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Discharge planning in homes for the aged : an analytical survey of a group of patients hospitalized for… Elmore, Eugene 1959

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DISCHARGE PLANNING IH HOMES FOR THE AGED An A n a l y t i c a l Survey of a Group o f Patients h o s p i t a l i z e d f o r Mental I l l n e s s i n the Homes f o r the Aged, Port Coquitlam, B. C., 1958. by EUGENE ELMORE Thesis Submitted i n P a r t i a l F u l f i l l m e n t of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of S o c i a l Work Accepted as conforming to the standard required f o r the degree of MASTER OF SOCIAL WORK School o f S o c i a l Work. 1959 The U n i v e r s i t y of B r i t i s h Columbia. ABSTRACT There has been a growing c o n v i c t i o n on the part of medical and nursing s t a f f i n the Homes f o r the Aged i n B r i t i s h Columbia, which provide p s y c h i a t r i c care f o r the aged, that some of the residents have s u f f i c i e n t p h y s i c a l and mental health to be discharged. This study makes an a n a l y t i c a l survey of some of the needs and resources of a group of patients considered to be ready to leave one of these i n s t i t u t i o n s (the Port Coquitlam U n i t ) . The purpose of the survey was to determine what kinds of resources these people would require to maintain an optimal l e v e l of adjustment i n the community, as w e l l as to describe the possible c o n t r i b u t i o n s o c i a l services could make i n f a c i l i t a t i n g t h e i r discharge. The areas selected f o r assessment were grouped i n t o two broad categories, ( l ) the patient's needs which r e s u l t e d d i r e c t l y from h i s h o s p i t a l i z a t i o n and (2) the personal and s o c i a l resources which he could employ upon d i s -charge. There are two steps involved i n s e l e c t i n g the group f o r study. F i r s t , through the use of a questionnaire submitted to the medical and nurs-in g s t a f f i n order to determine which patients were judged to be mentally and p h y s i c a l l y ready f o r discharge, and second, from t h i s l a r g e r number of p a t i e n t s , through the use of routine sampling procedure, a smaller group was selected f o r study. This f i n a l group was assessed by the c l i n i c a l team i n the i n s t i t u t i o n p r i m a r i l y through the use o f r a t i n g s c a l e s . An examination o f the needs and resources o f these patients revealed t h a t a l l of these patients could b e n e f i t from the assistance of s o c i a l work i n one or more of the areas evaluated. Although the needs and resources of the group v a r i e d considerably, there were some i n d i c a t i o n s that the patient's length o f stay had a marked e f f e c t upon the type of s o c i a l work service they could use. Those remaining i n h o s p i t a l f o r a period of l e s s than two years had u s u a l l y retained some resources i n t h e i r former community which could be mobilized to a s s i s t them i n discharge. On the other hand, the i n d i c a t i o n s f o r these patients i s that they would need an extension of h o s p i t a l services a f t e r they were discharged. The patients who had remained i n h o s p i t a l f o r a longer period of time, had l e s s need f o r out-patient h o s p i t a l s e r v i c e s , yet had l i t t l e i n the way of s o c i a l resources or contacts i n t h e i r former community to a s s i s t them once they had l e f t the h o s p i t a l . This group a l s o evidenced l e s s motivation f o r discharge and seemed to regard t h e i r h o s p i t a l -i z a t i o n as a permanent l i v i n g arrangement. In conclusion, the study points out the need f o r f u r t h e r d e f i n i t i v e assessments of the areas of f u n c t i o n o f a s o c i a l worker In an i n s t i t u t i o n where the aged, p s y c h i a t r i c a l l y i l l are treated. Also pointed out i s the need f o r s o c i a l work programme planning i n the l i g h t of these assessments, as w e l l as the insurance of adequate p r o v i s i o n s f o r f u r t h e r research to help develope i t . Treatment programmes i n other p s y c h i a t r i c i n s t i t u t i o n s are mentioned, i n d i c a t i n g that with the use of more advanced therapies, an i n -c r e a s i n g number of g e r i a t r i c p a tients with mental i l l n e s s e s are responding to treatment and are, therefore, e l i g i b l e f o r discharge. Thus, there i s a growing need f o r s o c i a l work contributions i n planning with the o l d e r person who i s l e a v i n g h o s p i t a l . Some i n d i c a t i o n s of community concern i n planning f o r these people are c i t e d as evidence of awareness on the part o f both the i n s t i t u t i o n s f o r the g e r i a t r i c p a tient and the community that the change from h o s p i t a l l i f e to community l i f e must be an uninterrupted process. In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver Canada. ACKNOWLEDGEMENTS I wish to express my appreciation to both the medical and nursing s t a f f at the Port Coquitlam u n i t o f the Homes f o r the Aged f o r t h e i r i n t e r e s t e d and co-operative p a r t i c i p a t i o n i n c a r r y i n g out t h i s study. I p a r t i c u l a r l y want to thank Dr. B.F. Bryson, Medical Superintendent, Homes f o r the Aged, f o r h i s help. I a l s o wish to acknowledge indebtedness to Dr. Leonard C. Marsh and Miss Dorothy R. Begg f o r t h e i r constructive suggestions and encourage-ment. xxxxxxxx i i TABLE OF CONTENTS Page Chapter I. The Increasing Aged Population The S o c i a l Adjustment of the Aged. The Dependent Aged. P s y c h i a t r i c care f o r the Aged. The B r i t i s h Columbia Homes f o r the Aged. Focus and method of t h i s study. 1 Chapter I I . An I n s t i t u t i o n a l Popuj.at i o n The Port Coquitlam u n i t of the Homes f o r the Aged. S e l e c t i n g the group f o r study. The v a l i d i t y of the information. Who are the patients- • • 22 Chapter III.Needs and Resources i n Discharge Planning The s e l e c t i o n of areas f o r assessment. P s y c h i a t r i c casework and medical needs. Housing needs. The need f o r Personal Supervision. P h y s i c a l a b i l i t y . F i n a n c i a l and Ma t e r i a l Resources. The i n t e r e s t of fa m i l y and f r i e n d s . The l e v e l of motivation f o r discharge 42 Chapter IV. S o c i a l Work f o r the I n s t i t u t i o n a l i z e d Aged Summary and assessment. The t r a n s i t i o n period of both the i n s t i t u t i o n s and the community. S o c i a l work programming f o r the aged i n p s y c h i a t r i c i n s t i t u t i o n s . Departments i n other areas 74 Appendices: A. Bibliography* 85 TABLES IN THE TEXT Table 1. The Proportion of Older People Admitted to General H o s p i t a l s i n B r i t i s h Columbia i n 1954 *« 8 Table 2. An Assessment of the Amount of Information A v a i l a b l e on a Group of Twenty-Four Patients at the Homes f o r the Aged, Port Coquitlam, 1958 35 Table 3. The Length of Stay of a Group of Twenty-Four Patients a t the Homes f o r the Aged, Port Coquitlam, 1958 38 i i i Table A. The. Diagnosis of a Group of Twenty-Four Patients at the Homes for the aged, Port Coquitlam, 1958 • AO Table 5* The Need for Counselling and Psychotherapy of a Group of Twenty-Four Patients of the Homes for the Aged, Port Coqultlam, 1958 AA Table 6. The Extent of Medical Needs of a Group of Twenty-Four Patients in the Homes for the Aged, Port Coqultlam, 1958 47 Table 7. An assessment of the Type of Housing Needed by a Group of Twenty-Four Patients in the Homes for the Aged, Port Coquitlam, 1958... • 5 j Table 8. The Amount of Supervision Required by a Group of Twenty*Four Patients i n the Homes for the Aged, Port Coquitlam, 1958 • 5 4 Table 9- The Physical Ability of a Group of Twenty-Four Patients in the Homes for the Aged, Port Coquitlam, 1958 56 Table 10 . The Financial and Material Resources of a Group of Twenty**Four Patients in the Homes for the Aged, Port Coquitlam, 1958 60 Table U . The Quantity of Family and Friends of a Group of Twenty-Four Patients in the Homes for the Aged, Port Coquitlam, 1958 • 65 Table 12. The Interest of the Family and/or Friends of a Group of Twenty-Four Patients in the Homes for the Aged, Port Coquitlam, 1958....... 