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University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

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6/01 chIRC/DateDuepBS-p. 15

A BROCHURE FOR UNDERSTANDING THE ROLE OF
THE GERONTOLOGY NURSE PRACTITIONER IN
CARE OF THE HOMEBOUND OLDER ADULT

BY
Linda A. Rollins

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

1998

ABSTRACT
A BROCHURE FOR UNDERSTANDING THE ROLE OF

THE GERONTOLOGY NURSE PRACTITIONER IN
CARE OF THE HOMEBOUND OLDER ADULT

BY
Linda A. Rollins

The population is growing older and the Gerontological
Nurse Practitioner (GNP) can be of great value in meeting
their health care needs. The GNP is specifically educated
to assess and manage common health care problems of older
adults. The role of the GNP is of recent origin and
continues to evolve. Physicians, consumers, and third party
payers have little to no previous experience with
Gerontological Nurse Practitioners (GNP)'s, and lack
knowledge of the role and services provided by GNP's. Lack
of awareness of the role of the GNP will be addressed by
development of an informational brochure. The primary goal
of this project is to develop a product to increase the
knowledge and awareness of services provided by the
Gerontological Nurse Practitioner to homebound older people

living in the community.

ACKNOWLEDGMENTS

I want to express my gratitude and thanks to several
people for their help, constant encouragement and support
throughout this project. I am thankful to my project
committee, Jacqueline Wright, RN, MSN, Sharon King, RN, CS,
PhD and Laura Struble, RN, CS, PhD, GNP for their efforts
and continuous reinforcement toward completion of this
project. Their criticism, was valuable to keep me on track
and make this a meaningful project.

I especially want to thank Diane Anderson and my
husband, Duane, without them I would have given up many

times during the last five years. I will always be grateful

for their love and support.

iii

LIST OF FIGURES . .

INTRODUCTION . . .

TABLE

Purpose of the Project

Background for Project

Conceptual Framework

Health Belief Model Concepts.
Relationships and Relevance to

Literature Review .

Role of Gerontological Nurse Practitioner

Homebound . .
Older Adults .

Description of Approach and Procedures for Project

Criteria and Rationale for Selection of Target Group

BROCHURE DEVELOPMENT

Methodology . . . .

Evaluation of Project
Implication for Advance Practice Nurse Research

Implication for Advance Practice Nurse Education
Implication for Advance Practice Nurses Practice

Summary . . . .
LIST OF REFERENCES

Appendix A: Brochure

OF CONTENTS

iv

Project

12
13
13
13
15
15
17
18
19
20

24

LIST OF FIGURES

Figure 1: Adapted Health Belief Model . . . . . . .

Figure 2: Adaptation of Modified Health Belief Model

Page
. 5
. 8

INTRODUCTION

The purpose of the scholarly project is to develop a
brochure to introduce the role of the Gerontological Nurse
Practitioner (GNP) to the homebound older adult. The
population of older adults 85 years and older is the fastest
growing population cohort. This older adult population has
increased 28.8% in the last decade and doubled in the last
two decades (Crump & McLeroy, 1994). George and associates
(1994) report that there will be 80 million people past the
age of 65 by the year 2020. Currently, the 65-year and
older age group is 13-15% of the population and consumes 35%
of the health care dollars (George, Koening & Schneider,
1994).

One trillion dollars was spent for health care in 1995
in the United States (this was 14.5% of the Gross Nation
Product) which is more than any other nation (Jamian, 1994).
Health care costs for the State of Michigan are 36% of the
state's expenditures, with 23 billion spent on health care
in 1990's and an estimated 129% increase in Michigan
expenditures by the year 2000 (Jamian, 1994).

The old-old (age 85 years and older) have the highest
incidence of immobility and self care limitations. Thirty
one percent of persons over 75 years of age have limitations
in mobility, vision or hearing compared to 4.5% of Michigan
citizens between the ages of 16 to 64 (Jamian, 1994). Older

persons have more complex problems, their needs are more

technical and their disease processes are generally more
chronic (Riley, 1994).

