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BY: DAVID A. JEWELL, MAUREEN L. TETTMAN, PAMELA A. GEORGE, LORI A. LAWSON, and JOAN E. FITZPATRICK

In Canada, as in the United States, financial pressures have combined with advances in medical science to reduce the average length of hospital stays. One result has been an increase of anxiety among elderly patients, who, although medically stable following surgery or therapy in a hospital, often feel they are not yet ready to be discharged to their homes. This can be especially true of patients who are physically frail and live alone.

In early 1993 the social work department of St. Joseph's Hospital, Hamilton, Ontario, began studying this problem. The department convinced the leaders of both the 400-bed hospital and St. Joseph's Villa, a 378-bed long-term care facility in nearby Dundas, Ontario, that the two organizations should search for a way to help fearful older patients rebuild their stamina, recover their confidence, and develop coping skills for life outside the hospital. The leaders of the facilities — both members of St. Joseph's Health Care — agreed to collaborate on the project.

The social workers noted that although the concept of convalescence has disappeared from many contemporary nursing and medical textbooks, it was for many years understood to be a vital stage in recovery from illness or injury. In fact, they learned, Florence Nightingale urged healthcare leaders in nineteenth-century England to build country convalescent homes, not only to help ill and injured patients return to health but also to relieve crowding in hospital wards. (George Castledine, "The Value of Convalescent Care," British Journal of Nursing, vol. 3, no. 14, pp. 728-729.)

Leaders of the two St. Joseph's facilities saw that an institutional form of convalescence could be beneficial for certain older patients as well as for local healthcare in general. They decided that the two organizations should create a "step-down" unit to be called the Supportive Care Program (SCP). Anxious elderly patients would, after leaving the hospital, spend two to four weeks convalescing in this unit before being discharged to their homes.

Developing the SCP
St. Joseph's Hospital and St. Joseph's Villa developed the SCP as a joint initiative. Planning for it was done by an ad hoc committee composed of representatives from both facilities, including representatives from social work, administration, finance, nurse management, and home care.

In creating the SCP, the ad hoc committee worked closely with local family physicians, many of whom agreed to recommend the unit to patients they thought might benefit from it. This involvement made it possible for physicians to plan their patients' discharges before they were hospitalized, thus ensuring a full continuum of care ranging from the preadmission stage through posthospital care.

Opening the SCP
In May 1993 the new unit was launched at St. Joseph's Villa as a single bed for a female patient; a bed for a male patient was added the following year. The beds, on different floors, are in semiprivate rooms close to nursing stations and resident kitchens.

The ad hoc committee decided that to be eligible for the SCP, patients should be capable of functioning in "board and lodge" or "retirement home" settings. (These are roughly equivalent to assisted living and independent living settings, respectively, in the United States.) Prospective patients must be:

• Medically stable, requiring minimal treatment
• Independently ambulatory, with or without mechanical aids
• Able to care for themselves with minimal supervision
• Requiring nursing care that primarily involves only supervision and assistance with activities of daily living
• Free of any severe psychiatric illness or other condition (e.g., alcoholism) that might lead to noncompliance with a medical regimen

Results of the SCP
Between May 1993, the SCP's opening, and May 1996, the unit admitted 31 patients — 25 of whom were women and 6 men. Their ages ranged from 64 to 95, the mean age being 80.

These 31 patients occupied the SCP's beds for 720 days out of 1,095 days (66 percent). The average length of stay was 21 days, some patients staying as long as 50 days, others leaving after only 3.

Seventeen SCP patients (54 percent) returned to live independently in their homes after discharge from the unit. Six patients (19 percent) decided they would need further care, and so arranged either to go home with nursing help or to enter a board and lodge or retirement home. Four patients (13 percent) were admitted to long-term care facilities. Three patients (10 percent) were readmitted to St. Joseph's Hospital for additional acute care. (See "Results of Supportive Care Program" at the end of this article.)

Patient Evaluation of the SCP
Following their discharges, 14 of the 31 patients were contacted by phone and asked a series of structured questions about their experience in the unit. About 86 percent said they would recommend the SCP unit to family members or friends who found themselves in a similar situation. About 80 percent gave the unit a high overall rating. And most former residents said their stamina and confidence increased significantly during their SCP stays. (See Figure below.)

Perhaps most telling, former patients often praised the SCP for having given them a "window" of time during which they could plan and make decisions about their future.

The SCP's Value
The SCP has proven to be beneficial for patients feeling ill prepared, for either physical or psychological reasons, to return directly home after surgery or other hospital therapy. For example, one elderly woman had a below-knee amputation. She chose to convalesce in the SCP. During this stay she underwent rehabilitative therapy, arranged to have her apartment adapted to fit her needs, and made periodic visits to it to familiarize herself with her new home setting.

By the same token, several St. Joseph's Hospital patients scheduled to be discharged to long-term care facilities asked to convalesce in the SCP. Their stay in the unit allowed them to personally assess their "fit" for long-term care.

But whether elderly patients leave the hospital to return home or to go into long-term care, they often need an intermediate place in which they can regain stamina and confidence before moving on. Facilities like the SCP represent a step toward the continuum of care that will be essential as more elderly persons require a range of options to meet their varying needs.

Mr. Jewell is supervisor, Department of Social Work, St. Joseph's Hospital, Hamilton, Ontario; Ms. Tettman is supervisor, Ms. George and Ms. Lawson are social workers, and Ms. Fitzpatrick is an intake worker, St. Joseph's Villa, Dundas, Ontario.

RESULTS OF SUPPORTIVE CARE PROGRAM