67 Table 13. The Level of Motivation of a Group of Twenty-Four Patients in the Homes for the Aged, Port Coquitlam, 1958 70 CHAPTER I THE GROWTH OF THE AGED POPULATION Almost any l i t e r a t u r e regarding the aged or the increasing aged population includes s t a t i s t i c a l surveys i n d i c a t i n g that the proportion of our people over s i x t y - f i v e years of age, when compared with the zero t o s i x t y - f i v e year old group, i s s t e a d i l y i n c r e a s i n g . These studies have had a gradual impact on the community as a whole and have given way to a very r e a l anxiety on the part of S o c i a l Welfare A u t h o r i t i e s occupied with attempting to meet the problems of t h i s p a r t i c u l a r group, A b r i e f mention of some of the causes f o r the increased proportion of aged, and a review of the h i s t o r y of the adjustment of t h i s group during the past three centuries i s h e l p f u l both i n terms of gaining further understanding of the problem, i n the present day, and i n seeing i n i t s development some po s s i b l e , p a r t i a l s o l u t i o n s , (1) Most recognized a u t h o r i t i e s on the problem of the aged point to two trends i n the evolution of our Western culture that contribute to an increasing number of aged i n the population. The f i r s t and p o s s i b l y the most recognized by the layman i s the f a c t that people are l i v i n g longer. Many developments such as more widespread and advanced (1) Of p a r t i c u l a r i n t e r e s t i n t h i s regard i s of Shock Nathan, Trends In Gerontology, Stanford U n i v e r s i t y Press, Stanford, C a l i f o r n i a , 1957. 2 medical care, better n u t r i t i o n and more ease of l i v i n g have contributed to a higher standard of p h y s i c a l health and r e s u l t a n t longevity. I t should also be pointed out, however, that t h i s increased l i f e span does not i n i t s e l f contribute s o l e l y to the l a r g e r proportion of aged. The second and most s i g n i f i c a n t f a c t i n terms of the increasing population of aged i s that l e s s c h i l d r e n per f a m i l y are being produced so that, i n terms of the t o t a l population, the proportion of the aged has s t e a d i l y increased. This s t e r i l i t y on the part of the population as a whole has several implications which w i l l be b r i e f l y outlined l a t e r i n terms of welfare costs and programmes and resultant a c t i v i t y of s o c i a l workers and working with the aged. S t a t i t i c i a n s have produced a great many surveys regarding population trends throughout the Western world. For example, the average number of c h i l d r e n born i n a marriage has dropped from f i v e or s i x i n the 18th Century to two or three i n our present (1) day.. . In terms of the population r a t i o , there i s a d e f i n i t e trend toward smaller numbers i n the young, economical, productive age group assuming r e s p o n s i b i l i t y f o r a l a r g e r proportion of older persons. (1) Report of the t h i r d congress of the I n t e r n a t i o n a l A s s o c i a t i o n of Gerontology, London, 1954* Old Age and the Modern World E, and S. Livingston,Ltd. 1955, Page 3. - 3 -The S o c i a l Adjustment of the Aged Some of the causes and Implications behind the growth i n s i z e of the older segment of the population have already been discussed. This growth constitutes only one facet of the present problems Western s o c i e t y encounters i n dealing with the aged. The following b r i e f h i s t o r i c a l summary taken from the work of (2) Paul E. Sauvey, a french s o c i o l o g i s t , o u t l i n e s the development of the aged during the past few centuries and points out some of the f a c t o r s which have contributed to the development of an "old age problem". Sauvey breaks man's s o c i a l adjustment i n terms o f the older person into three main phasess (a) The Family Phase - Many of the problems which today are described as s o c i a l were formerly resolved within the old p a t r i a r c h a l type family. This was notably so with the care of old people. The care of the o l d was a task delegated to the older person's o f f s p r i n g or immediate famil y members and i n the average family, which was predominantly large and i n a r u r a l area, such a task was no p a r t i c u l a r problem. I t should be added that at t h i s time the proportion of old people was f a i r l y small and was not undergoing any large scale growth as has been c h a r a c t e r i s t i c of recent times. This type of f a m i l y care has extended i n some of the more i s o l a t e d r u r a l communities up to modern times. (1) I b i d . , P. 35. - A -(b) Individualistic Phase - As society became more advanced towards the end of the 18th Century, dislocations became apparent in the institution of the family. There followed a geographic dispersion of the family into smaller, scattered units. Many family members went to work in the towns in factories. There followed also a decrease in parental authority which the sociologists believe helped to bind the family together as a unit. At about this time i t became possible to make financial investments with a view to providing for oneself in old age so that theoretically i f onewanted carein his old age one was responsible for providing this care through long term planning and saving. Such provision for old age for the major portion of the population was impossible because of poverty at this time as well as the lack, for the most part, of the population's a b i l i t y to foresee the problems of old age. (c) Social Phase - The growing concern on the part of thepublic of various social problems brought about this phase in which government authorities accepted some responsibility for planning and providing for the aged. The most notable example of this acceptance was i n the passing of numerous old-age pension acts throughout the nations of Europe and the Western hemisphere. This period might be said to date from about the time of the F i r s t World War up to and including the present. The author goes on to point out that these periods over-lapped considerably in view of the accelerated social movement in some areas and lags i n others. In addition he mentions different rates of evolution take place within the various socio-economic class. - 5 -In terms of the above analysis a report of a committee having completed a recent study i n B r i t i s h Columbia sums up the present l e v e l of adjustment of the aged i n t h i s area. A f t e r reviewing s t a t i s t i c a l information regarding the growth of the older population (1) t h i s groups concluded: "At the same time, through the development of Canada's economy, s o c i e t y has become i n c r e a s i n g l y i n d u s t r i a l and urban, p e n a l i z i n g the e l d e r l y , l i m i t i n g t h e i r opportunities f o r productive a c t i v i t y , r e s t r i c t i n g t h e i r share In the general p r o s p e r i t y and c u r t a i l i n g t h e i r p a r t i c i p a t i o n i n community l i v i n g . Increased m o b i l i t y and problems of urban housing have served t o separate parents and c h i l d r e n and have frequently deprived an older person of a secure place and f a m i l y l i f e . The higher income of post-war years has allowed f a m i l i e s to e n t e r t a i n and be entertained - they are "out" to a greater extent than ever before. The d e s i r e of young couples to be constantly "on the go" c o n f l i c t s with the need f o r e l d e r l y parents to have constant supervision and r e s u l t s i n the removal of parents to i n s t i t u t i o n s outside the home. Further, urban housing developments c a l l f o r the smaller house or cottage with enough rooms t o accommodate the immediate family. At the same time the development of modern I n s t i t u t i o n a l f a c i l i t i e s f o r the older person who can't look a f t e r himself or who i s i n need of nursing care has tended to l a g . " (1) From an unpublished report by the Greater Vancouver Health League, A Study by the Nursing Homes Committee. May, 1958. P . l . - 6 -Unfortunately, i t is very difficult to obtain any statistics on the actual numbers of aged who are