The Role of the Nurse Practitioner in Adult Day Care
Marjorie A. Maddox EdD, RN Associate Professor and Gerontologist, Regis University, Denver. Colorado
During the past 25 years, nurse practitioners (NPs) have become health care providers in a variety of settings. Adult day care is one of the settings in which it is increasingly clear that there is a role for the NP. Nurse practitioners have the potential to provide increased comprehensive primary health care to clients participating in these programs.
Twenty-five years ago, Doctors Loretta Ford and Henry Silver began the nurse practitioner (NP)movement with the establishment of the Pediatric NP Program at the University of Colorado (Pearson, 1990). Although the first program was planned to educate nurses to help meet the needs of rural children, today NPs function as primary health care providers for a variety of patients in a wide range of settings. A few of the settings include community clinics, schools, employee-student health departments, and private or collaborative practice (Towers, 1990). Recently, NPs have also been employed in acute care settings and nursing homes (Jennings, 1989). As NPs continue to expand into other health care settings, adult day care will be among those where NPs will be able to make a positive impact.
the program’s participants and enabling their continued involvement in the community” (p. 88). Historically, the idea of adult day care can be traced to a psychiatric hospital in Moscow in 1933. Because of a shortage of hospital beds, Doctor R. Dzhagarov developed day hospitals to help meet the needs of his patients (Wolf-Klein, Moor, & Foley, 1988). In only a few years, the idea spread to Montreal and London, where physicians D. E. Cameron and J. Bierer promoted the use of adult day-care programs to help meet the medical and psychosocial rehabilitation needs of soldiers returning from World War I1 (Wolf-Klein et al., 1988). Adult day-care programs were well received in Great Britain, and by 1976, there were more than 70 day hospitals throughout the United Kingdom (Padula, 1985: Wolf-Klein et al., 1988). Several factors contributed to the establishment of adult day-care programs in the United States. Linnet ADULT DAY CARE Cosin, a physician who had opened a day hospital The National Institute on Adult Day Care, founded program at the Cowley Road Hospital of the United in 1979, composed the following definitions regard- Oxford Hospitals in 1950, played a major role in the ing adult day care (Padula, 1985): “Adult day care is introduction of such programs in America. During the a generic term that applies to a variety of programs 1960s, &sin introduced an adult day-care program on offering services that range from active rehabilitation the hospital grounds at Cherry State Hospital in to social and health-related care.... Adult day care is Goldsboro, North Carolina (Padula, 1985). Later in coordinated with, and relates to, other agencies and 1971,he testified about the success of his program before services such as senior centers, in home services and the U. S. Senate Subcommittee on Long-Term Care institutions, and hospital care... An adult day care of the Special Committee on Aging (Padula, 1985; Webb, program provides a gamut of health and social services 1989). in a congregate setting, enhancing the daily lives of Adult day care was only beginning to be an alternative to institutional care in 1971, when President Nixon had the Department of Health, Education and Welfare explore options to decrease institutionalization Address correspondence to Marjorie A. Maddox, RN, EdD, Regis of older adults (Hardner, Gornick, & Burl, 1986). At University, 3333 Regis Blvd., Denver, CO 80221. VOLUME 4, NUMBER 3, JULY-SEPTEMBER. 1992
107
