their goals should be. Considering that providers at this center are treating patients whose conditions range from dementia, depression and diabetes, this mindset is extremely important in the day-to-day operations of the center. The challenges in today’s society is associated with the ability to delivering patient-centered care at an affordable rate is complicated for the senior population and despite the availability of health insurance coverage through Medicare the issue is sometimes relate to mobility. Not only do seniors face multiple acute and chronic conditions in many areas it is becoming increasingly difficult for new Medicare patients to find providers due to federal limitations and issues regarding reimbursement. Independent research shows that in many instances, elderly citizens are relying on their children in the golden years for assistance. In the past forty years, the average number of children in the family has decreased from four children per household to 1.5. In effect, we are placing the burden of taking care of our elderly onto on child. The cost of medication has dramatically affected the quality of care and without legislation; this single factor can negatively impact the quality care system.
Research questions posed to healthcare providers shows an unwillingness to take the older patients on as patients due to physician concerns about the adequacy of Medicare reimbursement rates.
How CTUHR Practices Patient-Centered Care (PCC)
The CTUHR’s mission well be to establish a system of care that acknowledges and addresses the needs of the elderly population through the use of interdisciplinary teams. These teams will concentrate on the psycho-social aspects of life and determining what elements are affecting an individual’s physical health. The proposed plan uses the center’s leaders as data collectors to ascertain the acceptable order of care needed to provide high-quality, cost-effective care to a growing elderly population; new models of care will be needed in the next 10 to 20 years as we see the baby boomers entering the retirement mode. The staff acknowledges that the interdisciplinary team model approach is flawed; we must also acknowledge that the adoption at current rates is a financial loss leader. At the current rate of reimbursement, centers around the United States are not able to survive without financial support from the government and other funding sources. The CTUHR plan shows promise as a promising model for continued study and refinement for its long-term efficiencies and potential to improve the health and functionality of the elderly health care plan currently in place. In support of the interdisciplinary team approach, the CTUHR suggests the utilization of the “Shared Care Plan,” and other practices described below.
The coordination of Care via the Interdisciplinary Team Approach
In addition to usage of physicians, the CTUHR employs advanced practices of using PA’s, Nurses, and the multi-level platforms of prescribed care offered by geriatric pharmacist, nutritionist, Herbalist, and licensed clinical social workers to deal with end of life issues.
Empowerment and Activation via the Shared Care Plan
The Shared Care Plan (SCP) web-based internet tool was developed by the Community Health Improvement Consortium (CHIC), a group of healthcare providers in Whatcom County, Washington, one of whom is affiliated with has shown that patient involvement has the potential to yield enormous results. Among the many trivial tasks is the inclusion of the patient personally recording the personal health record? The patients is responsible to fill out lists and a patient’s personal profile, self-management goals, treatment goals, prescriptions and medications, allergies, chronic diagnoses, document advance directive, and health care team members review this data. The scheme was developed as a tool to help individuals with chronic conditions better manage their multiple needs, providers, and pharmaceuticals. It will be a widely used tool by CTUHR patients and practitioners. The resurgence of old time medicine has proven to be the missing link between quality care and effective care management. One proven element in the treatment of elderly is the “Welcoming, Familiar Environment” Prior to the initial meeting with physicians, patients and family members are provided with an orientation in which they meet with staff members, review their medications, insurance information, and medical history, and generally become familiar with the CTUHR environment. This will become a standard of care and unfortunately regulatory organizations frown upon home bound health care. As providers meet with patients, they are given an overview of available services, which helps to broaden their awareness of primary and preventive services from which they could benefit. One case study the home environment was mentioned as a determining factor in the recovery time. This case was in Whatcom County, Washington, a community of almost 180,000 people.
Socio-Cultural Competence and Data Collection Processes
Current facilities do not see the elderly as a whole person. Administrators and healthcare providers do not understand the nee for the understanding the elder lies needs of educational, cultural, and especially the social history. Each new patient who walks in the door receives a “new patient” packet, including questionnaires that information on a variety of issues, such as their past medical history, basic demographics, current living arrangements, frequency of contact with family and friends, recent emergency department, hospital, and physician visits, ability to conduct activities of daily living (ADLs), screening for previous falls, urinary incontinence, depression, immunizations, and concerns about health risks, such as fear of falling. These data are used to create a health risk stratification rating. A patient is determined to be either low, medium, or high risk based on this rating. This allows their team members to focus on issues from the beginning of their relationship with the CTUHR. Finally, physicians will be trained to probe patients on their responses to gather complete and factual data.