living socially or economically independent lives. This paucity of information Is especially apparent when one attempts to review the Canadian scene (perhaps because independent citizens seldom find themselves listed on the various roles or records of agencies or organizations.) Some inferences, however, can be drawn from the available figures on the aged in Canada. In the Province of British Columbia in the year 1956 there were 27,028 people listed as receiving financial assistance supplementary (1) to the Federal Old Age Security Pension of #40.00. This figure compared (2) with 96,701. indicates that over 69,000 had maintained some measure of economic independence or have made financial provision for themselves. Similarly a survey of the labour force of the USA completed in 1951 (the author has been unable to find similar figures for Canada) indicates that forty per cent of the male population of the United States sixty-five years of age and over were s t i l l listed as "active w. This same survey indicates that 9.5 per cent of the women from this same age group were s t i l l listed on the labour force. In addition, the breakdown of this sixty-five years and over age group In 1953 for (1) British Columbia, Annual Report of the Department of Sbcial Welfare, Queens Printer, Victoria, 1956, Pt 61. . (2) Canada, Dominion Bureau of Statistics, Census of Canada, 1956, Population Bulletin* 1-10, Single Years of Age, Queens Printer, Ottawa, 1957. PP 21-5, 21-6. (3) Shock Nathan, Trends in Gerontology, Stanford University Press, Stanford California, 1957, PP 34-35. the USA indicates a similar proportion i n the various vocational categories as that found in the fourteen to sixty-four year old age group. This would seem to indicate that the aged can carry on with a l l the various types of work despite the varying physical (1) and mental demands made upon them i n these jobs.. There are many surveys too numerous to mention about the economic adjustment of the aged in other countries along with studies of housing, recreational medical and other f a c i l i t i e s for the aged. The Dependent Aged Although the proceeding paragraphs indicate that there are varying levels of adjustment in our older age group, the fact remains that older age does bring on greaterphysical and mental infirmities. Hospital and other Institutions devoted to the care of the sick for example, usually record a;proportionately larger number of older (2) people in residence . than any other age group when compared with the same groups in the general population. Published figures (Table l ) also indicate that the geriatrics group i n British Columbia tends to remain for a longer period in hospital than those in every other age group* (1) Shock Nathan, Trends in Gerontology, Stanford University Press, Stanford California, 1957, PP 34-35. (2) These figures usually exclude those figures classified as births. TABLE 1 The Proportion of Older People Admitted to General Hospitals i n B r i t i s h Columbia i n 1954.  as compared with The Age Percentage D i s t r i b u t i o n of the T o t a l Population of B r i t i s h Columbia and the Percentage of the T o t a l P a t i e n t Days Older People were i n Hospital during 195A.  Age Percentage o f General Popu-l a t i o n . Percentage of Pat i e n t s Admitted During 1954. Percentage of P a t i e n t Days During 1954 65 - 69 4.54 4.4 7.4 70 - 74 5.26 4.3 8.0 75- 79 1.78 3.0 5.8 84 - 89 .84 1.6 3.3 90 .40 .9 2.0 Source* B r i t i s h Columbia, Report of the Hospital Insurance Services, Department of Health & Welfare, Queens P r i n t e r , ¥ictoria, 1955 Similar findings to these have been recorded in other areas. In Ontario, for example, patients in general hospitalin the geriatric age group total only eight per-cent of the total hospital population but accounted for nineteen per cent of the total days in general hospitals. In i l l u s t r a t i n g these figures, one author made the following (1) comments about the longer stay of older patients, "For a good many among them the illness or d i s a b i l i t y which sent them to hospital means the end of a previous l i v i n g arrangement the impossibility of returning home without a period of intermediate care, or a satisfactory discharge to their homes only i f follow-up home care i s provided. These are the basic reasons why a good many cannot be discharged at the appropriate time even when their i l l n e s s does not require a transfer to permanent institutional nursing care.*1 It would appear then, that perhaps these figures are somewhat misleading i n terms of the degree of impairment that many of these older patients may have. Many perhaps could return to the community even though they might have to accept a more marginal level of social adjustment than they previously enjoyed. Miss Bradford went on to comment further, "Positive welfare and rehabilitation programmes should embrace the long stay in hospital and after care in one continuity and the planning of these activities must take into account the fact that many of these older patients do not have the physical homes and immediate families that are generally pre-supposed for younger people," (1) lBd P22 Bradford Marjorie, A Study of the Need3 of Older and Chronically 111 Persons in the City of Ottawa. Council of the Corporation of the City of Ottawa, 1954, P.21, - 10 -Again, the s o c i a l i s o l a t i o n of the older person i s seen to p l a y an important part i n d e a l i n g with other handicaps, i n t h i s case, p h y s i c a l i l l n e s s . P s y c h i a t r i c Care f o r the Aged Older people, as t h e i r p h y s i c a l and mental powers begin- to wane, seem to be more susceptible to mental i l l n e s s . Unfortunately, they a l s o tend to have a greater degree of organic and chronic i l l n e s s . Thus, to the layman and even to many p r o f e s s i o n a l people, mental i l l n e s s i n an older person seems to be equated with long term i n s t i t u t i o n a l care and poor prognosis, or at best, discharge from a mental h o s p i t a l with a c r i p p l i n g p s y c h i a t r i c r e s i d u a l and only a marginal adjustment to be hoped f o r . Added t o t h i s common f e e l i n g o f a gloomy prognosis i n the p s y c h i a t r i c treatment of t h i s group i s the d i f f i c u l t y the aged person has i n moving back i n t o the community a f t e r the lengthy period i n h o s p i t a l that treatment u s u a l l y e n t a i l s . Old age i s often associated with s o c i a l r i g i d i t y ~ that the older person Is not as s o c i a l l y or p s y c h o l o g i c a l l y adept i n making a d i f f e r e n t adjustment, having a need to preserve and extend thos things they know and with which they are comfortable. One need not look back over f i f t y years to f i n d t h a t a l l mental i l l n e s s i n any age group was viewed as a rather hopeless, irremedial i l l n e s s and that any patient's recovery was viewed almost as an act of God. Since the turn of the century, however, both psychological and somatic therapies have been used to such an extent that many types o f p s y c h i a t r i c i l l n e s s have an optomistic prognosis; the layman i s gradually accepting mental i l l n e s s , p a r t i c u l a r l y - 11 -in the younger age groups, as a treatable il l n e s s involving periods of institutional l i v i n g and a loss of time and money. Somatic therapies, such as coma insulin, electro-shock therapy and more recently the ataractics (tranquilizers) as well as the use of psycho-analysis and other forms of psychotherapy, to name only a few treatment techniques, have been effectively used in combatting the so-called effective disorders (e.g. schizophrenia, manic depressive disorders, etc.) as well as modifying some of the illnesses with irreversible organic changes (e.g., epilepsy, General Paresis of the Insane, etc.) Although there seems to be an awakening optimism regarding the treatability of most aged groups and most types of i l l n e s s , there also seems to be a considerable lag i n both the layman and professional groups regarding the tr e a t a b i l i t y of the older age group. One author in commenting on the psychiatric treatment of the aged, describes the result of a survey performed in the State of New York. "A report of patients on the Books of the New York State Mental Hospitals, 65 years of age and older, as of March 31st, 1953, shows 28,250 such patients. Of these 59.A per cent have been hospitalized for a period of from five to over twenty years. The diagnostic categories indicate that only 50.3 per cent carried a primary diagnoses which might be said to relate more or less s p e c i f i c a l l y to the process of aging in the sense that these diagnosis were* Psychosis with Cerebral Arteriosclerosis - senile and Involutional Psychosis* The other 49.7 per cent carried diagnosis that in no way were specific for that age group, instead 32.7 per cent of the total were diagnosed as Demeatia Praecox. These figures have tremendous implications for the evaluation of the problem of the type of psychiatric reaction related specifically to the aged factor".