that time, there were less than 15 adult day-care programs in the United States. These had been established with funds authorized under Title I11 of the 1965 Older Americans Act, which served to stimulate an increase in programs providing socialization and recreational services for the elderly (Harder, Gornick, & Burl, 1986; Padula, 1985; Webb, 1989). In 1974, state level Medicaid funds were made available to help establish adult day-care programs, but coverage varied from state to state. Medicare still does not reimburse costs for adult day care (Padula, 1985;Webb, 1989). Although a report by Weissert in 1977 concluded that adult day-care programs were not cost-effective, their numbers continued to grow (Wolf-Klein et al., 1986).By 1980, more than 600 adult day-care programs had been established (Padula, 1985; Wolf-Klein et al., 1988; Webb, 1989).During that year, the 96th Congress held the first hearing on adult day care programs before the House Subcommittee on Health and Long-Term Care of the Select Committee on Aging, and identified adult day care as a national policy concern (Hardner, Gornick, & Burl, 1986). At that time long-term care was defined as a continuum of support services that was not limited to nursing homes, but also included adult day care and other community-based services (Webb, 1989). The Omnibus Budget Reconciliation Act of 1981 served as an additional impetus for the expansion of adult day care. This act revised Medicaid regulations to permit states to be reimbursed for coordinated community-basedalternatives to institutional long-term care (Hardner, Gornick & Burl, 1986). By 1986, there were more than 1,200 adult day-care programs in the United States (Webb, 1989). During the 1970s and 1980s, several researchers attempted to describe adult day care according to models. Weissert (1976) developed a two-model topology and Robins (1975)and Welter and Rathbone-McCuan (1978) expanded the models to four. These models were used to describe the types of services provided, classifying the day care centers according to the social or medical orientation of their services. In 1984, the National Institute of Adult Day Care (NIAD)expanded the range of adult day care to include both the social and health needs of the individual (Webb, 1989). A1though national leaders were encouraging adult day-care settings to be more flexible and include a variety of services, funding sources continued to promote a dichotomy by differentiating among programs according to their primary orientation toward either a social or medical model. Medicaid, Medicare, and private insurance companies recognize “health care” and are more willing to reimburse for services 108
provided in an adult day care following a medical model. In contrast, some government funding, such as that provided through the Social Service Block Grants or the Older American Act, is restricted to the provision of social services to the elderly (Webb, 1985).
TRADITIONAL NURSING AND MEDICAL RESPONSIBILITIES IN ADULT DAYCARECENTERS The National Institute of Adult Day care has established standards for the proper functioning of adult day-care programs in the United States (1990).According to those standards, services provided by registered nurses are to include a basic initial assessment of the client’s health status, an observation of dietary habits, the administration of medications, assessment for any changes in the client’s condition, and the provision of supportive nursing care regarding dressings, skin care, hygiene, and other activities of daily living. Physicians, according to the standards, serve primarily as consultants. If the interdisciplinary care team identifies a change in the client or has a question regarding medical care, the physician is to be informed. Each participant must have a physician available for such consultation. In some adult day-care settings, physicians are a part of the staff either under direct contract to the center or as a physician on staff of the institution in which the center is located (Welter & Rathbone-McCuan, 1978).These physicians provide onsite care needed by the clients attending the center.
POTENTIAL NURSE PRACTITIONER RESPONSIBILITIES According to the 1987 American Nurses Association (ANA, 1987) Standards of Practice for the Primary Health Care Nurse Practitioner, NPs function as primary health care providers. The standards define primary health care as “continuous and comprehensive care and include[s] all services necessary for the promotion of health, the prevention of disease, and the early detection and treatment of illness” (p. 2). Adult day-care programs provide excellent settings where NPs can provide direct patient care.