The need for health care reform focuses on lack of
access and the need to contain escalating health care costs.
The growing numbers of older Americans are seen as major
contributors to the increasing costs of health care because
they consume a disproportionate amount of health care
dollars. 5

Gerontological Nurse Practitioners (GNP) are autonomous
expert nurses who promote health and help to prevent disease
by diagnosing and managing individual patient problems
(Jenkins & Sullivan-Mars, 1994). Principles of health
promotion are integral to primary care and the historical
roots of primary care Nurse Practitioners (NP) are grounded
in public community health nursing (Jenkins & Sullivan-Marx,
1994). The role of the GNP evolved from the primary care
NP. Gerontological Nurse Practitioners have been in
existence since 1966 and are slowly evolving into a
distinctive professional role.

Purpose of the Project

The purpose of this scholarly project is to develop a
brochure that can serve as an introduction to the role of
the GNP for the homebound older adult as that role relates
to their homecare health needs. The brochure will inform
consumers that the GNP does not replace the physician but,
rather is in, collaboration with the physician to ensure
access to health care that is of high quality and cost
effective to the homebound older person.

2

Informing the homebound older person about the services
the GNP can furnish may help older persons gain confidence
in the GNP skills in health promotion and disease
prevention. Care provided by the GNP focuses on a holistic
approach (Kupina, 1995) unlike the medical model, which
focuses on disease treatment. The brochure would be useful
in explaining the type of services the GNP provides.

Background for Project

There have been numerous articles written telling how
physiological and psychological stressors affect an older
person health status (Fromer, 1979). Medication errors and
poor compliance with medical recommendations may occur
because of failure to understand the clinicians'
instructions (Alessi et al., 1995). The GNP may educate
older persons on maintenance of health and wellness and
assist in lowering the level of disability and reducing
nursing home admissions (Alessi et al., 1995).

Improving the overall health system available to the
older person (Atchley, 1980) is the primary concern of the
GNP. The following functions are within the realm of the
GNPs practice: assessment of physical, functional and
mental status, review of medications and management of
immunizations, counseling families, providing referral to
community resources, home safety, nutrition education,
exercise programs, stress reduction, group therapy and
rehabilitation services. Gerontological Nurse Practitioners
are able to manage problems common to clients with dementia
and other chronic diseases common to older persons, evaluate

3

the home environment, and assess its impact on functional
ability.

To increase the utilization of GNPs it is necessary
that they be visible in the community and develop
professional relationships. They also educate the client
and continue research on the effectiveness of their care.
The brochure is intended to increase understanding of the
role of the GNP by the homebound older adult.

Conceptual Framework

The conceptual framework guiding development of this
project is the Health Belief Model (HBM) that was introduced
by Rosenstock in 1966.

Hea1th_Belief_MQdel_CQnQents

The concepts of the HBM include the following:

1. Perceived susceptibility: Subjective perception of
risk of contracting a disease.

2. Perceived severity: Feelings concerning the
seriousness of contracting a disease.

3. Perceived benefits: Beliefs regarding benefits/actions
available in reducing the threat of disease.

4. Perceived barriers: Potential negative aspects of an

action which acts as an impediment (Becker, 1974, p.3).
(See Figure 1).

The GNP approaches their client with an attitude and
acceptance that facilitates the motivation of the older
adult to accept responsibility for their health care actions
(Gartner & Twardon, 1992). Bluestein and Rutledge (1993)
state that health beliefs are key mediators linking

4

 

 

 

 

 

 

Knowledge About

Disease and Therapy

 

 

 

 

 

Perceived ‘ .
Severity

of
Disease

i 'n act rs

0 Complexity and
Longevity of Regimen

' Disruption of Regimen
to Customary Activities

 

 

 

Perceived
Benefits of
Therapy

¢

Perceived
Barriers to
Therapy

 

 

 

 

 

 

 

i

Decision to
Assume
Responsibility
for Disease
Management

+

Actual
Health
Behavior

 

 

 

 

 

 

 

 

+

 

Improved
Health
State

 

 

 

Emmi. Adapted Health Belief Model.

 

Personal
Responsibility
for Control
Motivation
to Control
Disease

 

 

 

Cues to Action
Support from
Provider/Family/
Friends

 

 

 

psychosocial vulnerabilities, delayed care and adverse
outcomes. Their study proposed an HBM framework that
examined how psychosocial and sociodemographic attributes
lead to delayed care.

