Dr. Michael R. Rose

The Problem
The elderly population statistically ranks in the highest group of individuals for depression and suicide in the United States (Heisel, 2004; Karel & Hinrichsen, 2002; National Institute of Mental Health, 2005). Yet, community programs assess and treat this pervasive problem inadequately.

Rationale for the Study
While the current literature suggests that homecare services help to increase life satisfaction, it is not clear what other service benefits are derived for homebound elderly individuals living alone in the community without consistent informal supports.

Purpose of the Study
The purpose of the study was to explore the perceived impact of homecare services on the emotional functioning/states of well-being and the cognitive perceptions of homebound elderly individuals living alone in the community and receiving services through the SAIL program.

Methodology
The researcher used a phenomenological case study design that generated themes consistent with other interviewees and observers. The phenomenological and case study process focused on (a) the meaning of the experiences of elderly homebound individuals receiving homecare services and (b) the impact of the SAIL program, because no prior information of this nature existed (Creswell, 1988). To offset possible client bias, triangulation was used with three outside observers to confirm or contradict the clients’ recorded and transcribed responses.

Definition of Terms
Golsworthy and Coyle (1999) found that elderly individuals find meaning of their world from the interpretation of past experiences. Kegan (1982) defined meaning as a construction of an activity by how the individual perceives that event and the underlying forces that mold it. Emotion is the felt experience of that reaction.

Research Procedures
To explore these research questions, the investigator asked open-ended questions of 7 purposively selected SAIL clients and 3 additional individuals who had indirect contact with one or more SAIL clients. Their perceptions were compared to those of the elderly clients.

By obtaining the thoughts (cognitions), feelings (emotions), and meanings (perceptions) of the SAIL program to the clients, the investigator probed as deeply as possible to see if and how the meaning of the SAIL program impacted on their life satisfaction and well-being, without leading or biasing their answers. The open-ended questions involved a search for any differences in how the SAIL clients thought and felt about themselves in relation to changes in their life and beginning the program.

Validity Concerns and Controls

• Even with the safeguard of advising clients that there would be no negative consequences to their responses, biases cannot be ignored. Clients may have been reticent to share problems because of a positive regard toward their case manager, who was the study investigator.
• A colleague who reviewed the accuracy of the transcription may have a bias for the continued success of the program. The bias of the colleague was countered with one other reviewer and the outside observers.
• The triangulation of the outside observers’ interviews to those of the SAIL client interviewees (Devers, 1999; Mays, 2000) provided a different perspective to check and balance the dependency of the clients’ relationship with their case manager.

Assumptions

• The participants were not influenced unduly by the case manager’s presence.
• The participants were advised verbally and in writing that their participation in the study had no bearing on the quality or quantity of services they received or their relationship with their case manager.
• The participants could withdraw at anytime without consequence or ill will.
• The participants did not have dementia and were not taking any mood-stabilizing medications. They were selected for their capacities for reasoning and were to have no stated or observed problems with memory or awareness of person, place, and time (DSM-IV, 1994).

Limitations

• Due to the qualitative nature of the study, the findings may have face validity resonating with the reader, but may not empirically generalize to the greater SAIL population.
• The design of a qualitative study does not use a control group to validate the perceptions of the interviewees. The validity of the clients’ responses was taken on face value and was subjective to their own interpretation.
• Even though the clients were told that no consequence would result from their frankness, the bias of the relationship could not be dismissed.

Results
The confidence in the data was the strongest when the responses of two or more clients were consistent and corroborated by the outside observers. The findings are as follows:

• There was a perceived impact of homecare services on emotional functioning and life satisfaction, including (a) a feeling of reassurance, (b) a feeling of connection to others, and (c) a sense of control.
• The perceived impact of homecare services on cognitive functioning was the knowledge of having (a) a case manager to contact, (b) their reasonable expectations met, and (c) someone who cared for their welfare.
• The program cognitively impacted the client’s life satisfaction by their having a more positive attitude toward their adjustment to living by themselves.
• Case management assisted clients in monitoring compliance with medications and other aspects of treatment for chronic diseases.
• Thus, while the homecare services through the Senior Adult Independent Living (SAIL) program may not address the underlying personality issues and social skill deficits,  the services may be enough to encourage hope and self-esteem by providing clients (a) a sense that others care and (b) some control over their environment.