-—-(New knowledge of syndromes) should have an important impact on the attitude toward prognosis and treatment. A fatalistic attitude of the inevitability of deterioration has led to a programme of involving custodial care primarily. This new insight opens a completely different vista and must involve a totally different programme of active therapy and research at (1) a l l echelons. One can only conclude from these and other studies that there is a growing awareness within the professional disciplines dealing with the psychiatrically i l l that many people are treatable and capable of discharge into the community, yet considerable work will have to be done in this area to intensify our efforts in treatment and l i f t the public level of awareness in this regard. (1) Gruenberg, Dr. Ernest and Kaufman, Dr. Ralph M., Charter 'for the Aging. Report of the New York State Conference at Albany, New York, 1956. P. 263» - 13 -Treatment i n B r i t i s h Columbia B r i t i s h Columbia, during the past quarter of a century, has developed a vast programme f o r the s p e c i a l p s y c h i a t r i c care of the aged. A comparison i n t h i s regard with a l l other provinces indicates that t h i s province i s the only one outside of A l b e r t a having a small 300 bed i n s t i t n t i o n , which has made any s p e c i a l p s y c h i a t r i c provisions (1) f o r the aged. . O f f i c i a l r ecognition of the need and provisions f o r the care of t h i s group i n t h i s province dates back to 1936 when the Homes f o r the Aged Act was passed by the British Columbia government. This act provided f o r separate administrative organization and f a c i l i t i e s to care f o r the p s y c h i a t r i c a l l y i l l of 65 years of age and over. These f a c i l i t i e s were i n i t i a l l y made an a u x i l i a r y s e r v i c e t o the P r o v i n c i a l Mental H o s p i t a l i n that a l l admissions to the Homes f o r the Aged, as they l a t e r became known, were screened through the P r o v i n c i a l (2) ^fental H o s p i t a l . For several years p r i o r to 1936 the D i r e c t o r o f Mental Health Services (Dr. A.L. Crease) had stressed the overcrowded conditions and the need f o r more space i n the Mental H o s p i t a l . (1) Mental Health Services i n Canada. Research D i v i s i o n , Department of National Health & Welfare, Ottawa, J u l y 1954, P.P. 102, 103. (2) For a f u l l d e s c r i p t i o n of the e a r l y development of the Homes fo r the Aged see* Clark, Richard James, Care of the Mentally 111 i n B r i t i s h Columbia, 1945. PP 92-94. - H -In response to this need, the Provincial Secretary made two buildings available, which were formerly part of the Industrial School and which were adjacent to the hospital at Essondale. These buildings were quickly occupied by a small group of the older patients from various wards in the Mental Hospital* There were approximately forty patients transferred at that time. Dr. Crease in his Mental Health Services report for the year 1936 commented that this arrangement was most satisfactory and that the buildings were converted to very pleasant living accommodations for this group of patients. In 1939 two more wards were converted from a former Boys' Industrial School building in this same area and these were used to house geriatric patients requiring isolation (for contagious diseases such as Tuberculosis, Syphilis, e t c ) This small unit served to illustrate the efficacy of special facilities for the aged and this experience, coupled with the findings of other institutions of a similar nature throughout the world, created an increasing demand for more units of this kind. Growth, however, was very gradual and in 1945 the annual report (Provincial Mental Health Services) recorded only 132 patients in residence at the Homes for the Aged. In 1948, in response to this need an additional unit was established at Vernon, B.C. The Vernon unit had formerly been a military hospital and as such was easily converted to house two hundred patients i n i t i a l l y . The majority of these patients were transferred from Essondale and the Homes for the Aged itself, and at that time, these patients were selected on the basis of their stamina for with-standing the long train journey and the fact that they would require long term care as a hospital patient. - 15 -In 1951, the third unit was established at Terrace, B.C., and at the end of that f i s c a l year an average of seventy-five patients were in residence. The Terrace home had also been a former military hospital converted for the use of geriatric patients. The three units at Vernon Terrace and Port Coquitlam provided a nucleus for the present geriatric programme Bri t i s h Columbia has for i t s psychiatrically i l l . Each unit has expanded throughout the years with the addition of new buildings or converted older buildings up to the present time when the Homes for the Aged have an approximate total of 1,100 patients in residence (Port Coquitlam - 550, Vernon - 300 and Terrace - 250). Present Policies According to the terms of the Act for the establishment of the Homes for the Aged, any person over the age of sixty-five years who i s judged to be suffering from changes as a result of old age, can be assessed for admission to these units. The Act and the institutions themselves are administered by a Medical Superintendent who i s responsible for the admission and care of the patients and for setting up an administrative organization to provide this care. Requests for admission to the Homes for the Aged, are made by the applicant's physician in the community. The doctor completes an application form containing his opinion as to the patient's s u i t a b i l i t y for admission as well as essential medical and psychiatric data, and forwards this to the Medical Superintendent. - 16 -As mentioned earlier, there has been a steadily increasing demand for f a c i l i t i e s for the Homes for the Aged which these services have been unable to f u l f i l l . (The annual report of the Medical Superintendent has consistently pointed out the shortage of bed space for the past ten years). A l l requests for admission are, therefore, carefully screened by the Medical Superintendent and are either admitted or placed on a l i s t for admission based upon urgency of their committal). There has been a l i s t of patients awaiting admission throughout the years and these cases are periodically reviewed and assessed to s ee whether or not there has been any change i n their p r i o r i t y rating. Boring the year 1958, for example, there was a total 266 applications of men aid women over sixty years of age. It was possible to accept 252 patients for admission and of these, 111 or forty-two per cent of the number received, were considered urgent so that admission could not be delayed. The remainder are s t i l l on the waiting l i s t and hopefully, w i l l be admitted at some later date. In addition to dealing with o f f i c i a l application, the Medical Superintendent has: "Spent many hours during the year interviewing relatives and others by telephone, by mail or i n person, who have been burdened or intimately concerned with the problem of caring for disturbed, elderly relatives. Wherever possible, advice and encouragement have been given to maintain - 17 -these patients in community as long as possible. In many cases, suitable accommodation or medical treatment has been worked out so that admission to the Homes for the Aged could be delayed