The Health Belief Model key components of perceived
susceptibility of the older persons perception of their risk
to contracting a disease, encompasses the element of the
threat of disease. A homebound older person "exhibiting an
optimal level of beliefs in susceptibility and severity
would not be expected to accept any health action unless it
was perceived as feasible and efficacious" (Hughes &
Tartasky 1996, p.219).

The direction of the health care that an older adult
accepts will be influenced by their beliefs regarding the
relative effectiveness of known available alternatives
(Becker, 1974). The alternative must also be available to
the homebound older adult. Using the components of the
Health Belief Model as a framework for this brochure assists
in explaining to the homebound older adult the role the GNP
can fulfill in their health care.

Literature has shown that health is a personal
commitment that has an interrelationship with the physical
environment (Becker, 1974). Assessing the health of older
adults requires a multidimensional approach. Actualizing
the persons potential for optimum health is accomplished
through competent personal care and meaningful relationships
with others. The GNP understanding the social and
psychological aspects of aging in a multidisciplinary

6

approach may assist the older person in acquiring optimum
health.

"Using the HBM simplifies complex issues and suggests
hypotheses concerning relationships among modifiers, beliefs
and care-seeking actions" (Bluestein & Rutledge, 1993,
p.271). The health Belief Model provides the framework that
attempts to understand why people do or do not choose to
pursue healthful behavior changes and life styles.
Individuals make the choices about actions that constitute

their lifestyles and, in turn, their profile of health and

illness (Walker, 1994).
E J l' l' i E J l E . I

The HBM is a psychosocial model that explains health
related behaviors. When barriers are minimal a person will
experience a greater likelihood of taking a health related
action such as using the services of a GNP (Becker, 1974).

Increasing the older person's knowledge of the role of
the GNP and their sense of personal responsibility, will
impact their perception of the benefits of using the GNP.
The brochure (a cue to action) will impact older persons
perception of benefits and barriers and, in the final
analysis, will impact their decision to use the GNP.

For the purpose of this project selected variables of
the modified Health Belief Model have been identified to
illustrate the impact of an informational brochure to

explain the role of the GNP to the homebound older adult
(See Figure 2).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal
Knowledge about ¢ > Responsibility
Role of GNP for Control
, of Health Care
Perceived
Benefits of
Use of GNP
Perceived Cues to
Barriers to % > Action
Use of GNP (Brochure)
Decision to
Use GNP

 

 

 

Figure 2. Adaptation of modified HBM, as related to development of a brochure to
increase understanding of the role of the GNP.

Literature Review
This section presents the literature review for the key
concepts: Role of Gerontological Nurse Practitioner,
Homebound and Older Adult. The research literature is

limited in relation to the GNP treating older homebound
adults.

E J E E l J . 1 H E I'll

Gerontology is a branch of science that deals with the
problems of adaptation and disease of older adults. The
function of the GNP is to assess the nursing needs of older
adults and then plan and implement nursing care to meet
those needs (Hodges & Staab, 1996). A critical role of the
GNP is to function as a practitioner and serve as the expert
direct care provider (Gartner & Twardon, 1992). The goal of
the GNP for the older person is to maintain the highest
level of wellness allowed by the limitations imposed by the
aging process and diseases that may be present. One of the
many roles of the GNP is to improve the quality of life for
the older adult. Gerontological Nurse Practitioners
understand and assess the unique types of assistance the
older adult may need to remain safely in their home
(Sweeney, 1996).

The case management role of the GNP may assist home
health to rein in costs in the organization of each
patient's ancillary care (Monaghan, 1996). The GNP must
play many roles: facilitator of nursing process, change
agent, educator, case manager, researcher, consultant and
coordinator. The GNP moves in and out of these and many

9

other roles, while identifying factors that facilitate and
inhibit functioning. The Gerontological Nurse Practitioner
is a member of a very specialized area of nursing related to
the problems of the aged that are associated with daily
functioning (Hodges & Staab, 1996). The GNP makes a
commitment to provide health care to meet the needs of the
older adult and provide care of the highest quality
including preventive, restorative and maintenance services.

For the purpose of this project it will be understood
that the GNP functions to coordinate clinical data, provide
continuity, consultation, referral and advocacy for the
older adult (Jenkins & Sullivan-Marx, 1994), and that
physical, mental and functional status is assessed and
evaluated by the GNP (Belle et al., 1996).

