Other Free Encyclopedias » Medicine Encyclopedia » Aging Healthy - Part 3

Nursing Homes: Special Care Units

aging social differences scus alzheimer disease residents

A movement to establish dementia special care units (SCUs) began in the United States in the 1960s. The movement gained momentum, becoming widespread in 1980s and 1990s. This growth was fueled by the recognition that Alzheimer's disease and other progressive dementias represent a serious public health problem, and by the advocacy of the Alzheimer's Disease and Related Disorders Association to improve care for individuals suffering from dementia. SCUs were also established in many nursing homes because it was recognized that their presence improved the image of the nursing home and helped to attract privately paying patients. Another impetus for establishing SCUs was the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), which emphasized a decreased use of physical and chemical restraints. In addition, the growing number of old-old persons, and thus the growing number of persons with dementing illnesses, mandated the development of "quality care" for such persons. For these reasons, SCUs have become more prevalent—in 2001 they existed in almost one-quarter of the nursing homes in the United States, almost double the number of SCUs that existed in 1990. Special dementia care programs are also being developed in residential settings.

SCUs vary greatly in terms of the number and composition of staff, the nature of activity programs, and patient care, but several features are generally found in all such units: they house only residents with dementing illness, and they offer specialized staff training, specific activity programming, family involvement, and a segregated and modified physical environment. However, all of these features are not necessarily present in any single SCU. As a result, while some SCUs reflect an honest effort to enhance the quality of care given to this population, some reflect primarily the response to a marketing imperative, and the degree of care enhancement in such facilities, is, at best, questionable. For example, a survey of 436 nursing homes indicated that not all SCUs offered richer or more tailored services for dementia than did non-SCUs, and that most non-SCUs offered some dementia-specific features similar to those made available in SCUs. Another survey, which evaluated SCUs and non-SCUs according to the presence or absence of activity programming, mental health support, and nursing rehabilitation, found that 12 percent of SCUs did not have any of these special programs, and another 20 percent were deficient in two of the categories. Insufficient staffing and sparse activity programming was also found in a survey of nursing homes in the eastern United States: one-fourth of the facilities provided only minimal features, such as secure units.

Such differences fostered the creation by some states of standards for SCUs. These standards include elements such as: separate written policies and procedures, secured entries and exits, modification of the physical environment, including a separate dining room, access to a secure outdoor area, special staff education and training, specific staffing levels; and specific activities and social support. There is some evidence that these standards have had a positive impact on the type and quality of services provided by SCUs.

Prevalence estimates of dementia in nursing homes vary widely, mainly due to differences in study methodology. Studies that use direct assessment by trained clinicians yield higher estimates (65 percent to 75 percent) than surveys that use chart data or administrative data sets. A recent study of a new admission cohort (Moguziner, et al.) yielded an estimate of 48 percent. About 80 percent to 90 percent of nursing home residents are cognitively impaired. Recent findings suggest that all SCU residents suffer from a dementing illness. Among these residents, almost two-thirds are communication-impaired; 68 percent to 85 percent are in the late-stages of dementing illness; over half have severe-stage cognitive impairment; and, because of their level of dementing illness, almost half are not testable on neuropsychological tests. These prevalence estimates are significantly and substantially higher than are those found among non-SCU residents.

Perhaps dwarfing other considerations, the potential cost of providing care to persons with dementia in specialized settings is staggering. Nursing-home expenditures constitute a large and rapidly growing component of overall health care expenditures. In 1997, approximately $82 billion was spent on nursing-home care in the United States—about 8 percent of total health care expenditures. It is estimated that by 2030 the level of nursing-home health care spending will rise to $1,477.4 billion—9.25 percent of the estimated $15,969.6 billion total health care spending. While many disease processes lead to nursing-home placement, persons with Alzheimer's disease and related dementias are likely to contribute, at a minimum, 20 percent of total nursing home expenditures. However, given the increasing proportions of nursing-home residents with cognitive deficits, this almost certainly constitutes an underprojection.