or (1) was no longer required". Insofar as possible, a l l applicants are admitted to the unit which serves the area from which they come, i.e., those patients in the Vernon d i s t r i c t are admitted to that unit and similarly with the Port Coquitlam and Terrace units. This occasionally results i n vacancies in the units serving the less populated parts of the Province (Vernon and Terrace) and may create over-crowding i n the Port Coquitlam unit. Thus approximately once yearly, patients are transferred to the Vernon or Terrace units from the Lower Mainland area i f they can withstand the rigors of a long train journey and are suitable for the type of care that i s given in these respective units. Treatment Services As previously outlined i n mentioning the history of the development of the Homes for the Aged, two of the units (Vernon and Terrace) are converted military hospitals and some of the buildings in the Port Coquitlam d i s t r i c t are converted industrial school buildings. These f a c i l i t i e s are, for the most part, more suitable for providing custodial, medical and nursing care. Since (1) B r i t i s h Columbia, Annual Report of the Mental Health Services, Queens Printers, Victoria, 1958. P.L 106. - 18 -a great many g e r i a t r i c patients, because of the p h y s i c a l f r a i l i t i e s of old age and the o r g a n i c i t y of t h e i r i l l n e s s e s require p r i m a r i l y bed care, these wards p a r t i c u l a r l y i n the Vernon and Terrace units are kept i n f u l l use. P s y c h i a t r i c treatment i n the Homes f o r the Aged, at the present time, features, f o r the most part, c u s t o d i a l , p s y c h i a t r i c , medical and nursing care by an experienced and understanding s t a f f . Heavy use i s made of the newer t r a n q u i l i z i n g drugs and other pharmacological therapies i n a l l three units n t o maintain the patient's maximum improvement and adjustment i n the h o s p i t a l environment, and t o provide f o r the patient's greatest possible (1) comfort and contentment." Unfortunately, l i m i t e d use i s made ofthe p s y c h i a t r i c a u x i l i a r y services (such as Occupational and Recreational therapies, physiotherapy, Psychology and S o c i a l Services) p a r t i c u l a r l y i n the Vernon and Terrace units, as there i s no pro v i s i o n with s t a f f establishment f o r these s e r v i c e s . In t h i s respect the Port Coquitlam unit d i f f e r s , i n that because of i t s close proximity t o the P r o v i n c i a l Mental Hospital and the heavily populated lower Mainland area, services are more r e a d i l y a v a i l a b l e from t h e i r sources than i n the more i s o l a t e d areas of Vernon and Terrace. (1) (Excerpt from treatment aims as set out i n a memo sent from the Medical Superintendent to the writer.) - 19 -The Port Coquitlam unit i s described i n the f o l l o w i n g chapter, the s e t t i n g f o r the d e t a i l e d study. The two other units at Vernon and Terrace have spacious grounds surrounding them, and o f f e r ambulatory patients ample opportunity f o r excercise or l i g h t work i n order to maintain optimal p h y s i c a l health. Such a c t i v i t i e s a l s o a i d patients t o keep occupied i n meaningful a c t i v i t y and contributes to t h e i r own f e e l i n g of well-being. These units are served medically through the use of p r i v a t e p r a c t i t i o n e r s In the community contracted by the Province, They, therefore, o f f e r constant care and have substitute physicians a v a i l a b l e i f necessary. S u r g i c a l and other more extensive medical treatments are provided by t r a n s f e r r i n g patients to the l o c a l general h o s p i t a l s w i t h i n the area. The nursing s t a f f works f u l l time i n these i n s t i t u t i o n s . Regarding occupational and r e c r e a t i o n a l therapy, as p r e v i o u s l y mentioned, there are no provisions f o r these a c t i v i t i e s , although some nurses have been interested In these areas and have obtained some t r a i n i n g i n handicrafts, hobbies and r e c r e a t i o n a l organization, so that as part of t h e i r duties they can give these services to p a t i e n t s . In a d d i t i o n , patients i n these units have weekly r e l i g i o u s services provided f o r them through the e f f o r t s of l o c a l church organizations i n the respective d i s t r i c t s • Volunteers are also a c t i v e so that there i s a monthly programme using l o c a l glees clubs, e t c . - 20 -Throughout a l l three Homes for the Aged units there i s no provision made for psychological or social services. The Medical Superintendent has consistently requested these services i n order to provide better diagnostic evaluations, as well as acti v i t y devoted to admission and discharge planning. Services Related to Discharge The present discharge rate from the Homes for the Aged i s extremely low: Out of a population of approximately eleven hundred patients, only fifteen men and four women could be returned to their families or to nursing homes during the year 1958* In commenting upon this the Medical Superintndent stated in his annual report, "It i s f e l t that many more patients could be discharged i f social service workers were available on the staff of the geriatric division." This service would provide better liaison with community agencies and families of improved patients whereby suitable arrangements could be (1) worked out to find accommodation away from hospital." The Medical Superintendent i s , in making these statenmts, not only indicating the need for social workers in these institutions but also expressing the growing conviction on the part of both medical (1) Br i t i s h Columbia, Annual Report of Mental Health Services, Queens Printer, Victoria, 1958, P.L. 107. - 21 -and nursing s t a f f that a sizeable group of the patients now i n residence are capable of l i v i n g i n the outside community. Although the treatment provided consists of p r i m a r i l y c u s t o d i a l and medical and nursing care, many of these patients have responded to the extent that the symptoms which brought them to h o s p i t a l are e i t h e r cleared up, or are under c o n t r o l . Focus and Method of This Study A random sample was taken of a l l patients judged to be ready f o r discharge, with a view to determining the extent that they w i l l require s o c i a l service a c t i v i t y i n lea v i n g the h o s p i t a l and i n maintaining an optimal adjustment i n the community. An a n a l y t i c a l survey ( i n v o l v i n g an adaptation of the r a t i n g scale method) was made of some of the needs these patients w i l l have i n being discharged and p o t e n t i a l resources they have r e l a t i v e t o t h e i r discharge plans. The focus of t h i s survey i s on areas i n which a s o c i a l worker could make a cont r i b u t i o n i n both pre-discharge planning and i n follow-up care. - 22 -CHAPTER I I AN INSTITUTIONAL POPULATION I t has been observed that not a l l of the patients are i n residence at the Homes f o r the Aged because they remain p s y c h i a t r i c a l l y i l l . Some, f o r example, who are we l l enough to leave are u n w i l l i n g to do so because they are happy i n h o s p i t a l and are relu c t a n t to re t u r n to t h e i r former community because of the d i f f i c u l t i e s they may have experienced i n g e t t i n g along p r i o r to t h e i r admission. Others because of the lengthy h o s p i t a l i z a t i o n and other reasons f i n d they have l o s t contact with t h e i r family or f r i e n d s and therefore would have no-one to help them i f they were to return. P o s s i b l y some patients l a c k the f i n a n c i a l resources to be able to a f f o r d s u i t a b l e housing accommodation or medical care. I f there are patients remaining i n h o s p i t a l f o r any of the above reasons there would appear to be a need f o r s o c i a l services to a s s i s t them i n discharge planning. For example, the s o c i a l worker could assess with the patient the a v a i l a b i l i t y of f i n a n c i a l resources provided under e x i s t i n g s o c i a l l e g i s l a t i o n , or could contact r e l a t i v e s or f r i e n d s i n order to assess the p o s