Chapter 3 Residential Care Facilities for the Elderly

Abstract

Residential Care Facilities for the Elderly (RCFEs), known as board and care homes, are licensed in California and many other states for non-medical care in the community. RCFEs are examined here to provide illustrative issues in the definition of types of long-term residential care. The research examines physical functioning, social supports, and course of residential placement for 109 RCFE residents (mean age 84 years). A significant portion of the residents had personal assistance needs not usually provided at the RCFE level (75% assistance with medication, 52% used walking aids, 29% assistance in bathing). Additionally, a third of the residents had restricted social supports and social activity. Residents report declines in functioning and support as reasons for moving to residential care. Length of residence in the facility (range less than a year to 15 years) was not related to physical functioning or social activity. These findings do not support “aging in place,” within the facility, as the rationale for increased need for assistance in residential care. Implications include the need to maintain the social model of residential care ample for the majority of residents while assuring the availability of a higher need for assistance of a significant portion of the residential care population.     

Mom and Pop Versus the Big Boys: Adult Family Homes as Providers of Medicaid-Funded Residential Care

This paper compares assisted living apartments (ALs), adult residential care facilities (ARCs), and small adult family homes (AFHs) for Medicaid residents in Washington State, with particular emphasis on the settings, staffing, services, and policies of AFHs. We targeted for enrollment all residents entering an AFH, ARC, or AL setting on Medicaid/state funding in a three-county area of Washington State. We obtained information on 199 settings, interviewing administrative and direct care providers. AFHs are smaller than ARCs and ALs and less likely to be part of a chain, with no significant difference in staffing ratios of registered nurses and licensed practical nurses. Sixty-four percent of AFH residents were receiving public funds compared to 32% of AL residents. AFHs report admitting residents with more activities of daily living needs, health conditions, and behavior problems. They are less likely to have autonomy-related policies, and they provide more services and fewer activities. While attention should continue to be paid to staff supports, policy and practice should support the continued role of AFHs, which are of special interest because of their potential to provide more homelike, less costly care but with possible trade-offs compared to larger facilities.     

Australian Approaches to Resident Classification and Quality Assurance in Residential Care

Summary

This paper begins with an account of the structure of Australia's residential long-term care program, which was divided into two distinct levels of hostel and nursing home care until 1997. In response to changed policy objectives, a number of measures were then taken to create an integrated residential care system. The main measures were the development of a single scale for classification of resident care need and associated funding to replace two previous separate scales, and the implementation of a new quality assurance system, which included new standards for buildings as well as revised standards for care. I give accounts of these measures and the extent to which they have achieved their intended outcomes before proposing some further developments that could see closer links among pre-admission assessment, resident classification, and quality assurance.     

A Valued Relationship with Nature and Its Influence on the Use of Gardens by Older Adults Living in Residential Care

ABSTRACT

While there is growing interest in inclusion of gardens and outdoor spaces in residential care facilities for older adults, these spaces are often underutilized despite many identified, evidence-based benefits. A qualitative study of participant observations with behavior mapping, and individual and focus-group interviews, using a grounded theory methodology was used to understand value versus use of outdoor garden spaces. Individual and focus-group interviews were conducted with 32 residents from two facilities. Results revealed that views of nature are fundamentally important to resident well-being, that access to nature influences facility choice, and use of garden spaces is influenced by the way in which individuals prefer to enjoy nature.     

Foster and Residential Care Reassessed: A Research Perspective

SUMMARY. Professionals in Britain and many other countries have long been concerned about whether children in need, who have to live away from their parents, are best placed in foster or residential settings. The issue has become particularly significant in recent years in view of the adverse publicity surrounding residential childcare. This paper summarises recent British research findings on the role and impact of foster and residential care for children and young people in need. It demonstrates that research conclusions often do not support commonly held public and professional views, particularly regarding the contribution of residential care.     