Homebnund

Homebound refers to a person who is unable to access
programs outside their place of residence. Homebound adults
have functional limitation's such as: difficulty with
walking and prolonged standing (Hughes & Tartasky, 1996),
lack of activity tolerance due to cardiac or respiratory
impairment, pain and frailty related to disease processes.
These functional limitations will threaten older adults'
independence and their ability to remain in their own homes
(Folden, 1990).

Homebound, according to Medicare guidelines refers to a
normal inability to leave one's home without assistance
(Hughes & Tartasky, 1996). Homebound adults not only have
functional limitations, but they also have a need for

10

different types of services, unlike the older adult who can
go outside their residence for assistance. People who are
homebound and have to receive assistance describe an
underlying feeling of loss when they are unable to leave
their home when they want to (Folden, 1990).

Clinical studies have shown that patients treated at
home have lower rates of mortality and morbidity than
patients treated with the same disease in the hospital
(Editor, California Medicine, 1996). Home care is a cost-
effective service that provides patients with better medical
outcomes and better quality of life (California Medicine,
1995).

Folden (1990) states that homebound is when absences
from home for the frail adult require a considerable and
taxing effort and must be infrequent and of short duration.
Many older adults feel homebound when they lose the ability
to drive. They are able to walk around but they have to be
driven and they resist having to ask for help (Folden,
1990). This population is not considered truly homebound.

"Homebound older adults have to make unique and
innovative changes in their environment and life styles to
remain independent as possible" (Folden, 1990, p.12). Belle
et al. (1996) classified homebound as older adults who leave
the house once or less per week. Generally, the educational
level of homebound elderly was less than a high school
education (Belle et al., 1996).

For the purpose of this project homebound will be
defined according to the Medicare guidelines that refer to

11

an older persons inability to leave their place of residence

without assistance.
Older_Adult

Older adult is identified as an elder 65 years or
older. Currently 3.5 million United States residents are 85
or older and the census for this age group is projected to
be 24 million by the year 2040 (LeSage & Muhmud, 1997).

The projected increase in the number of disabled older
adults poses a challenge for health care related to
affordability and accessibility (Alessi et al., 1995).
Medicare established the age of 65 years as the minimum age
criteria for eligibility for health benefits. This group
has been further divided as, young old (65-74 years), middle
old (75-84 years) and old-old (85 years and older) (Hodges &
Staab, 1996).

It is sometimes hard for the older adult to get help
from the family network because their children are middle
age or older adults. Folden (1990) states that for the
first time in history adult children will spend more years
of their lives caring for dependent parents, than for their
own children.

For the purpose of this project an older adult will be
defined as a person 65 years of age or older.

Description of Approach and Procedures for Project

This brochure is being developed as a tool to deliver
information to the older homebound adult about using the GNP
in the home. The HBM is the framework used to define the

structure for the brochure.

12

Criteria and Rationale for Selection of Target Group

The target group is homebound older adults. This would
include any older homebound adult with chronic and acute
health problems, in the need of health promotion and illness
prevention. There are four communication techniques that
could be used to educate people about the GNP role:
personal, mass, direct and interactive communication (Ball-
Rokeach & DeFleur, 1982). Mass communication in the form of
a brochure will be the most effective if it does not clash
with the readers present values and is related to the older
person's goals. People develop subjective and shared
constructions of reality from what they read, hear or view
(Ball-Rokeach & DeFleur, 1982).

The HBM suggests that a person will develop predictors
that control how they accept care, and communication is a
variable that affects these attributes and can lead to the
acceptance of health care. Bluestein and Rutledge (1993)
state that health care beliefs are mediators that can be
linked to psychosocial vulnerabilities. People may delay
care which can lead to adverse outcomes because of these
beliefs.

BROCHURE DEVELOPMENT
Methodology

The purpose of this brochure is to inform the homebound
elderly of the role of a Gerontological Nurse Practitioner.
The brochure has evolved from the review of current
literature, which is limited, on the use of a GNP for the
care of a homebound older adult to improve the elder's

13

quality of life and assist them in safely staying in their
own home.