Easy Access to Care
An important priority among community members (learned through focus groups, discussed below), was for elderly patients to be able to get as many services as possible in one location, thereby cutting down on travel which could be physically and mentally exhausting. As a result, the proposed centers will provide not only primary and consultative care services, x-ray and laboratory services, social work and care coordination, but also specialty care such as audiology, and foot care. In addition to making the center a “one-stop shop” for patients, one medical provider noted that diversifying the income stream by adding services that are paid for out-of-pocket can benefit the financially stability of the organization.
Community Outreach
Community outreach is an important element to the design of the qualitative aspects of the elderly center. At the CTUHR’s team members conducted focus groups and interviews with Doctors and Administrators in order to obtain a better understand of the needs of the elderly, we began to get a sense of shame. Currently, community outreach is reflected in other ways. For example, the elderly centers have space on-site for community-based organizations
to hold meetings. In addition, staff is not trained to actively link patients with relevant community resources. While not traditionally considered community outreach, it should be noted that CTUHR physicians and nurses will play an important role in the care being offered to their patients at off-site facilities, long-term care facilities, and nursing homes, by conducting onsite visits and continuing to coordinate care. CTUHR also proposes contracting with those same off-site facilities to provide care to patients who were not originally CTUHR patients. According to some interviewees, this practice counters the trend by which fewer geriatric providers in the community are taking the time to visit their patients in these facilities. The CTUHR will propose the use of Health Risk Stratification system. This system was developed by Provident Health Care System, Portland OR, to create a risk rating for each patient. This is often confused with SOAP charting. .
Committed Leadership and Customer-Driven Planning Process
In February, 1997, after getting the green light from the Peace Health Oregon Region Governing Board to begin working on a senior clinic concept, a number of staff began to think about how to create a service delivery environment tailored to the unique needs of the elderly population They employed an information-gathering model utilized by Toyota and others in the manufacturing industry called the Quality Functional Deployment tool, or, as the CTUHR leadership refer to it, “the voice of the customer”
Additional Areas include Staff Recruitment and Career Development Protocol
Like clinical care, staff recruitment and hiring at the CTUHR is done in a team setting. That is, physicians, nurses, and other provider and administrative staff work together to determine staffing needs, interview prospective employees, and train those who are hired. Through this process, the staff is able to carefully determine whether an applicant is an appropriate fit, and do not hire those who are uncomfortable with the highly integrated, interdependent, interdisciplinary work team model that they have established.
1.3 Technological changes
Today, 800,000 doctors struggle to treat adequately the 250 million Americans who have insurance. Obama will add 50 million more to their caseload with no expansion in the number of doctors or nurses. Indeed, his plan will likely reduce their number by lowering reimbursement rates and imposing bureaucrats above them who will force medical decisions down their throats. Fewer doctors will have to treat more patients. The inevitable result will be rationing.
The Role of Technology
Proposed legislation states that clinics and hospitals utilize an electronic medical record that houses all outpatient and inpatient encounters as well as lab, X-Ray, and ancillary services in order to verify who is authorized to receive health care. Also, as mentioned above, the CTUHR will begin to use of the Shared Care Plan (SCP), which enables patients to collect all of their pertinent health information in one place – In essence, this will put the elderly in control of their data, and at the same time gives all the members of their health care team a history of where the patient is in the care protocol. This system has been used for chronically ill diabetes patients for years. By implementing the CTUHR plan, it will put us closer to offering qualitative health care for our seniors. It was originally used simply as a way for providers and the center’s geriatric pharmacist to reconcile patients’ extensive pharmaceutical usage and make sure that they were not being prescribed drugs that were contraindicated. Additional studies shows that this program was a pilot for the VA hospital under the name of “ Agency for Healthcare Research and Quality (AHRQ) Patient Safety” The original grant studied looking at medication safety, and the role that technology such as the Shared Care Plan can play. As a result of this study, the VA center is aiming to broaden its use by registering all 1,700 of its patients in the program and have them develop their individual SCP. Since potential patients at the CTUHR will see other non-center providers for specialty care needs, the center’s staff hopes that the SCP will make it easier for these patients and their providers to coordinate their care needs. Because the VA patients tend to have extensive health histories, and are likely to be taking multiple prescriptions, CTUHR will have a staff on hand to train patients in how to collect their data and input into the SCP secured website. There is also a computer terminal in the lobby of the center so that patients can create and update their SCP before or after their appointments. As a result of the AHRQ grant work, interfaces have been developed to give healthcare providers access to their patients’ SCP from the providers EMR and vice versa, for patients to have better access to important information in their EMR record.