ASSESSMENT In adult day care, clients must be screened before they are accepted as active participants in the program. These screenings often consist of phone calls to the potential clients and family members, with follow-up interviews in the day-care center. In addition to the
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
traditional nursing activities described above, NP involvement would include the use of history-taking skills to obtain information about current and past medical status, prior immunizations, and other health preventative measures undertaken by the client. Nurse practitioners would use their medical knowledge to note areas needing further investigation and follow-up should the individual be accepted into the program. Cognitive functioning could be evaluated by the NP who would note areas of deficit and areas that might be improved by incorporating certain activities into the individual plan of care. At the completion of the “intake assessment,” the profile of the individual compiled by the NP would be comprehensive, including not only baseline data regarding physical and cognitive functioning, but also additional information regarding potential problem areas, health promotion concerns, and issues of continued health maintenance (Webb, 1988). Frequently, new participants are required to have a physical examination before their acceptance into an adult day-care program. This usually consists of the physician completing a simple form that serves as a basis for monitoring the health maintenance of the participant. An NP in the adult day-care setting can not only perform the physical examination on each new participant, but also combine this with a comprehensive history that can be kept with the participant’s health records at the center.’ In the report “Healthy People 2000” (U.S. Department of Health and Human Services, 1990), the most important aspect of health promotion among older people was maintaining health and functional independence. Nurse practitioners can be instrumental in implementing this national objective in adult daycare programs. Not only can assessments and physical examinations monitor on-going medical concerns, but they can also identify potential problems and facilitate early interventions that can produce multiple benefits. These benefits include increased functional status, improved cognition, reduction of medication use, and prolonged survival (Rubenstein, 1987).
therapies. The problem of too much medication, contradicting medications, or evidence of undesired side effects of present medications might also be noted. Nurse practitioners can coordinate the total health care of participants, increasing the potential for adult day-care centers to actually deliver ambulatory health care to the aged (Welter& Rathbone-McCuan, 1978; Wolf-Klein et al., 1988). Acute episodic health care can also be provided by the NP. Accidental falls, problems with incontinence, minor injuries, and exacerbations of chronic and acute illnesses can be addressed by the NP. Immediate medical attention would be available without the need to contact a physician for emergency medical care or to transport the participant to an emergency room. Although some situations may involve conferring with other medical or emergency room staff, an NP is prepared to diagnose and treat many of the common medical problems found in adult day-care settings. This would result in increased quality of health care for the client and potential cost savings to the client and the center. The United States Office of Technology Assessment states that reimbursing NPs rather than physicians, where appropriate, would reduce health care costs considerably (Staff, 1989).
HEALTH PROMOTION AND DISEASE PREVENTION
A final area of contact is in the realm of health promotion and disease prevention. The elderly need to participate in health promotion activities because behaviors can be modified and problems can be identified, which may result in more appropriate use of health services as well as improvement in the individual’s health status (Gilford, 1988). An adult day-care program provides an excellent setting for preventive screening for the elderly. Periodic testing and monitoring can be performed for hypertension, cancer, glaucoma, hearing and vision deficits, podiatry problems, and dental problems. Although screening could be offered on a periodic basis, the NP can also establish clinic hours on a weekly or biweekly basis to deal with common concerns. EVALUATING AND MANAGING Immunizations that are extremely important to the ONGOING HEALTH PROBLEMS elderly can be provided, often preventing unnecessary The NP can play an active role in evaluating the illness and even death. Annual influenza vaccinations on-going medical therapies of each participant. For for all persons over the age of 65, and for persons of instance, a need for treatment change might be identified; any age who have chronic diseases that may increase the NP can consult with the community-based their risk of contracting this illness (Dychtwald, 1986), physician, and then prescribe and monitor on-going pneumococcal vaccination for all persons older than the age of 65, and tetanus and diphtheria every 10 years (Albert, 1987; Lindberg, 1987),could be included in each ‘Adult day-care programs maintain documentation of on-going client’s treatment plan. assessments, but often they are in the form of a “yes or no” checklist Annual breast and Pap smear screening for all women with little room for additional documentation. VOLUME 4, NUMBER 3, JULY-SEPTEMBER, 1992
109
regardless of age can also be provided by the NP. Likewise, older men can be examined for enlarged prostate and signs of early prostatic cancer.