s i b i l i t y of help from these sources, to mention only two possible areas of a c t i v i t y . I t would follow, i f a s o c i a l worker were to a s s i s t any of these p a t i e n t s i n discharge planning, the f i r s t step would be to determine which s p e c i f i c p a tients are dischargeable. One of the ways i n which t h i s i d e n t i -f i c a t i o n could be accomplished i s through the use of an a n a l y t i c a l survey of the p a t i e n t population made i n terms of c r i t e r i a under which these patients are p r e s e n t l y i n h o s p i t a l . That i s , a survey to determine which pat i e n t s have responded to treatment t o the extent that they now have s u f f i c i e n t mental health to be discharged. - 23 -The second step would involve a more d e f i n i t i v e assessment o f those patients who are judged ready to leave h o s p i t a l . Such an a n a l y s i s would include a survey of some of the personal resources these patients possess and how these resources could be used t o a s s i s t them to leave the h o s p i t a l . In addition-, some of the patient's needs would have t o be surveyed i n terms of how they could be met i f they were to maintain a s u c c e s s f u l adjustment i n the community. The f o l l o w i n g outlines the r e s u l t s of a survey of the p a t i e n t population of the Port Coquitlam u n i t o f the Homes f o r the Aged. This s e t t i n g was chosen because i t provides a good cross s e c t i o n of the p a t i e n t population of the three u n i t s (nearly one h a l f of the t o t a l population of a l l the Homes f o r the Aged i s i n residence i n t h i s area) and i s e a s i l y a c c e s s i b l e f o r study as i t i s only a short distance from Vancouver. An I n s t i t u t i o n a l Population. The Coquitlam u n i t of the Homes f o r the Aged i s s i t u a t e d about twenty-five miles east of Vancouver and i s immediately adjacent to the P r o v i n c i a l Mental H o s p i t a l . The buildings border the main highway on one side and are bordered by f o r e s t lands and mountains on the other. The s e t t i n g features well-kept grounds (with lawns and shrubs) and winding roadways, and gives the e f f e c t o f quiet r e s t f u l spaciousness. Although the h o s p i t a l seems to be a considerable distance from the c i t y , i n terms of present-day transportation (and an e x c e l l e n t road) one can traverse the route i n approximately t h i r t y - f i v e minutes. A regular bus schedule i s maintained g i v i n g v i s i t o r s and other persons from the community ample opportunity to go to and from the h o s p i t a l . The Port Coquitlam u n i t , being located next to the B r i t i s h Columbia P r o v i n c i a l Mental H o s p i t a l and the Crease C l i n i c , has the use - 2U -of the extensive f a c i l i t i e s found i n these i n s t i t u t i o n s . Considerable use i s made of these services i n both diagnostic and treatment planning. For example, patients are not admitted d i r e c t l y t o the Port Coquitlam u n i t , as i s the case i n the Vernon and Terrace i n s t i t u t i o n s , but are admitted as w g u e s t s w of the P r o v i n c i a l Mental H o s p i t a l while they are given a f u l l d iagnostic work-up. S i m i l a r l y , i f intensive p s y c h i a t r i c somata therapy (such as electro-convulsive therapy) or major surgery i s required, a pat i e n t can be transferred to the mental h o s p i t a l as a guest. In a d d i t i o n to usi n g diagnostic and treatment f a c i l i t i e s i n -v o l v i n g p a t i e n t t r a n s f e r s , p a t i e n t s themselves can use the numerous r e c r e a t i o n a l f a c i l i t i e s found a t the h o s p i t a l . Those patients enjoying "Grounds P r i v i l e d g e s " , t h a t i s freedom to go out onto the grounds during s p e c i f i e d hours o f the day (over one-half o f those i n residence a t Port Coquitlam) may go bowling, swimming, pl a y g o l f or attend movies and other a c t i v i t i e s as they are scheduled. S t i l l another advantage t h i s u n i t enjoys i s the use of any av a i l a b l e a u x i l i a r y services from the h o s p i t a l or c l i n i c , within the Homes f o r the Aged. As w i l l be noted from the b r i e f d e s c r i p t i o n below, many of the treatment personnel, not provided f o r i n the s t a f f establishment of the u n i t , are "borrowed" from these other ser v i c e s to be used i n the G e r i a t r i c u n i t on a part-time b a s i s . As p r e v i o u s l y o u t l i n e d (Chapter I) the basic aim of the treatment programme i s to maintain i n each p a t i e n t h i s optimal l e v e l of p h y s i c a l m o b i l i t y and p s y c h i a t r i c health. B a s i c a l l y , the Port Coquitlam u n i t , along with other u n i t s , provides a high l e v e l of c u s t o d i a l care along with proper medical and p s y c h i a t r i c treatment. Regarding medical s t a f f , the medical superintendent and one physician work f u l l - t i m e i n meeting the medical and - 25 -p s y c h i a t r i c needs of the p a t i e n t s . In a d d i t i o n , there are approximately seventy-five nurses and "aides" employed i n t h i s h o s p i t a l . Regarding a u x i l i a r y s e r v i c e s , there has of recent years been some p r o v i s i o n made f o r the establishment of several departments which are ex-(1) e l u s i v e to the l a r g e r Home f o r the Aged u n i t at Port Coquitlam. There i s a f u l l time Occupational Therapist on s t a f f and t h i s worker has an a c t i v e treatment programme i n force at the present and many pa t i e n t s are engaged i n hobbies or handicrafts. One r e c r e a t i o n a l t h e r a p i s t , on loan from the P r o v i n c i a l Mental H o s p i t a l , spends the major part of h i s working day at the Homes f o r the Aged organizing various s o c i a l a c t i v i t i e s such as p a r t i e s , card games, etc. and has a marked impact on the spare time a c t i v i t y of the o l d e r p a t i e n t i n t h i s u n i t . The services of a physio-therapist are a l s o on loan from the P r o v i n c i a l Mental H o s p i t a l and considerable a c t i v i t y i s being maintained i n the form of e x e r c i s i n g and t r a i n i n g various p a t i e n t s to improve t h e i r p h y s i c a l m o b i l i t y and consequently t h e i r mental outlook. A psychologist i s also a v a i l a b l e i f required to conduct group therapy programmes or provide diagnostic evaluations. There i s no establishment a t the present time f o r a s o c i a l worker. In cases of emergency, however, the Medical Superintendent has requested and employed the services of the s t a f f of the S o c i a l Service Department o f the E a s t Lawn B u i l d i n g , one of the u n i t s o f the P r o v i n c i a l Mental H o s p i t a l . However, these services are not frequently used because of the demands on these workers i n t h e i r own u n i t . (1) B r i t i s h Columbia, Annual Report o f the Mental Health S e r v i c e s , Queen's P r i n t e r , V i c t o r i a , 1952 - 1958. - 26 -The Port Coquitlam unit, because of i t s close proximity to various areas i n the Lower Mainland area, maintains very effective ties with the (1) community through the use of a Volunteer Programme* Twice weekly, groups of Volunteers come to the unit, v i s i t i n g individual patients who have no contact with outside community, conducting sing-songs with patient groups and assisting i n ward socials. One example of this a c t i v i t y i s to be found i n the presentation of a Christmas g i f t to each patient, thus contributing to the patient's feelings that he i s s t i l l a part of the larger, outside community. Periodically, bus-loads of patients from the Homes for the Aged, when weather permits, w i l l go on outings and picnic trips to Stanley Park i n Vancouver or on mystery bus t r i p s , a l l of which provides for the patient's enjoyment and well being. Regular ward programmes, as well as special parties on such holidays as Easter, Valentine's Day, etc. In addition the Audio Visual Department at Essondale presents regular weekly movies. Television sets are also i n evidence on each ward and contribute a great deal to the patient's enjoyment of their leisure time. Religious