Residential Child Care Agencies as Learning Organisations: Innovation and Learning from Mistakes

The residential child care sector has been scrutinised via numerous inquiries following revelations of abusive and poor practice. These inquiries have made numerous recommendations which involve changes in practice and organisational culture, much of which is congruent with the features of a learning organisation. This article details research which evaluates the extent to which residential child care agencies exhibit the characteristics of a learning organisation. The research involved qualitative and quantitative methods, drawing on the experiences of a range of staff from the residential child care sector within Scotland. The findings revealed that residential child care agencies exhibit many features of a learning organisation, yet the extent to which these characteristics are perceived to exist differs significantly in line with the position staff occupy. Most significant were the findings that many staff do not feel supported to take risks nor encouraged to develop innovative practice; mistakes are not used as learning opportunities and a culture of blame is felt to exist. The implications of this are significant and this article identifies changes necessary to allow residential child care agencies to operate as learning organisations.     

Workforce Issues in Residential Care Facilities in Rural China

This study examined contemporary frontline workforce issues related to residential care for elders in rural China. Residential facilities in rural China are in transition from exclusively providing shelter to childless elders to providing long-term care for frail elders. These facilities are also under pressure to improve the quality of services that they provide. The study is based on in-depth interviews with administrators and field observations of facilities. The study focused on the following issues related to the workforce: recruitment and retention, training, work environment, workforce organization, regulations, compensation, and career ladders. The implications of resident characteristics for demands on the work force were examined. The study found that lack of skilled personnel is one of the major reasons that the overwhelming majority of facilities deny admission to frail and demented elders. Improving workers’ skill is critical if these facilities are to meet the increasing demand for institutional long-term care needs.     

What do Potential Residents Need to Know about Assisted Living Facility Type? The Trade-off between Autonomy and Help with More Complex Needs

The current study surveyed 74 assisted living facilities to examine the effect of facility type on resident autonomy and the willingness of providers to admit residents requiring complex services. Facility types included adult family homes, residential care facilities, and traditional assisted living facilities. Adult family homes were more willing to admit residents with higher care needs. By contrast, assisted living facilities’ policies did not support the provision of intensive services, but their policies promoted higher resident autonomy, suggesting that consumers may have to choose between autonomy and help with complex needs when exploring assisted living for long-term care.     

Residential Differences in Filial Responsibility Expectations Among Older Persons1

Abstract This study examines variation in filial responsibility expectations-the extent to which adult children are expected to assist and care for their aging parents-among a sample of 440 older persons. The analysis focuses on the relationship of filial responsibility expectations to residential location and tests the hypothesis that older rural residents have higher expectations for assistance from their children than do older urbanites. Current residential location is found to have little impact on expectations, but older persons who were raised in rural areas, particularly on farms, have significantly higher expectations for filial assistance than do older persons from urban backgrounds. Possible consequences of these patterns for the transmission of expectations from parents to children are discussed.     

Resident councils between lifeworld and system: Is there room for communicative action?

In long-term care facilities, the participation of older people relates to individual care provision (individual level) and to policy decisions that affect all residents in a care organization (collective level). In the Netherlands, resident councils are set up in order to improve resident participation on a collective level. However, our research shows that managers and resident councils are faced with mutual frustration and ineffective interaction. This article investigates the extent to which Habermasian communicative action (herrschaftsfreie Kommunikation) between resident councils and managers in residential elderly care is actually possible by examining the interaction between resident councils and managers in two case studies. We conclude that resident councils find themselves between lifeworld and system. There is communicative action between resident councils and managers, but it is easily dominated by strategic action. Therefore, space for communicative action needs to be deliberately created in order to support resident council participation and influence.     