OTHER ROLES Nurse practitioners also function in several subroles that could be incorporated into the adult day-care setting. These roles include educator, administrator, researchers, and consultant (ANA, 1985). Health education is an extremely important part of preventative health maintenance. The NP can include health teaching while monitoring chronic health problems, such as hypertension, or discuss nutritional concerns while examining or treating a client. As a component of any preventative health maintenance program, teaching would be provided for the individual and appropriate caregivers in the setting and at home. As part of their continued health maintenance functions, NPs can serve as consultants with the participants' community-based physicians assuming a case management role by coordinating care and identifying appropriate referrals. The NP is an ideal person to be the head of the interdisciplinary team, or
the medical director of the adult day-care program, with an administrative director to assist in the operations of the program. NPs can also function as researchers. In the setting of an adult day-care program, there would be ample opportunities to further validate various assessment tools based on this population. Specific treatment plans and educational methods can be developed. The opportunity for collaborative research presents itself with the interdisciplinary team of the adult day-care program.
CONCLUSION As the NP movement continues into the next 25 years, additional opportunities for role expansion will become available. Providing primary care services to clients in adult day-care centers opens unique opportunities to increase the comprehensiveness of care for the elderly and handicapped. One way to facilitate this expansion is through legislation that would provide direct reimbursement to NPs functioning as direct providers of medical services.
References Albert, M. (1987). Health screening to promote health for the elderly. Nurse Practitioner, 12(5), 42-56. American Nurses'Association. (1 985). Scope ofpractice of the primary health care nurse practitioner, Kansas City: American Nurses' Association. American Nurses' Association. (1987). Standards of practice for the Primary health care nurse practitioner. Kansas City: American Nurses Association. Dychtwald, K. (1 986). Wellness and health promotion for the elderly. Rockville, MD: Aspen Publications. Gilford, D. M. (1 988). The aging population in the twenty-first century, Washington, DC: National Academy Press. Grady, K. E. (1988). Older women and the practice of breast selfexamination. Psychology of Women Quarterly, 12(4), 473-487. Harder, W. P., Gornick, J. C., & Burl, M. R. (1986). Adult day care: Substitute or supplement? Milbank Quarterly, 64(3), 414-441. Jennings, C. P. (1989). Long-term care legislation:An issue of concern for nurse practitioners.Journal of the American Academy of Nurse Practitioners, 1(4),145-1 49. Lindberg, S. C. (1 987). Adult preventive health screening, 1987 update. Nurse Practitioner, 12(5), 19-41, National Institute of Adult Daycare (NIAD). (1990). Adult day care: A treatment program for persons with functional impairment. Washington, DC: National Council on the Aging. National Institute of Adult Daycare (NIAD). (1990). Standards and guidelines for adult day care. Washington, DC: National Council on the Aging.
Padula. H. (1985). Developing adult day care. Washington, DC: National Council on the Aging. Pearson, L. J. (Ed.). (1990). 25 years later: 25 exceptional nurse practitioners look at the movement's evolution and consider future challenges for the role. Nurse Practitioner, 15(9), 9-28. Robins, E. (1975). Operational research in geriatric day care in the United States. Paper presented at the 10th international Congress on Gerontology, Israel. Rubenstein, 1. Z. (1 987). Geriatric assessment An overview of its impact. Clinical Geriatric Medicine, 3(1), 1-1 5. Staff. (1989). Newswatch. Geriatric Nursing, 10(2), p. 8. Towers, J. (1990). Report of the national survey of the American Academy of Nurse Practitioners, part 111: Comparison of nurse practitioner characteristics according to education. Journal of the American Academy of Nurse Practitioners, 2(3), 121-1 24. US. Department of Health and Human Services. (1990). Healthy people 2000. Washington, DC: U.S. Public Health Service. Webb, L. C. (1 989). Planning and managing adult day care. Owing Mills, MD: National Health Publishing. Weissert, W. G. ( 1976). Two models of geriatric day care: Findings from a comparative study. Gerontologist, 16(5). 420-427. Welter, P., & Rathbone-McCuan, E. (1978). Adult day care. NY: Springer Publishing. Wolf-Klein, G. P., Moor, V. K., & Foley, C. J. (1988). Adult day care: A recent past and a growing future. New York State Medicine, 104(10),528-530.