services are held weekly on each ward throughout the year, i n addition to the regular Sunday services i n the Chapel. Both Protestant and Catholic services are conducted by the regular Chaplain for the Provincial Mental Hospital and pastors of other denominations i n the d i s t r i c t . A very welcome additional s ervice for patients i s that of a beautician assigned to the institution. She i s steadily occupied throughout the year doing hair styling, etc., for the female patients. Other services (l) Mr. Robert M. Ross has made an analysis of the use of Volunteers in the B r i t i s h Columbia Mental Health Services in his A Volunteer Programme for the Patients of a Mental Hospital, 1958. MASTER OF~SOCIAL WORK THESIS, University of B r i t i s h Columbia, 1958. - 27 -such as barbering and chiropody, are a l s o provided by those employed by the P r o v i n c i a l Mental H o s p i t a l , devoting part of t h e i r time to the Homes f o r the Aged. The Port Coquitlam u n i t i s composed of a t o t a l o f eight b u i l d i n g s . Of these, seven buildings are used to house and service patients ( i . e . cooking, etc) and one b u i l d i n g i s used as an administrative u n i t , housing headquarters s t a f f . Five of these buildings were converted from the former Boys' I n d u s t r i a l School which occupied t h i s s i t e , and three b u i l d i n g s were e s p e c i a l l y structured f o r the g e r i a t r i c p a t i e n t . The o l d e r b u i l d i n g s are not too suitable f o r the h o s p i t a l i z a t i o n of aged people because o f the steep, narrow s t a i r w e l l s , narrow c o r r i d o r s and small rooms. The newer u n i t s , however, were s u i t a b l y structured with no s t a i r s (replaced by gentle ramps), hand r a i l s i n the c o r r i d o r s and i n the wards f o r semi-ambulatory p a t i e n t s , and f l o o r lighting... I t would seem rather i r o n i c a l that the most hopeful or a c t i v e cases are therefore housed i n the o l d e r b u i l d i n g s because they are able to adjust to the shortcomings i n the c o n s t r u c t i o n of these b u i l d i n g s , whereas, the patients with the poor prognosis or more extreme handicaps are housed i n b r i g h t , new, modern b u i l d i n g s . I t should a l s o be mentioned that a l l f a c i l i t i e s r eveal considerable concern and a c t i v i t y on the part of a l l s t a f f i n order to maintain a c h e e r f u l and b r i g h t atmosphere and to cater to the needs of the p a t i e n t population as much as p o s s i b l e . The f o l l o w i n g i s a breakdown of these wards i n terms o f the type of p a t i e n t they house: 1 Male Infirmary Ward 2 Male w»rds Ambulant (Part PMH Workers) 1 Female Infirmary Ward 2 Female Ambulatory Patients - 28 -2 Female Ambulatory - Older Buildings 1 Female Special 1 Female Semi-Infirm The patient population at this time i s 484, made up of 142 men and 342 women. This imbalance i n sexes i s due in part to the fact that Vernon unit has a population of 300 men only so that some of the men are transferred to that unit when the Coquitlam unit becomes over-crowded. Of the patient group, 80 to 85 per cent have been diagnosed as showing senile brain changes with a major portion due to cerebral arterio sclerosis. Approximately 135 patients are considered non-ambulatory and as such occupy two wards. Unfortunately, l i t t l e information i s available about the social, marital and cultural backgrounds of the resident population of the Homes for the Aged. However, an analysis of new admissions during the past five years reveals some significant data. A very high proportion (about 85$) of the patient group i s either Canadian or Bri t i s h born. A similar per-centage are of the Protestant f a i t h , attending either Anglican, Baptist or United Churches. The majority of the patients are either single or widowed and are i n the 70 - 79 year old age group. As mentioned previously over 85$ of the population have been diagnosed as either chronic brain syndromes, senile psychosis or psychosis with cerebral arterio sclerosis. Of the 484 patients i n residence, approximately 245 are sufficiently well enough to enjoy grounds privileges. In selecting a suitable representative group of patients for study of their potential social need, resources and discharge planning, i t was essential to keep several c r i t e r i a i n mind: These are l i s t e d as follows: (1) Psychiatric Qualifications: Since a patient i s admitted and treated i n the Homes for the Aged for his or her psychiatric i l l n e s s , the - 29 -f i r s t c r i t e r i o n i n terms of discharge planning would have to be that t h e i r mental health had improved to the extent that they could be considered ready f o r discharge and that they would maintain a s u f f i c i e n t l y high l e v e l of mental health once they were out i n community. (2) Nursing and Medical Q u a l i f i c a t i o n s : Many p a t i e n t s , because of the f r a i l t i e s o f old age and p h y s i c a l i l l n e s s e s accompanying t h e i r p s y c h i a t r i c problems, require constant nursing and medical care. As p r e v i o u s l y o u t l i n e s , many of the patients i n the Homes f o r the Aged are s u f f i c i e n t l y i l l p h y s i c a l l y to require constant bed care. Since discharge t o community of the p a t i e n t r e q u i r i n g constant nursing or medical care would involve f i n d i n g a s i t u a t i o n s i m i l a r to that of Homes f o r the Aged such as a p r i v a t e h o s p i t a l or general h o s p i t a l s e t t i n g , i t was f e l t that they would be excluded from the group study, i n that the type of car they could receive i n community would not d i f f e r markedly from that which were already r e c e i v i n g . I t was decided that only p a t i e n t s who were p h y s i c a l l y robust enough to be maintained i n a normal community (with some supports such as a moderately sheltered housing or r e s t r i c t e d r e c r e a t i o n a l resources) would be considered f o r the study. (3) Representativeness: Any group selected f o r t h i s study would n e c e s s a r i l y have to be s u f f i c i e n t l y representative of the t o t a l p a t i e n t population. This could be reqarded i n terms o f s o c i a l c r i t e r i a such as n a t i o n a l i t y , r a c i a l o r i g i n , r e l i g i o n , sex, e t c . Thus, rather than s e l e c t i n g the "top group1* i n terms of medical, nursing and p s y c h i a t r i c c r i t e r i a f o r study, a random sampling a more representative group would be gathered and therefore would present s o c i a l problems more common to the en t i r e h o s p i t a l population - 30 -S e l e c t i o n and Assessment Process. Four basic steps were taken i n s e l e c t i n g the group and i n assessing t h e i r s o c i a l p o t e n t i a l f o r r e h a b i l i t a t i o n to community: These are b r i e f l y o u t l i n e s below. (1) Screening f o r Medical and Nursing C r i t e r i a : This f i r s t step was taken to a s c e r t a i n that group of patients w i t h i n the i n s t i t u t i o n which presented the l e a s t problem i n terms o f the need f o r nursing and medical care. Approximately s i x weeks before the sample group was f i n a l l y obtained, a memorandum was sent t o the Charge Nurses o f each ward by the Medical Superintendent requesting the names of patients who f u l f i l l e d the f o l l o w i n g c r i t e r i a with respect to general care and management. (They were asked to d i v i d e the patients i n terms of group A to include patients who f u l f i l l e d the c r i t e r i a completely and group B to include those patients who were border-l i n e or showed c h a r a c t e r i s t i c s which might make care outside the i n s t i t u t i o n d i f f i c u l t . ) P h y s i c a l Factors: 1* Ambulatory without assistance. 2. Regular D i e t . 3» Able to dress and give adequate care to personal appearance with minimal assistance. A. No I.V. or I.M. medication required. Mental and. Behavioural Factors: 1. Co-operative and amenable to d i r e c t i o n and supervision. 