Administrative Mechanisms:
There are a number of processes and mechanisms built into CTUHR that support its ability to provide quality patient-centered care:
• Billing Increments: All appointments at the center are scheduled in 30, 60, or 90 minute increments, as opposed to the 10 minute appointment increments used by other geriatric providers in the community. It became clear early in the planning process that without longer appointment times, the interdisciplinary team approach would not work.
• Train staff to provide patient-centered care. In other words, patient-centered care cannot simply be a mindset that the staff has. It must be an expected standard and must include the following: :
• Involve family members in the care process if the patient so desires;
• Provide additional and recurrent training
• Provide written material to include documented notes outlining protocol and instruction sheets and written records to rely on. Asking for feedback and invite patients to tell you what it means to be served at your clinic.”
Quantitative Measurement and Qualitative Feedback:
CTUHR is currently in the process of studying processes to evaluate how well it will be able to accomplish its mission. CTUHR conducted a quasi-experimental study with medical professional to evaluate whether the interdisciplinary team would work and it was met with anticipated quality results and it was heralded as a viable tool to improved health outcomes and patient satisfaction. Qualitatively, staff spoke to several elderly patients and caregivers over the course of five weeks and came away with significant validation that the concept of using the interdisciplinary team approach or one-stop shopping, employment of geriatric nurse practitioners, longer appointments would be a valuable tool to increase quality and satisfaction among the elderly, The local group provided staff members with ideas concerning improvement concerns, among these concerns was: (See below)
• The expansion of services and giving patients their “own” doctor.
• Providing preliminary, unpublished assessment: sample of their patients records at the time of visit, compared to other hospitals who treat elderly patients..
• Higher immunization rates;
• Decreasing the incidence of falls,
• Decrease number of medications;.
Observed Challenges and Opportunities:
One of the greatest challenges in developing this model will be the size of the patient population. Ostensibly the plan will work to improve the speed at which Medicare reimburses the system. Notably, the Medicare system was not designed to work with an interdisciplinary team. As one medical provider stated “patients don’t experience care in the same way that care is reimbursed” by Medicare. What was meant was Medicare services are reimbursed according to Diagnostic Related Groups (DRGs), the CHR’s patients require more coordinated interventions that cut across multiple DRGs and are difficult to bill. The CTUHR will receive the funding from Medicare and it is understood that revenues will not be enough to provide continual operations unless we develop alternative sources of funding and grants if we are able to succeed. As one interviewee said, “the way healthcare is financed and organized has a very big impact on whether this care can be delivered in a patient-centered manner.
1. EDUCATIONAL CHANGES
This section include the following driving forces that impact Elderly healthcare
1. Improved Methodology of learning
2. Information and Telecommunication Technology in Education
3. Knowledge Acquisition
3.1 Improved methodology of learning:
In the declining quality of elderly care, managers who must deal with day-to-day issues and conflicts brought on by elder care need, work/conflicts must be given proper trainings and to devise activities, programs and policies to minimize losses in production due to these conflicts, and community organizations leaders will help employees deal effectively with elder care/work conflicts through information and skills in balancing their responsibilities for elder care and work (Littlefield, 2005).
With the increase in access to these new technologies, educators have had opportunities to explore different ways to teach and design instruction. Where once drill and practices exercises dominated computer use environments, word processing and databases have become the most used software applications. New technologies continue to evolve into more powerful and sophisticated applications (Elmore, 2004).
Improving and advancing the quality of education and learning will upgrade the degrading quality of care which is one of the trends and critical issues in educational settings, especially during the expansion of education. Information and Communication Technology is very powerful and effective tool for expanding opportunities in education, either non-formal and formal, to previously elderly populations in rural areas and scattered constituencies, geopolitical, cultural or ethnic groups which are excluded traditionally from education because of social or cultural reasons (Schroeder, Trehearne & Ward, 2007).
Elderly health care workforce do not have to depend primarily on books and other resources in housed in many hospital or public libraries which are available only in definite numbers for their needs in education (Blum, 2004). With the emergence of Internet and the use of World Wide Web, a variety of learning materials and resources in many subject areas and specialization including media are now available anywhere and anytime in any part of the globe, night and day utilized by vast number of populations (Lichtman, 2008).
3.2 Information and Telecommunication Technology in Education:
One of the most popular reasons for the utilization of Information and Communication Technology in elderly care educational settings is the best way to prepare the current health care workforce for an environment or workplace where Information and Communication Technologies, particularly the Internet and computers, other related software technologies, are now emerging as more ubiquitous in nature (Kleinman, 2001). Literacy health advancement in Technology, or the ability to use Information and Communication Technology efficiently and effectively, is being viewed as a representation of a competitive edge in an advancing globalization of jobs in the market (Elmore, 2004).