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110
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
Marjorie A. Maddox EdD, RN Associate Professor and Gerontologist, Regis University, Denver. Colorado
During the past 25 years, nurse practitioners (NPs) have become health care providers in a variety of settings. Adult day care is one of the settings in which it is increasingly clear that there is a role for the NP. Nurse practitioners have the potential to provide increased comprehensive primary health care to clients participating in these programs.
Twenty-five years ago, Doctors Loretta Ford and Henry Silver began the nurse practitioner (NP)movement with the establishment of the Pediatric NP Program at the University of Colorado (Pearson, 1990). Although the first program was planned to educate nurses to help meet the needs of rural children, today NPs function as primary health care providers for a variety of patients in a wide range of settings. A few of the settings include community clinics, schools, employee-student health departments, and private or collaborative practice (Towers, 1990). Recently, NPs have also been employed in acute care settings and nursing homes (Jennings, 1989). As NPs continue to expand into other health care settings, adult day care will be among those where NPs will be able to make a positive impact.
the program’s participants and enabling their continued involvement in the community” (p. 88). Historically, the idea of adult day care can be traced to a psychiatric hospital in Moscow in 1933. Because of a shortage of hospital beds, Doctor R. Dzhagarov developed day hospitals to help meet the needs of his patients (Wolf-Klein, Moor, & Foley, 1988). In only a few years, the idea spread to Montreal and London, where physicians D. E. Cameron and J. Bierer promoted the use of adult day-care programs to help meet the medical and psychosocial rehabilitation needs of soldiers returning from World War I1 (Wolf-Klein et al., 1988). Adult day-care programs were well received in Great Britain, and by 1976, there were more than 70 day hospitals throughout the United Kingdom (Padula, 1985: Wolf-Klein et al., 1988). Several factors contributed to the establishment of adult day-care programs in the United States. Linnet ADULT DAY CARE Cosin, a physician who had opened a day hospital The National Institute on Adult Day Care, founded program at the Cowley Road Hospital of the United in 1979, composed the following definitions regard- Oxford Hospitals in 1950, played a major role in the ing adult day care (Padula, 1985): “Adult day care is introduction of such programs in America. During the a generic term that applies to a variety of programs 1960s, &sin introduced an adult day-care program on offering services that range from active rehabilitation the hospital grounds at Cherry State Hospital in to social and health-related care.... Adult day care is Goldsboro, North Carolina (Padula, 1985). Later in coordinated with, and relates to, other agencies and 1971,he testified about the success of his program before services such as senior centers, in home services and the U. S. Senate Subcommittee on Long-Term Care institutions, and hospital care... An adult day care of the Special Committee on Aging (Padula, 1985; Webb, program provides a gamut of health and social services 1989). in a congregate setting, enhancing the daily lives of Adult day care was only beginning to be an alternative to institutional care in 1971, when President Nixon had the Department of Health, Education and Welfare explore options to decrease institutionalization Address correspondence to Marjorie A. Maddox, RN, EdD, Regis of older adults (Hardner, Gornick, & Burl, 1986). At University, 3333 Regis Blvd., Denver, CO 80221. VOLUME 4, NUMBER 3, JULY-SEPTEMBER. 1992
107