The formation of the written text for the brochure has
evolved from the literature that relays that the older adult
may have limited literary skills. Davis et al. (1996),
state that ninety million Americans have limited literacy
skills which are a burden that profoundly affects the
quality of their health care. Seventy-five percent of
Americans with chronic physical or mental health problems
scored low in the skills of reading and the spoken word
(Davis, Meldrum, Tippy, Weiss & Williams, 1996). Adults do
not want to admit to illiteracy which in turn, hinders them
when seeking health care. A study by Emory University in
1998 found that 63% of the general public frequently misread
instructions on how to take medications (Boodman, 1998).
Ninety-seven percent of elderly patients report that
television is where they get information about their health
(Boodman, 1998).

The last important concept that must be recognized is
the homebound status of the elderly. Literature identifies
homebound many different ways. Folden (1990) states it is
functional limitations. Hughes & Tartasky (1996) state it
is functional limitations and lack of activity tolerance.
For Medicare guidelines it is more vague yet and Hughes &
Tartasky (1996) refer to the older adults normal inability
to leave one's home without assistance. For the purpose of

the brochure all items have been taken into consideration

14

and will use the normal inability to leave one's home

without assistance.
W

With distribution of the brochure an increase in the
utilization of the GNP in homecare would hopefully ensue.
Another way to measure the brochure's effectiveness is to
monitor the outcomes of clients. However, it may take some
time to thoroughly evaluate the impact GNP's have on older
homebound adults to increase/decrease their quality of life.

Focus groups could be used to determine the brochure's
effectiveness. Questions to be asked during the session
would include: Are older adults in the home accepting the
GNP? Have they tried GNP services? Have they had good/bad
experiences using an GNP and why? Much can be learned by
groups like these i.e.: What is being said about the GNP.
The most important indicator of the value of the brochure
will be: 1) The number of brochures distributed; and 2) The

number of homebound older persons who utilize the services

of a GNP.

O 0
no . o. o ;o .0 ‘ ' a ‘ \. ‘ 4'\ :' "- I

As stated previously in this paper, more research is
needed to evaluate cost and outcomes of ANPs in primary care
and GNPs in providing homebound services. Geriatrics is an
area where ANPs are greatly needed. Early research has
shown that the GNP can bring an increased focus on patient
care needs, spending time, exchanging information, and
communicating to learn more about the needs of the older

homebound person (Riley, 1994).

15

Any study must also measure quality of care as well as
cost, both are important to patient welfare. With the
increased use of managed care the GNP can fulfill the case
management role and help contain health care cost (Mirr,
1993).

Mirr (1993) reports that the following limitations
related to the ANP's effectiveness, scope of practice,
prescriptive authority and reimbursement. These barriers
need to be removed or lessened to increase the functional
usage of the GNP.

The Office of Technological Assessment (1986), did an
exhaustive study assessing quality of care of the ANP based
onprocess, outcomes, patient satisfaction and physician
acceptance. The Office of Technological Assessment
concluded that ANP's care was equivalent to that of a
physician and ANPs were superior regarding patient
satisfaction (Inglis & Kjervik, 1993). The ANP takes on the
responsibility to show how the role is cost effective and
financially justified by obtaining positive changes in
patients and desirable behaviors that are attributable to
the ANP intervention (Hamric, 1989).

The GNP as the expert direct care provider facilitates
the older adults motivation to participate in their own
health care needs (Gartner & Twardon, 1992). Research
development and promotion of patient education material is

an integral part of the GNP services for the older homebound

adult.

16

The GNP must constantly validate findings during their
practice and disseminate information about current health
care practice. There is a constant need to conduct research
on nursing interventions and to define and expand the GNP's
knowledge base. Promoting and maintaining quality care and
development of standards of care for the GNP are both
indicators for research for advance nursing practice.
WW

There are many implications for education about the
role of the APNs. Advance Practice Nurses can provide
inservices, workshops, seminars or lectures to groups of
older adults on multiple health promotion and prevention
topics. The GNP can inform other health care providers that
the older homebound adult may have the issue of illiteracy.
Investigating to find if this is a problem for the older
adult may help to decrease the time needed for education of
the client.

Advance Practice Nurses need to have confidence in
their sills as expert nurses. Clinical experience under the
guidance of a physician or another APN is one of the best
ways to get this confidence.

It is imperative that APNs use all opportunities to
educate clients about their role. The brochure will help
clarify some of the ways' a GNP may fulfill an important
role for the homebound older adult. There are many ways
that the APN can educate the public on why the older adult

should make the APN their health care provider.