A question remains as to whether the amount, and thus the cost, of personal care differs between special care and traditional care settings. A related question is the degree to which differential impacts are associated with such differences as have been found to exist. It is important to distinguish between costs (monetized service-time inputs) and charges made by nursing homes for services to residents. While the latter usually are regarded as estimates of the former, it is possible, perhaps even probable, that charges are sensitive to market pressures and, therefore, do not accurately reflect the actual costs associated with care for different individuals in different settings. The issue of possible differences in costs of staff inputs made in SCUs, as contrasted with counterpart costs in traditional care units, is particularly important for several reasons. First, staff inputs account for over 80 percent of the total costs of nursing-home care. Similarly, staff time expenditures constitute the largest component of cost of care that relates directly to the characteristics of individual residents. Second, in addition to the stipulation that SCUs house only residents with dementing illness, the majority of definitional criteria usually applied in making a distinction between special care and traditional care are staff related. Adhering to the view of SCUs as a separate form of nursing care, one would expect there to be higher staff ratios, more staff time spent in therapies and in staff support and supervision, and to have more SCU time spent in case management, including reporting and planning. Third, staff inputs are the most immediately malleable major component of nursing home care: staff ratios, assignments, and patterns can be changed at will. In contrast, environmental changes usually take far more time to plan and implement.

Most evaluations to date, however, have shown that there are few, if any, differences between SCUs and traditional nursing-home units in terms of any of the dimensions along which such differences might be expected. In fact, there is a growing tide of feeling which holds that special care is really quality care for the growing proportion (now the majority) of nursing home residents who suffer from dementing illnesses. On the other hand, there is some evidence that there are slight (and statistically significant) differences between SCUs and traditional units (favoring the former) in terms of aide time spend serving residents, and in the impacts that increases in aide time have in SCUs. For example, using advanced data-gathering techniques, it has been shown that, on average, SCU residents receive almost eight minutes more (of an average total of slightly more than fifty-one minutes per resident, per day) of aide time than do their non-SCU counterparts in facilities which maintain both kinds of units. This difference increases to almost twenty-one minutes per day when the SCU residents are contrasted with residents of traditional facilities that do not maintain SCUs. Perhaps more important, from a cost-of-service point of view, it was found that additional aide service inputs gave more "bang for the buck" in SCUs than in traditional units—that is, for whatever reason, substantial increases (more than forty minutes average increase per day, per resident) in aide time had far greater effect in reducing resident agitation in SCUs than it did in non-SCUs.

Generally, it appears that SCU residents incur greater costs of inputs than do residents of more traditional types of units in terms of aides and speech therapists. However, although statistically significant, the differences between SCUs and traditional units tend to be clinically and economically trivial (e.g., less than three dollars per resident, per day, between SCUs and traditional units). However, these differences do become substantial when applied to all residents on a unit. For example, for a typical thirty-six-bed SCU, the difference is the equivalent of about one extra aide, divided between the day and the evening shifts. Additionally, investigators have suggested that both SCUs and non-SCUs (in nursing homes which support both) provide more aide and RN time per day on the day shift than do traditional units. This may reflect the fact that the presence of an SCU in a facility can have a beneficial facility-wide effect in terms of staff training and lower staff turnover. It is discouraging to note, however, how relatively few minutes are spent in the provision of direct care in either type of facility.

DOUGLAS HOLMES

BIBLIOGRAPHY

BURNER, S. T.; WALDO, D. R.; and MCKUSICK, D. R. "National Health Expenditures Projections Through 2030." Health Care Financing Review 14, no. 1 (1992): 1–29.

DAVIS, K; SLOANE, P.; MITCHELL, C.; PRESSIER, J.; GRANT, L.; HAWES, M.; LINDEMAN, D.; MONTGOMERY, R.; LONG, K.; PHILLIPS, C.; and KOCH, G. "Specialized Dementia Programs in Residential Care Settings." The Gerontologist 40, no. 1 (2000): 21–42.