Choosing Privacy over Interaction: Restructuring Expectations and Interpretations of Community Integration in Canadian Small-House Long-Term Care Settings

In Nova Scotia, Canada, the small-house model of care has been introduced as an alternative to institutional care settings, and the province has funded and built 11 new long-term care (LTC) communities in the small-house model. Each of the new facilities was built with multiple cottages housing 12 to 15 residents; each cottage features private bedrooms and a residentially scaled kitchen and dining area. Through smaller numbers of residents living in home areas, the goal of the Provincial Department of Health was to encourage relationship building, as well as to provide opportunities for autonomy and choice in resident daily living. A qualitative case study was conducted in one of these small-house communities, focusing on the model's impact on resident interaction and community integration. Thematic analysis revealed that while resident social patterns were directly impacted by the physical environment and culture of care in the new model, interpretations of these patterns by staff and family members were influenced by preexisting expectations of community integration rooted in institutional care models of the past.     

The Seniors' Outdoor Survey (SOS Tool): A Proposed Weighting and Scoring Framework to Assess Outdoor Environments in Residential Care Settings

Spending time outdoors offers substantial health benefits for older adults. However, in long-term care settings, outdoor areas may fail to adequately support elderly residents' needs and preferences. The Seniors' Outdoor Survey (SOS Tool) was recently developed to help users evaluate outdoor areas and indoor–outdoor connections in residential facilities for seniors, by rating 60 environmental features on a 1–7 scale. This article proposes a weighting strategy to approximate the relative importance of different items on the tool, according to their potential level of support for resident usage and preferences. A standardized scoring system will allow multiple stakeholders to apply the results to research, design, construction, and renovation projects.     

Pioneering partnerships: Resident involvement from multiple perspectives

Resident involvement in residential care homes is a challenge due to shortcomings of consumerist and formal approaches such as resident councils. The PARTNER approach aims to involve residents through collective action to improve their community life and wellbeing. The purpose of this article is to provide insights into the process of resident involvement by the PARTNER approach from the perspectives of multiple stakeholders, including residents, volunteers and staff members. A responsive evaluation was conducted, using participant observations, semi-structured interviews with residents, volunteers and professionals (n = 16), and three focus groups. The findings show that critical elements in this process of resident involvement were the agenda-setting by residents, the formation of a cohesive resident group, the sharing of experiences and stories, the development of collective action, and the development of partnerships between residents and professionals and other stakeholder groups. Residents developed actions (gallery parties and a buddy project) to strengthen social interactions and realized these with the help of volunteers and professionals. We conclude that bringing residents together around a shared topic creates room for activism and leads to empowerment, feelings of social belonging and learning processes. We argue that it is a worthwhile enterprise to further develop structural partnership relations between residents, volunteers and staff in residential care homes.     

Fathers' Investments of Money and Time Across Residential Contexts

Fathers' roles in family life have changed dramatically over the past 50 years. In addition to ongoing breadwinning responsibilities, many fathers are now involved in direct caregiving and engagement with children. Yet there is considerable variation in what fathers do, especially depending on whether they live with or away from their child. In this article, the authors use data from the Fragile Families and Child Wellbeing Study (N = 3,869) to describe how fathers' economic capacities (money) and direct involvement with children (time) are associated over child ages 1 to 9 for resident versus nonresident fathers, net of confounding factors. They found suggestive evidence that money and time investments operate differently across residential contexts: Resident fathers experience a trade‐off between market work and time involved with children. In contrast, nonresident fathers' higher economic capacities are associated with more time involvement, underscoring the greater challenge for such fathers to remain actively involved.     

Improving Australian Residential Aged Care Facilities: A Review of Minor Refurbishment Elements

The objective of this study is to identify elements pertaining to minor refurbishments of residential aged care facilities. A narrative review of relevant publications was conducted. Inductive content analysis was used to categorize coded data into major or minor refurbishment or staff practices. Further analysis identified minor refurbishment domains. There were 14 major refurbishment, seven minor refurbishment and two staff practices domains established. The minor refurbishment elements (n?=?7) identified were lighting, furniture, color and contrast, wayfinding, noise, signage, and flooring. Assessing these elements would assist residential aged care providers to prioritize the provision of minor improvements to the environment for residents.     