17

This brochure is an important concept for marketing the
GNP to the older homebound adult. Marketing should be in
the early part of the student APNs education. This will
assist in giving the student an accurate picture of whom
APNs are and what they do. The APN in turn can increase the
client's knowledge about their role.

Continuing education is on going and one would hope

that ANPs would continue to grow from positive experiences

and relationships.
I II I' E £1 E ll H E l'

Advanced Practice Nurses can have a positive impact on
health care today, because of the shortage of health care
dollars, their care is cost effective. Their education is
best suited for providing health promotion, preventive
health care and provide the care in a comprehensive and
coordinated fashion (Safriet, 1992).

The Advance Practice Nurse may initiate interventions
for potential or actual health problems. The APN's
interventions are intended to lead the client to ultimately
assume independence in their health care. The APN is an
advocate for the client and would direct efforts toward a
patient's self-actualization.

This brochure impacts what the GNP can do to assist the
older homebound adult and lets the GNP be seen as a valuable
asset in their health care. It is within the clinical scope
of the GNP to assess the patient's response to disease

processes, diagnosing the patient status, develop and

18

implement treatment plans. They are an essential link
between the homebound older adult and their physician.
Summary

The development of this brochure is to inform the older
homebound adult that using the GNP in the home may delay the
development of disability and decrease nursing home
admissions (Alessi et al., 1995). Conducting in-home
geriatric assessments involves shifting of many present
paradigms. Shifting of primary care from the office setting
to the older adults home will be a major change for health
care professionals. Gerontological Nurse Practitioners have
an investment in the success of the community, where they
must be active members and work to remove barriers to
optimum health care. They merge vision, power and concerns.
"Having a Gerontological vision is needed if the future is
to improve on the past" (Riley, 1993, p.445).

Holistic care helps people to understand that they have
to help themselves. "The delivery of quality home health
care services is a challenge" (Gartner & Twardon, 1992,
p.53). Problems related to patient population, the practice
of nursing, and financial and regulatory constraints must be
addressed to assure continuing quality care by the GNP.

Statistics have shown that more health care services
are performed in the home every year and the GNP have a
unique opportunity to shape the future of home care for the

older homebound person (Gartner & Twardon, 1992).

19

LI ST OF REFERENCES

LIST OF REFERENCES

Alessi, C., Aronow, H., Beck, J., Bula, C., Gold, M.,
Nisenbawm, R., Steiner, A., Stuck, A., Rubenstein, L., &
Yuhas, K. (1995, Nov, 2). Special article, A trial of
annual in-home comprehensive geriatric assessments for
elderly people living in the community. Ihe_New_England
lcurnal_cf_nedicine. pp. 1184- -1189-

AtchleY. R- (1980). The_SQc1al.£crces_in_Later_Life
(3rd ed., rev.). Belmont, CA: Wadsworth Publishing Co.

Ball-Rokeach, S., & DeFleur, M. (1982). Theorie§_gf
Mass_£gmmnn1gat1gn (4th ed.). New York, NY: Longman.

Becker. Mo (1974). The_Health_Belief_M9del_and_Eerscnal
Health_fiehay12r. Thorofare, New Jersey: Charles B. Slack
Inc.

Belle, 8., Fox, A., Ganguli, M., & Gilby, J. (1996).
Characteristics of rural homebound older adults: A
community-based study. JAQS1_11, 363-370.

Bluestein, C., & Rutledge, C. (1993). Psychosocial
determinants of late prenatal care: The Health Belief Model.
Famil¥_nedicinei_25(4). 269-272-

Boodman, S. (1998, April 7). Illiteracy keeps patients
from following medical direction. Mnskeggn_§hrgn191e1 p. 20.

California Medicine, Editorial (1996, March). Parents
who live far away or have special needs may require a
geriatric case manager. Galifgrnia_Medicine1

Crump, C., & McLeroy, K. (1994). Health promotion and

disease prevention: A historical perspective. Generatign§1
Sarina, 9- 17.

Davis, T., Meldrum, H., Tippy, P., Weiss, B., &
Williams, M. (1996). How poor literacy leads to poor health
care. Patient_care1_10(10). 94-127-

Editorial (1996). Parents who live far away or have
special needs may require a geriatric case manager.

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21

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22

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