Moreover, in dealing with elderly populations, technological and cultural literacy competence in the use of information and communication technologies is essential to prepare practitioners in the near future. Information literacy, ability to find, evaluates and makes appropriate use of information, including via the use of technology (Littlefield, 2005). Cultural literacy appreciations of the diversity of cultures are also important features of modern technology applied in educational settings. Global awareness understanding of how clients and communities all over the world are interrelated (Elmore, 2004).
In implementing technological approach to elderly care practice, professionals must learn the ability to have excellent learning and communication skills, exhibit organizational and leadership ability The particular problem which is the main issue of the study conducted by Littlefield (2005) which suggests that the ability of nurses to perform their responsibilities and duties by exhibiting clinical skills and professional abilities are important. Health care professionals must possess good assessment skills and have good insight and judgment skills in order to anticipate or interpret the needs of the client in health care practice. This model can be used to accommodate change process for the observed facts and laws that can be related to a particular aspect of elderly care practice (Schroeder, Trehearne & Ward, 2007).
As elderly care workforce began using different instructional strategies, they discovered that traditional forms of learning were not always adequate. Moreover, technology rich environment increasingly generated new situations related to advance learning. Their increased interest in computer activities brought up additional issues related to time management, curriculum, and ultimately learning (Littlefield, 2005). Moreover, their high level of engagement in working with this population group led many to go beyond the requirement of their assignment, leaving health professionals grappling with questions of whether to and where to draw boundaries. Using technology effectively in the work environment will enable health care professionals to be successful and will assist them in learning what they need to be effective, which was the main impact of modern technology to the industry (Lichtman, 2008).
In addition to conveying information, the visual and emotional impact of modern technology can have significant influence on their attitude and behaviors. The perception of conflicts can perpetuate roles and stereotypes or be used to break down existing role stereotypes and build more broadminded attitudes (Littlefield, 2005).
Eventually, health care workforce focused on the effects of their care on elderly clients and began to employ technology to their advantage in managing the interventions. Rather than just troubleshooting, managers developed technological supports for monitoring work, keeping records, sheets, developing new materials, and individualizing interventions (Littlefield, 2005). As workforce learned more about technology and software, they discovered that technology could save them time rather than create additional demands. Different learning styles may also apply to the use of technology, and learners need to assume that not all clients will find the same type of experience with technology rewarding (Blum, 2004).
3.2 Knowledge Acquisition:
The development of health services during recent years in the health care system put much emphasis on the expanding role of elderly care. The main purpose of the role is to take on characteristics of different health professionals to instigate innovation in the performance of roles and responsibilities in the provision of care. Littlefield (2005) states that advance skills and knowledge are necessary to increase number of patients and improve quality of care. Comprehensive care requires that the provider understands the different types and techniques for assessing elimination pattern and needs of the patient. They must also provide supportive care by helping the patients to make necessary physical adjustments while at the same time, constantly assessing their condition for problems that can be caused by altered activity pattern (Lichtman, 2008).
Having sufficient knowledge on the relationship between patient needs and proper management of patients is integral in this practice because it can either hinder or foster faster recovery on the part of the patient (Davies, 2005). Knowing the context and current condition of patients with his/her need problem is vital in determining what kind of education, management, complications, and treatments will increase their quality of care. In this case, proper education and training for medical professionals will result to proper understanding of quality of care in the field and how to better handle the varying needs of elderly patients (Fallows & Bhanot, 2002).
Apparently, the recall of knowledge has been the mainstay of the educational system for decades. As access to vast quantities of information becomes easier, the emphasis on remembering that information will shift to being able to manage the sources, ask pertinent questions, and draw conclusions (Moyra, 2009).. Data rich work environment will cause us to shift away from simply attempting to recall the facts to attempting to put these facts together in a meaningful way to solve problems and make value judgment about what ought to be. Research findings based on actual health care practices suggest that effective management spend time learning about the technology and software programs, and planning on how to infuse the technology into practice. As health care practice become more independent and patients become facilitators of learning, learning related to particular area of study begins to occur in a number of places in and outside the school with the aid of technology (Schroeder, Trehearne & Ward, 2007).