that time, there were less than 15 adult day-care programs in the United States. These had been established with funds authorized under Title I11 of the 1965 Older Americans Act, which served to stimulate an increase in programs providing socialization and recreational services for the elderly (Harder, Gornick, & Burl, 1986; Padula, 1985; Webb, 1989). In 1974, state level Medicaid funds were made available to help establish adult day-care programs, but coverage varied from state to state. Medicare still does not reimburse costs for adult day care (Padula, 1985;Webb, 1989). Although a report by Weissert in 1977 concluded that adult day-care programs were not cost-effective, their numbers continued to grow (Wolf-Klein et al., 1986).By 1980, more than 600 adult day-care programs had been established (Padula, 1985; Wolf-Klein et al., 1988; Webb, 1989).During that year, the 96th Congress held the first hearing on adult day care programs before the House Subcommittee on Health and Long-Term Care of the Select Committee on Aging, and identified adult day care as a national policy concern (Hardner, Gornick, & Burl, 1986). At that time long-term care was defined as a continuum of support services that was not limited to nursing homes, but also included adult day care and other community-based services (Webb, 1989). The Omnibus Budget Reconciliation Act of 1981 served as an additional impetus for the expansion of adult day care. This act revised Medicaid regulations to permit states to be reimbursed for coordinated community-basedalternatives to institutional long-term care (Hardner, Gornick & Burl, 1986). By 1986, there were more than 1,200 adult day-care programs in the United States (Webb, 1989). During the 1970s and 1980s, several researchers attempted to describe adult day care according to models. Weissert (1976) developed a two-model topology and Robins (1975)and Welter and Rathbone-McCuan (1978) expanded the models to four. These models were used to describe the types of services provided, classifying the day care centers according to the social or medical orientation of their services. In 1984, the National Institute of Adult Day Care (NIAD)expanded the range of adult day care to include both the social and health needs of the individual (Webb, 1989). A1though national leaders were encouraging adult day-care settings to be more flexible and include a variety of services, funding sources continued to promote a dichotomy by differentiating among programs according to their primary orientation toward either a social or medical model. Medicaid, Medicare, and private insurance companies recognize “health care” and are more willing to reimburse for services 108
provided in an adult day care following a medical model. In contrast, some government funding, such as that provided through the Social Service Block Grants or the Older American Act, is restricted to the provision of social services to the elderly (Webb, 1985).
TRADITIONAL NURSING AND MEDICAL RESPONSIBILITIES IN ADULT DAYCARECENTERS The National Institute of Adult Day care has established standards for the proper functioning of adult day-care programs in the United States (1990).According to those standards, services provided by registered nurses are to include a basic initial assessment of the client’s health status, an observation of dietary habits, the administration of medications, assessment for any changes in the client’s condition, and the provision of supportive nursing care regarding dressings, skin care, hygiene, and other activities of daily living. Physicians, according to the standards, serve primarily as consultants. If the interdisciplinary care team identifies a change in the client or has a question regarding medical care, the physician is to be informed. Each participant must have a physician available for such consultation. In some adult day-care settings, physicians are a part of the staff either under direct contract to the center or as a physician on staff of the institution in which the center is located (Welter & Rathbone-McCuan, 1978).These physicians provide onsite care needed by the clients attending the center.
POTENTIAL NURSE PRACTITIONER RESPONSIBILITIES According to the 1987 American Nurses Association (ANA, 1987) Standards of Practice for the Primary Health Care Nurse Practitioner, NPs function as primary health care providers. The standards define primary health care as “continuous and comprehensive care and include[s] all services necessary for the promotion of health, the prevention of disease, and the early detection and treatment of illness” (p. 2). Adult day-care programs provide excellent settings where NPs can provide direct patient care.