Family Therapy for Kids Without Families: Working Systemically With Children and Young People in Residential Care

A significant proportion (4%, Australian Institute of Health and Welfare, 2008) of children and young people in Australia live in some form of residential care, usually in small group‐homes staffed by residential care workers in shifts. However, as Hawkins‐Rodgers (2007) points out, these placements are often not resourced to heal the effects of trauma and multiple attachment disruptions in their residents. The lack of an archetypal ‘family’ has led in the past to family therapists considering that there is little work to be done with such clients. This leaves such placements to be supported most frequently by clinicians who specialise in behaviour management and other linearly founded models of practice. The Alternate Care Clinic (ACC) is the first mental health service in New South Wales dedicated entirely to children and young people in out of home care with a high level of complex needs. This article examines the systemic therapeutic model the clinic has developed in the last two years. In particular, the article seeks to explore the importance of ‘meaning making’ in a diffuse parental system, particularly with regards to the term ‘family’. The complexities of working in this area and possible ways forward are illustrated with a closely worked case study.     

Elder Abuse in Residential Settings in Sweden

ABSTRACT

To investigate frequencies and types of elder abuse occurring in residential settings in two municipal areas of Sweden, nursing staff were asked to answer a questionnaire; 499 responded. The findings indicated that elder abuse involving the staff did occur. Eleven percent of the staff knew of situations of elder abuse and two percent admitted that they themselves had been abusive towards an elderly resident. Psychological and physical abuse related to caring activities were most common. In the specific situations reported, the abusers were mostly characterised as hot-tempered, exhausted, and burned out. The abused people were often mentally and/or physically handicapped and generally over 80 years old. Feelings such as powerlessness, anger towards the abuser, and compassion for the abused person were reported. To cope with the situation, they talked to each other or to the manager. They recommended more education and support as the main preventive strategy.     

Mental Illness in Assisted Living: Challenges for Quality of Life and Care

ABSTRACT

An unknown number of mentally ill elders in the United States receive care in assisted living, along with persons facing physical or cognitive challenges. While dementia is familiar in assisted living, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily interresident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted-living settings having varying presence of mental illness among residents.     

Scandalous Care: Interpreting Public Enquiry Reports of Scandals in Residential Care

ABSTRACT

This article reviews an earlier study written for the Wagner Committee (1988) on scandals in residential care. That review was based on a study of ten enquiry reports, only two of which were about homes for older people. The main events that were described are grouped as: institutionalised practices, indifference and neglect, physical cruelty, humiliation, too authoritarian a life-style, a dull and depressing life-style, an overcrowded and run down environment, disharmony amongst the staff team, and staff misappropriating goods or money. Now, more weight should be given to: residents' abuse of residents and of staff, an improper influence on the life-style of others, and sexual abuse. Explanations proposed are: structural, environmental, and individual and worker style. Abuse is considered in the context of the nature of direct care and the acts of intimate caring of others.     

Contextual Residential Care Reviewed

This paper examines a contextual model of residential care for children whose behaviour is described as out-of-control. Developed by Menses & Durrant (1986), the model combines principles of cybernetic theory, cybernetic therapy and ritual. The purpose of this study was to investigate the current wide use of the Contextual Residential Care model, focusing on the cybernetic theory-base of the model and how it has been employed in practice. The study followed a narrative format, utilising semi-structured interviews with co-ordinators of Contextual Residential Care programmes, to gain information about the nature and theoretical baseline of their programmes and their hopes and concerns for the future of the model. The interviews were analysed using a discourse analytic procedure. The study found a contextual approach which is immature and lacking in theoretical clarity. If its proponents can establish and understand a sound cybernetic framework and adapt it with flexibility to their particular context, they can ensure the successful evolution and application of this model of residential care.