Recommendations

1. To improve practices in case management systems would involve (a) the use of a standardized depression assessment screening tool, (b) counseling services, and (c) case managers to pay closer attention to possible adverse reactions from medications, such as dizziness, falling, and increased confusion.
   
   
2. While the results of this study cannot be directly applied to the entire elderly population, these findings can and will be used to prompt public policy debate regarding the best use of available resources to meet the needs of this growing population. As the absolute and relative numbers of elderly people in the U.S. population continue to increase, society will have to address these issues. The findings from this study will help inform that debate.
   
   
3. Services through the SAIL program help to bridge the gap between quality of life and cost of skilled nursing care by keeping elderly individuals out of assisted-living facilities, maintaining their self-esteem and dignity. By monitoring needs and compliance with medications through case management, serious complications of chronic conditions are prevented. Therefore, public funds are well-spent in homecare programs, such as SAIL.
   
   
4. The findings from this study would suggest that the National Coalition on Aging  reevaluate their findings to eliminate case management as part of a homecare system assisting the elderly and disabled. The role of the case manager was significant in helping the clients feel reassured that they could live alone in the community. Contributing to those feelings of reassurance was a relationship of trust formed from empathy, respect, and a nonjudgmental attitude.

References

Backman, K., & Hentinen, M. (1999). Model for the self-care of home-dwelling elderly. Journal of Advance Nursing, 30(3), 564–572.

Beusterien, K., Steinwald, B., & Ware, J. (1996). Usefulness of the SF-36 health survey in measuring health outcomes in the depressed elderly. Journal of Geriatric Psychiatry and Neurology, 9(1), 13–21. Abstract retrieved April 30, 2004, from Medline database.

Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage.

Devers, K. (1999). How will we know “good” qualitative research when we see it? Health Services Research, 34(5 Pt. 2), 1153–1188 [Electronic version]. Retrieved November 14, 2005, from http://www.findarticles.com/m4149/
5_34/58451870/p1/article.jhtml

Erikson, E. H. (1997). The life cycle completed. New York: Norton.

Hagberg, M., Hagberg, B., & Saveman, B.-I. (2002). The significance of personality factors for various dimensions of life quality among older people. Aging & Mental Health, 6(2), 178–185.

Hedelin, B., & Strandmark, M. (2001a). The meaning of depression from the life-world perspective of elderly women. Issues of Mental Health Nursing, 22(4), 401–420.

Hedelin, B., & Strandmark, M. (2001b). The meaning of mental health from elderly women’s perspectives: A basis for health promotion. Perspectives in Psychiatric Care, 37(1), 7–14.

Heisel, M. (2004). Suicide ideation in the elderly. Psychiatric Times, 21(3), 50–53.

Karel, M., & Hinrichsen, G. (2000). Treatment of depression in late life: Psychotherapeutic interventions. Clinical Psychology Review, 20(6), 707–729.

Kivett, V., Stevenson, M. L., & Zwane, C. (2000). Very old rural adults: Functional status and social support. The Journal of Applied Gerontology, 19(1), 58–77.

Mays, N., & Pope, C. (2000, January 1). Qualitative research in health care: Assessing quality in qualitative research. British Medical Journal, 320, 50–52 [Electronic version]. Retrieved November 14, 2005, at www.findarticles.com/cf_0/m0999/
7226_320/59018052/print.jhtml

National Institute of Mental Health. (2003). Older adults: Depression and suicide facts. (NIH Publication No. 03-4593). Retrieved November 14, 2005, from http://www.nimh.nih.gov/healthinformation/
elderlydepsuicide.cfm

Söderhamn, O. (1998). Self-care ability in a group of elderly Swedish people: A phenomenological study. Journal of Advanced Nursing, 28(4), 745–753.

Takkinen, S., & Ruoppila, I. (2001). Meaning in life as an important component of functioning in old age. International Journal of Aging & Human Development, 53(3), 211–232.