In Hawaii, therapists look to ?ohana?

A new Hawaii nursing home puts a priority on restoring patients? independence.

By Scott Sleek
Monitor staff

Deeply etched into the Hawaiian culture is a strong sense of ?ohana,? or extended family. It?s not uncommon for two or three generations to live under one roof and for younger family members to care for the elderly ones. Real estate ads even promote houses that have ?ohana? units, or add-ons for a grandparent or elderly uncle. Most native Hawaiians are loathe to place an ailing family member into a nursing home?even when that elder may need some professional care.

Psychologists and other health professionals in Hawaii are pioneering a way to provide quality inpatient care to elderly residents while keeping their family ties firmly bound. At the Center for Aging, a nursing facility run by the Veterans Affairs Medical and Regional Office Center (VAMROC) in Honolulu, wives, sons, daughters and grandchildren often come to spend the day with their ailing loved ones. And the facility has extra beds that family members can use if they want to stay through the night.

During the day, it?s hard to find any glimpse of the stereotypical nursing home patient lying in bed. Most patients are in the exercise room undergoing physical therapy, strolling about the brilliant, sun-soaked foliage in the enclosed yard or taking a cooking lesson in the kitchen.

These scenes reflect a respect for ?ohana? among the psychologists, physicians, nurses and other professionals who staff the Center for Aging. They view the presence of kin as a healing agent for veterans disabled by strokes, hip fractures or other aging-related ailments. And they want to provide more than the standard nursing care. They strive to rehabilitate their patients?to treat them as temporary guests rather than hopelessly permanent residents.

?We?re trying to return these people to the community, to their families, to a state of functioning, rather than immediately casting them into a sick role for the rest of their lives,? says Kathleen McNamara, PhD, staff psychologist and director of training at VAMROC?s outpatient mental health clinic. McNamara, a neuropsychologist who is also a member of APA?s Board of Directors, provides services to the center?s patients as needed.

The Center for Aging admitted its first patients in October and has since serviced 58 veterans from as far away as Guam and American Samoa. VAMROC officials hope the 60-room facility will serve as a new model of medical and psychological care for the elderly. The center also stands out as a model amid an ongoing reorganization in the U.S. Department of Veterans Affairs (VA) health-care system that has left many staff psychologists feeling discouraged. The reorganization has centered on streamlining and decentralizing the system, resulting in workload increases and staff cuts.

Demographic demands

Geriatric experts say the Center for Aging?s emphasis on rehabilitation may be a concept that most nursing homes will have to adopt as the elderly population reaches its peak after the turn of the century. The supply of nursing home beds continues to lag behind the demand, and the more patients that can be sent home, the better.

VAMROC officials view the center as a way to tap what appears to be the therapeutic power of ?ohana.? They believe the patients are more apt to recover from health setbacks when they?re surrounded by familiar faces and voices.

Carol Joseph, MD, medical director at the Center for Aging, says she believes the veterans have higher spirits and faster recoveries when they know they?ll be going home.

In many cases, the center serves as a set of starting blocks for elderly patients learning to regain their ability to live outside an institution. The first step is getting them the physical care they need to function as independently as possible, Joseph says. Stroke victims get help relearning the basic motor skills or day-to-day tasks that stroke-related brain damage may have erased or impaired. Those with potentially crippling injuries, such as a hip fracture or paralysis from stroke, exercise their way back to health. People with dementia may receive treatment that can slow or stop the progress of their memory decay.

The facility can accommodate 60 veterans. The walls along each corridor are in a different pastel color, representing a sort of coding system to help strolling patients recognize which section of the building they?ve entered. The exercise room is equipped with various machines for strength-building and aerobic activity. A physical therapist is on hand to help patients use the equipment.

Patients and family members often stroll around the courtyard, which boasts a gorgeous view of the city and the ocean beyond and includes a large gazebo where patients and their families can picnic. Patients can even garden on the grounds.

And the seniors are working on their minds as well as their bodies. A VAMROC psychologist, Cole Lew, PhD, is assigned to the center on a part-time basis. VAMROC hopes to eventually have full-time psychologists on site and also plans to have interns working there.

The facility also includes a secure geropsychiatric section for any patients who may present a danger to themselves. Joseph and other members of the center?s staff say they?ve come to rely heavily on psychologists? presence. Many patients present a host of mental problems ranging from alcoholism to post-traumatic stress disorder?the latter often the remnants of war experiences.

Craig China, MD, a physician who works at the center, says he relied heavily on the VAMROC?s mental health-care staff when he was treating a patient who was suffering not only from hypertension and a stomach infection, but from depression, post-traumatic stress disorder and substance abuse.

?All those mental health issues created some real problems for his treatment,? said China. ?He was rigid about taking medications. He went through a period of being emotionally labile, crying. And he could be manipulative with the staff.?

But through the collaborative care of the medical and mental health staff at the center, the man eventually recovered?both emotionally and physically?to the point where he could be released. He followed up with day care at VAMROC?s outpatient mental health clinic and still comes back to the center to visit staff and inpatients, China says.

Trouble in paradise

Psychologists also provide important counseling for the families who want to care for their family members once they are released. In addition to teaching family members about the patients? medical regimes, the center staff also help them cope with the stress associated with caregiving.

The economic stressors, in particular, are considerable in Hawaii, where the cost of living continues to soar far above the rest of the United States. That forces most households to seek dual or even multiple incomes just to pay the rent, leaving people less time and energy to take care of an aging family member.

Psychologists are also helping the Center for Aging staff understand the ethnic and cultural issues that their patients present. Hawaiians are a mosaic of several Eastern and Western cultures, and many of the islands? older patients believe in spiritual healing and mythologies that sometimes clash with modern medicine, explains Lew, who serves the center?s patients and has expertise in multicultural issues.

?When you?re dealing with geriatrics, you?re dealing with older values and beliefs about medical practices,? says Lew, a Chinese-American. ?Sometimes you have to think about different ways to treat someone who still believes in old traditions.?

In fact, Joseph credits Lew with helping her respond to a cultural barrier that arose in a patient?s care. The staff discovered that an outpatient?s wife was refusing to give him his medication for symptoms of his Alzheimer?s disease. Joseph learned that the wife, following some old Hawaiian myths, was upset that she and her husband slept in the same bed that the man?s first wife had died in.

?Under their tradition, if a person dies in bed, his or her spirit still inhabits that bed,? says Joseph. ?His new wife attributed his Alzheimer?s and diabetes to his wife?s spirit. She wouldn?t give him his medicine because she was convinced that the bed was the problem.

?The person who got to that was Cole, with his knowledge of multiethnic issues. And the treatment plan was to get a new bed. If you don?t treat these things first, you can prescribe all the medicine in the world, but it won?t do any good.?