ASSESSMENT In adult day care, clients must be screened before they are accepted as active participants in the program. These screenings often consist of phone calls to the potential clients and family members, with follow-up interviews in the day-care center. In addition to the
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
traditional nursing activities described above, NP involvement would include the use of history-taking skills to obtain information about current and past medical status, prior immunizations, and other health preventative measures undertaken by the client. Nurse practitioners would use their medical knowledge to note areas needing further investigation and follow-up should the individual be accepted into the program. Cognitive functioning could be evaluated by the NP who would note areas of deficit and areas that might be improved by incorporating certain activities into the individual plan of care. At the completion of the “intake assessment,” the profile of the individual compiled by the NP would be comprehensive, including not only baseline data regarding physical and cognitive functioning, but also additional information regarding potential problem areas, health promotion concerns, and issues of continued health maintenance (Webb, 1988). Frequently, new participants are required to have a physical examination before their acceptance into an adult day-care program. This usually consists of the physician completing a simple form that serves as a basis for monitoring the health maintenance of the participant. An NP in the adult day-care setting can not only perform the physical examination on each new participant, but also combine this with a comprehensive history that can be kept with the participant’s health records at the center.’ In the report “Healthy People 2000” (U.S. Department of Health and Human Services, 1990), the most important aspect of health promotion among older people was maintaining health and functional independence. Nurse practitioners can be instrumental in implementing this national objective in adult daycare programs. Not only can assessments and physical examinations monitor on-going medical concerns, but they can also identify potential problems and facilitate early interventions that can produce multiple benefits. These benefits include increased functional status, improved cognition, reduction of medication use, and prolonged survival (Rubenstein, 1987).
therapies. The problem of too much medication, contradicting medications, or evidence of undesired side effects of present medications might also be noted. Nurse practitioners can coordinate the total health care of participants, increasing the potential for adult day-care centers to actually deliver ambulatory health care to the aged (Welter& Rathbone-McCuan, 1978; Wolf-Klein et al., 1988). Acute episodic health care can also be provided by the NP. Accidental falls, problems with incontinence, minor injuries, and exacerbations of chronic and acute illnesses can be addressed by the NP. Immediate medical attention would be available without the need to contact a physician for emergency medical care or to transport the participant to an emergency room. Although some situations may involve conferring with other medical or emergency room staff, an NP is prepared to diagnose and treat many of the common medical problems found in adult day-care settings. This would result in increased quality of health care for the client and potential cost savings to the client and the center. The United States Office of Technology Assessment states that reimbursing NPs rather than physicians, where appropriate, would reduce health care costs considerably (Staff, 1989).
HEALTH PROMOTION AND DISEASE PREVENTION
A final area of contact is in the realm of health promotion and disease prevention. The elderly need to participate in health promotion activities because behaviors can be modified and problems can be identified, which may result in more appropriate use of health services as well as improvement in the individual’s health status (Gilford, 1988). An adult day-care program provides an excellent setting for preventive screening for the elderly. Periodic testing and monitoring can be performed for hypertension, cancer, glaucoma, hearing and vision deficits, podiatry problems, and dental problems. Although screening could be offered on a periodic basis, the NP can also establish clinic hours on a weekly or biweekly basis to deal with common concerns. EVALUATING AND MANAGING Immunizations that are extremely important to the ONGOING HEALTH PROBLEMS elderly can be provided, often preventing unnecessary The NP can play an active role in evaluating the illness and even death. Annual influenza vaccinations on-going medical therapies of each participant. For for all persons over the age of 65, and for persons of instance, a need for treatment change might be identified; any age who have chronic diseases that may increase the NP can consult with the community-based their risk of contracting this illness (Dychtwald, 1986), physician, and then prescribe and monitor on-going pneumococcal vaccination for all persons older than the age of 65, and tetanus and diphtheria every 10 years (Albert, 1987; Lindberg, 1987),could be included in each ‘Adult day-care programs maintain documentation of on-going client’s treatment plan. assessments, but often they are in the form of a “yes or no” checklist Annual breast and Pap smear screening for all women with little room for additional documentation. VOLUME 4, NUMBER 3, JULY-SEPTEMBER, 1992
109
regardless of age can also be provided by the NP. Likewise, older men can be examined for enlarged prostate and signs of early prostatic cancer.