ERNST, J., and HAY, J. "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited." American Journal of Public Health 84, no. 8 (1994): 1261–1264.

FRIES, B.; MEHR, D.; SCHNEIDER, D.; FOLEY, W.; and BURKE, R. "Mental Dysfunction and Resource Use in Nursing Homes." Medical Care 31, no. 10 (1993): 898–920.

GERDNER, L., and BUCKWALTER, K. "Review of State Policies Regarding Special Care Units: Implications for Family Consumers and Health Care Professionals." American Journal of Alzheimer's Disease and Related Disorders 11 (1996): 16–27.

GLANDON, G.; LINDEMAN, D.; and HOLMES, D. "Issues in Measuring Costs in Institutional Settings." Journal of Mental Health and Aging 3, no. 1 (1997): 129–144.

GOLD, D.; SLOANE, P.; MATHEW, L.; BLEDSOE, M.; and KONANC, D. "Special Care Units: A Typology of Care Settings for Memory-Impaired Older Adults." The Gerontologist 31 (1991): 467–475.

GRANT, L., and ORY, M. "Alzheimer Special Care Units in the United States." Research and Practice in Alzheimer's Disease 4 (1999): 19–44.

GRANT, L.; KANE, R.; and STARK, A. "Beyond Labels: Nursing Home Care for Alzheimer's Disease In and Out of Special Care Units." Journal of American Geriatrics Society 43 (1995): 569–576.

HOLMES, D. "Special Care Units: What Makes Them Special?" Nursing Home Economics (February/March, 1996): 28–31.

HOLMES, D.; SPLAINE, M.; TERESI, J.; MONACO, C.; RAMIREZ, M.; and BARRETT, V. "What Makes Special Care Special: Concepts Mapping as a Definition Tool." Alzheimer's Disease and Associated Disorders 8, suppl. 1, (1994).

HOLMES, D., and TERESI, J. "Characteristics of Special Care Units in the Northeast Five State Survey: Implications of Different Definitional Criteria." Alzheimer's Disease and Associated Disorders 8, suppl. 1 (1994): S97–S105.

HOLMES, D., and TERESI, J. "The Costs of Care in Dementia Special Care Units, As They Relate to Care Outcomes." Research and Practice in Alzheimer's Disease 4 (2000): 199–216.

HOLMES, D.; TERESI, J.; LINDEMAN, D.; and GLANDON, G. "Measurement of Personal Care Inputs in Chronic Care Settings." Journal of Mental Health and Aging 3, no. 1 (1997): 119–127.

HOLMES, D.; TERESI, J.; and ORY, M. "Editorial: Special Care Units for People with Cognitive Impairment, Including Alzheimer's Disease and Related Disorders: an Overview." Research and Practice in Alzheimer's Disease and Related Disease 4 (2000): 1–17.

HOLMES, D.; TERESI, J.; RAMERIZ, M.; and GOLDMAN, D. "The Measurement and Comparison of Staff Service Inputs in Special Dementia Care Units and in Traditional Nursing Home Units Using a Barcode Methodology." Journal of Mental Health and Aging 3 (1998): 195–207.

LEON, J. "Characteristics of Dementia Admissions to Standard Nursing Homes and to Special Care Units." American Journal of Alzheimer's Disease (Jan/Feb, 1998): 1–14.

LEON, J.; POTTER, D.; and CUNNINGHAM, P. Current and Projected Availability of Special Nursing Home Programs for Alzheimer's Disease Patients. (DHHS Publication No. (PHS) 90–3463). Rockville, Md.: Public Health Service, 1990.

MAAS, M.; SWANSON, E.; SPECHT, J.; and BUCKWALTER, K. "Alzheimer's Special Care Units." Nursing Clinics of North America 29 (1994): 173–194.

MAGAZINER, J.; GERMAN, P.; ZIMMERMAN, S.; HEBEL, J.; BURTON, L.; GRUBER-BALDINI, A.; MAY, C.; and KITTNER, S. "The Prevalence of Dementia in a Statewide Sample of New Nursing Home Admissions Aged 65 and Older: Diagnosis by Expert Panel." The Gerontologist 40, no. 6 (2000): 663–673.