Some of the activities needed to be practiced and learned in a clinical setting are the provision of the most current information possible for the client and co-professionals using the collaborative approach. During the session and actual learning practice can provide clear explanations of the physiological condition and processes of human illness (Davies, 2005). It also facilitates assessment process integrating information as vital component of clinical and evidenced based practice (Moyra, 2009). The role of changes must also facilitate professionals in learning on how to prioritize diagnoses and interventions specific to altered responses for illnesses and disease conditions. It must also emphasize the role of client needs as an essential factor to achieve highest possible recovery for every patient, providing case studies for each case so that we can envision the client as a person needing and requiring care and acquire knowledge regarding the specific case (Kleinman, 2001). They also need to foster critical thinking and decision making which is very important for every health care professional in clinical practice (Schroeder, Trehearne & Ward, 2007).
The technological changes will benefit health care professionals in terms of assessing patient needs and designing future programs to improve quality of life. Finally, this would also benefit other health practitioners and families who would wish to explore the concept of quality for patients, specifically patients with problems, while receiving management and medical treatments (Blum, 2004).
There is a need for discussion of each procedure of intervention including necessary evidenced based concept and background information, with carefully chosen management and scientifically precise intervention. They also need to fully understand how to identify and maintain normal lifestyle patterns and enhance the decision-making skills when performing the required skills in practice. Instructions are also needed to be presented to identify proper diagnoses, outcomes, and interventions for clients with problem (Moyra, 2009). This emphasis reinforces the fact that organized process is relevant to practice to ensure the patient’s safety and rehabilitation (Fallows & Bhanot, 2002).
Conclusion:
As information and communications technology has infused in elderly care practice, more attention will have to be paid to creating an environment that is conducive to establishing what the effective use is. Workforce and industry cannot be expected to acquire the needed skills to incorporate this technology into instruction which will supportive the environment and the availability of some assistance. It is also utilized to support wide range of research activities. When the heath provider and patient seek information not available in classroom, they need to go elsewhere, and computers make it possible to search other sources without leaving the field. By the aid of technology, these things are now possible in many educational settings (Moyra, 2009). Using variety of software, mini laboratory or demonstration tool were effective medium of learning in elderly care.
RECOMMENDATIONS
Our recommendations are based on the environmental scan of the Elderly healthcare.
Recommendations on the basis of Socio-cultural and Economic Changes in the next 20 years:
1. Developing Societies that promote Elderly Care
- Create elder Friendly Communities
- Create Healthy environment (Schools, work places, and neighborhood) that promote elder friendly communities
- Creating society-wide incentive for healthy living
- Expanding the use of volunteer time for the care of elderly
2. Developing a supportive Environment for the elderly of the future
- Involving seniors and advocacy groups in dialogue
3. Maximize Economic Resources
- Potential changes to the retirement age and the timing thereof
- Potential changes to social security (the percentage of contributions by employers and employees, reduction in benefits, privatizations such as person al savings plans etc.)
- Potential Changes to retirement saving plans, health saving accounts etc.)
- Potential changes to Medicare and Medicaid
4. Maximize societal resources
- On industry level this include sufficient supply of trained healthcare professionals, affordable and adequate health insurance (for long term care), affordable pharmaceutical products, and affordable and accessible transportation
- Providing alternative to ER for non emergency visits
- Incentive for healthy life styles
- Residential (elder-friendly communities; assisted living facilities; home health care for independent living; nursing homes)
- Affordable and accessible recreational and entertainment
5. Maximize cultural resources
- Educate Americans to understand and be sympathetic to the needs of elderly
- Values based on responsibility, caring, community, and partnerships
- Community resources ()volunteers, neighbors, families) that are available free for the elderly
- Elderly care centers in neighborhoods and workplaces
- School based programs (health and nutrition education, physical education, life style counseling, oral health)
Recommendations on the basis of Educational changes in the next 20 years:
1. Family of individual should learn about the client’s atypical development by proper identification system of people with disability. This awareness however should encourage family to teach the each member with appropriate behavior that will make more acceptable to the people around the client. Social and emotional skills should be learned by the individual and should be generalized to different environmental situations.
2. Educational level, participation, age and therapy were significant variables which impact the quality of life of the client. The better care behavior was, the better the satisfaction domain score; and emotional distress was the most significant explanatory feature for quality of life. Health professionals should evaluate family and client’s emotional distress in the early stage, providing them with emotional support and apply empowerment strategies and consultation to promote the quality of life.
3. Skills, Knowledge and ability as important part of health care team is the main armor of every health care provider whenever facing in the battlefield of care management. As member of health care team, these three factors are the most important thing in hand before going to the battle. It must be incorporated with competence and critical thinking. When all of these characters will be gained, surely, effective nursing care and desired outcome will be met. These are the things present beforehand to be an effective health care provide
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