OTHER ROLES Nurse practitioners also function in several subroles that could be incorporated into the adult day-care setting. These roles include educator, administrator, researchers, and consultant (ANA, 1985). Health education is an extremely important part of preventative health maintenance. The NP can include health teaching while monitoring chronic health problems, such as hypertension, or discuss nutritional concerns while examining or treating a client. As a component of any preventative health maintenance program, teaching would be provided for the individual and appropriate caregivers in the setting and at home. As part of their continued health maintenance functions, NPs can serve as consultants with the participants' community-based physicians assuming a case management role by coordinating care and identifying appropriate referrals. The NP is an ideal person to be the head of the interdisciplinary team, or
the medical director of the adult day-care program, with an administrative director to assist in the operations of the program. NPs can also function as researchers. In the setting of an adult day-care program, there would be ample opportunities to further validate various assessment tools based on this population. Specific treatment plans and educational methods can be developed. The opportunity for collaborative research presents itself with the interdisciplinary team of the adult day-care program.
CONCLUSION As the NP movement continues into the next 25 years, additional opportunities for role expansion will become available. Providing primary care services to clients in adult day-care centers opens unique opportunities to increase the comprehensiveness of care for the elderly and handicapped. One way to facilitate this expansion is through legislation that would provide direct reimbursement to NPs functioning as direct providers of medical services.
References Albert, M. (1987). Health screening to promote health for the elderly. Nurse Practitioner, 12(5), 42-56. American Nurses'Association. (1 985). Scope ofpractice of the primary health care nurse practitioner, Kansas City: American Nurses' Association. American Nurses' Association. (1987). Standards of practice for the Primary health care nurse practitioner. Kansas City: American Nurses Association. Dychtwald, K. (1 986). Wellness and health promotion for the elderly. Rockville, MD: Aspen Publications. Gilford, D. M. (1 988). The aging population in the twenty-first century, Washington, DC: National Academy Press. Grady, K. E. (1988). Older women and the practice of breast selfexamination. Psychology of Women Quarterly, 12(4), 473-487. Harder, W. P., Gornick, J. C., & Burl, M. R. (1986). Adult day care: Substitute or supplement? Milbank Quarterly, 64(3), 414-441. Jennings, C. P. (1989). Long-term care legislation:An issue of concern for nurse practitioners.Journal of the American Academy of Nurse Practitioners, 1(4),145-1 49. Lindberg, S. C. (1 987). Adult preventive health screening, 1987 update. Nurse Practitioner, 12(5), 19-41, National Institute of Adult Daycare (NIAD). (1990). Adult day care: A treatment program for persons with functional impairment. Washington, DC: National Council on the Aging. National Institute of Adult Daycare (NIAD). (1990). Standards and guidelines for adult day care. Washington, DC: National Council on the Aging.
Padula. H. (1985). Developing adult day care. Washington, DC: National Council on the Aging. Pearson, L. J. (Ed.). (1990). 25 years later: 25 exceptional nurse practitioners look at the movement's evolution and consider future challenges for the role. Nurse Practitioner, 15(9), 9-28. Robins, E. (1975). Operational research in geriatric day care in the United States. Paper presented at the 10th international Congress on Gerontology, Israel. Rubenstein, 1. Z. (1 987). Geriatric assessment An overview of its impact. Clinical Geriatric Medicine, 3(1), 1-1 5. Staff. (1989). Newswatch. Geriatric Nursing, 10(2), p. 8. Towers, J. (1990). Report of the national survey of the American Academy of Nurse Practitioners, part 111: Comparison of nurse practitioner characteristics according to education. Journal of the American Academy of Nurse Practitioners, 2(3), 121-1 24. US. Department of Health and Human Services. (1990). Healthy people 2000. Washington, DC: U.S. Public Health Service. Webb, L. C. (1 989). Planning and managing adult day care. Owing Mills, MD: National Health Publishing. Weissert, W. G. ( 1976). Two models of geriatric day care: Findings from a comparative study. Gerontologist, 16(5). 420-427. Welter, P., & Rathbone-McCuan, E. (1978). Adult day care. NY: Springer Publishing. Wolf-Klein, G. P., Moor, V. K., & Foley, C. J. (1988). Adult day care: A recent past and a growing future. New York State Medicine, 104(10),528-530.
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