MASLOW, K. "Current Knowledge about Special Care Units: Findings of a Study By the U.S. Office of Technology Assessment." Alzheimer's Disease and Associated Disorders 8, suppl. 1 (1994): 14–40.

MEHR, D., and FRIES, B. "Resource Use on Alzheimer's Special Care Units." The Gerontologist 35 (1995): 179–184.

MORRIS, J., and LOMBARDO, N. "A National Perspective on SCU Service Richness: Findings from the AARP Survey." Alzheimer's Disease and Associated Disorders 8, suppl. 1 (1994): S87–S96.

PALMER, H., and COTTERILL, P. "Studies of Nursing Homes Costs." In Long Term Care: Perspectives from Research and Demonstrations. Edited by R. Vogel and H. Palmer. Washington, D.C.: Health Care Financing Administration, 1982. Pages 665–722.

TERESI, J. A.; MORRIS, J. N.; MATTIS, S.; and REISBERG, B. "Cognitive Impairment Among SCU and Non-SCU Residents in the United States: Prevalence Estimates from the National Institute on Aging Collaborative Studies of Special Care Units for Alzheimer's Disease." Research and Practice in Alzheimer's Disease 4 (2000): 117–138.

VOLICER, L., and SINARD, J. "Establishing a Dementia Special-Care Unit." Nursing Home Economics 3, no. 1 (1996): 12–19.

Nutrition - Factors Affecting Adequate Nutrition In Elderly Individuals, Challenges In Assessing Energy Requirements, Summary And Future Considerations [next] [back] Nursing Homes: History

User Comments

The following comments are not guaranteed to be that of a trained medical professional. Please consult your physician for advice.

Your email address will be altered so spam harvesting bots can't read it easily.
Hide my email completely instead?

Cancel or

Vote down Vote up

about 1 year ago

I work with a lot of dementia residents. Its takes compassion and respect for the elderly. I enjoy my residents everyday.

Vote down Vote up

about 2 years ago

I love working with the residents on the SCU. Yes, they do take more time and patience, but it is all worth it. They might not remember it tomorrow, but it makes a difference in the "here and now"

Vote down Vote up

over 2 years ago

I always felt that patient's with dementia take more time and patience to care for. Yes it is sad they suffer due to the lack of education and empathy for these dear ones.

Vote down Vote up

over 2 years ago

i didnt realize the scu residents really do require much more time. i love being on the unit

Vote down Vote up

about 1 month ago

Our facility has a secure unit included, so we deal with the special care needs of dementia and Alzheimer's. It most definitely take care and compassion, as well as patience, that very special people have. So thankful there are people out there with the abilities!

Vote down Vote up

2 months ago

To be honest, I love working with the residents at my facility that have dementia. Sometimes they are a handful to deal with but if you can make them smile that one time it is all worth it in the end.

Vote down Vote up

7 months ago

I enjoy my residents

Vote down Vote up

about 1 year ago

I love working with the SCU residents. I love taking my time and care with them.

Vote down Vote up

about 1 year ago

I wish there were more secure units in Texas for dementia patients. This is a growing epidemic because of the way we eat, live, consume or inherit. And it comes on so quick, and the can get away so fast.

Vote down Vote up

over 1 year ago

really makes sense. those residents off the scu's do not require the kind of attention that residents with dementia require. they are child like and need proper supervision.

Vote down Vote up

about 2 years ago

this is good reading about dementia patience because it a difference with them and the resident in a nursing home to me time and love and understanding is require.

Vote down Vote up

about 3 years ago

This was very interesting, I enjoyed the studies between scu's and non scu's. I also think that the discussion af ound increased services between the tow needs to continue. There are clear benefifs for adequate staffing and sefvices for both.

Vote down Vote up

over 6 years ago

Special Care Units began in the 1960's but became widespread in 1980 & 1990. SCU's only house residents with dementing illness.