2. Behavior not influenced by d e l u s i o n a l ideas, h a l l u c i n a t i o n s , etc. 3* Minimal t o moderate confusion, d i s o r i e n t a t i o n , memory l o s s . A. Minimal tendency to wander. - 31 -The l i s t s were subsequently returned to the Medical Superintendent's o f f i c e and i n d i c a t e d that throughout the i n s t i t u t i o n a t o t a l of 39 p a t i e n t s f u l -f i l l e d the c r i t e r i a of Group A completely and 158 p a t i e n t s were l i s t e d under Group B. Although there was no ac t u a l medical assessment made at t h i s time, as w i l l be noted, medical f a c t o r s are i m p l i c i t within the questions given to the nursing s t a f f i n terms of each patient's need f o r medical care given by the nurses when ordered to do so by the patient's doctor. When the sample group was obtained, a check was made with each pat i e n t ' s physician as t o the v a l i d i t y of the nurses' assessment regarding the d i s c h a r g a b i l i t y of each patient and i t i s to be noted that there was no v a r i a t i o n regarding the patients* need f o r medical carej i . e . , the nursing c r i t e r i a as applied to each p a t i e n t was s u f f i c i e n t l y v a l i d i n terms of medical c r i t e r i a f o r the purpose of t h i s study so that the doctor was only required to check on the nursing assessment. (2) P s y c h i a t r i c Screening: The group of 197 patients which were screened by the nurses were then assessed by the p s y c h i a t r i s t s who were a c t i v e i n these p a r t i c u l a r cases. This assessment included not only a diagnosis of the patient's mental and p h y s i c a l health, but a l s o such conditions as the pat i e n t ' s emotional r e a c t i o n to discharge planning, as w e l l as the patient's need f o r f u r t h e r p s y c h i a t r i c therapy unique to t h i s i n s t i t u t i o n i n order to preserve treatment gains made or f o r f u r t h e r improved mental health which could not be provided i n the outside community. As a r e s u l t of t h i s screening, a t o t a l of 74 patients were selected as being p o t e n t i a l l y amenable to discharge planning. These patients were from both the A and B groups i n terms of medical c r i t e r i a , as i t was the doctor's opinion that some of the patients i n group B who had s p e c i a l needs could have these needs met i n community - 32 -(3) S e l e c t i n g the Sample Group: Twenty-five patients were chosen from t h i s group of seventy-four through the process of taking every (1) t h i r d p a t i e n t from the l i s t as which was i n i t s e l f i n random form. A f t e r t h i s s e l e c t i o n was made a preliminary assessment of each patient was (2) c a r r i e d out by examining the patient's c l i n i c a l and correspondence f i l e s i n order to obtain i d e n t i f y i n g s o c i a l information as w e l l as to assess some of the areas (such as the patient's f i n a n c i a l s i t u a t i o n , information from outside community sources, correspondence from patient's r e l a t i v e s , etc.) which was not a v a i l a b l e to the c l i n i c a l team i n contact with the p a t i e n t . (A) C l i n i c a l Team Discussion: Each p a t i e n t was discussed with the Charge Nurse on h i s or her ward, as well as with the patient's doctor a f t e r the f i l e s were studies. In a d d i t i o n to these contacts, some i n -formal interviews were held by the s o c i a l worker with several p a t i e n t s who were on the ward at the time these meetings were taking place. Although these interviews were not structured they were h e l p f u l i n g i v i n g worker some idea of the type of person being assessed i n terms of the patient's a b i l i t y to r e l a t e . Occasionally, some confirming i n -formation was obtained from the study, such as the patient's l e v e l of motiv/ation f o r discharge. (1) A short time a f t e r the group was selected one of the pa t i e n t s suffered a severe stroke with the r e s u l t that she was confined to bed. This p a t i e n t was taken o f f the l i s t , so that twenty-four remained. (2) The contents of the c l i n i c a l f i l e included the admission papers, medical charts and the notes made by the patient's doctor. These doctors' notes summarize the r e s u l t s o f p e r i o d i c examinations and are r e -corded from the time of the patient's admission to h o s p i t a l . The cor-respondence f i l e records a l l incoming and outgoing correspondence regarding the p a t i e n t . - 34 -One of the f i r s t problems confronting the c l i n i c a l team was whether or not there was s u f f i c i e n t information about each p a t i e n t i n the group so that he could be adequately assessed. That i s , i n terms of the focus o f t h i s study, could the c l i n i c a l team evaluate what i t proposed to evaluate with any degree of assurance that the r e s u l t s would not be inconclusive because of gaps i n the information a v a i l a b l e . A l l a v a i l a b l e data about each p a t i e n t was therefore assessed i n terms of its source, ( f o r example, from the s o c i a l worker, or the p a t i e n t h i m s e l f ) , and the amount a v a i l a b l e (that i s was there information from s o c i a l agencies or r e l a t i v e s i n the community about the p a t i e n t , or were the doctor's notes and the admission papers the only sources). - 35 TABLE 2. The amount of information available on a group of twenty-four patients at the Homes for the Aged, Port Coquitlam, 1958.  Description Number 1. Recorded information based upon observations of 7 a professional social worker (l) or doctor during the patient's previous adjustment in the com-munity in addition to the information available on the regular admission forms. This data i s supplemented by the psychiatric or nursing recording while the patient i s i n hospital re-garding his needs and resources which i s judged by the therapeautic teairto be valid. 2. In addition to the admission forms, information 1A written i n by relatives or friends or given to and recorded by professional hospital personnel or an assessment of needs and resources as given by patient and f e l t by the therapeutic team to be p a r t i a l l y valid. 3. Recalled information by professional hospital 2 personnel or written a nd verbal information regarded as only p a r t i a l l y v a l i d as submitted by friends and relatives i n addition to that found on the admission forms. A. Incomplete information as found only on admis- 1 forms, voluntary letters from friends or r e l -atives or from the patient with a permanent psychiatric residual. (1) The term "professional social worker" implies any social worker hired by a bona-fide public or private agency. (2) Those on the therapeutic team include the psychiatrist or patient's doctor the nurse i n charge of the patient's ward and/or other nurses familiar with the patient's case and the social worker. - 36 -The r e s u l t s o f t h i s assessment i n d i c a t e d that f o r the most part (twenty-one of twenty-four patients) the c l i n i c a l team considered the i n -formation r e l i a b l e and s u f f i c i e n t f o r t h e i r purposes. Who are the Patients? From the information a v a i l a b l e on the p a t i e n t population on the whole, i t was considered that the group selected f o r study was f a i r l y representative i n terms of t h e i r s o c i a l background. Information about the re s i d e n t population i n these i n s t i t u t i o n s i s , unfortunately, not a v a i l a b l e to any great extent so that i n many areas the w r i t e r had to r e l y on the observations made by the Medical Superintendent and others working with these patients as to whether or not the group selected was representative. Of the twenty-four patients studied, ten of them were men and fourteen, women* The group was predominantly of Canadian or B r i t i s h e x t r a c t i o n . Ten of the group were born i n Canada (seven of B r i t i s h parents) s i x were born i n England, f o u r i n Scotland and four i n ether countries. Figures f o r the population as a whole would indi c a t e that the group selected i s not too representative i n terms of sex i n that the male population represents approximately o n e - f i f t h of the t o t a l number i n residence. I t should be pointed out, however, that t h i s f i g u r e would be somewhat more representative of the population of the Homes f o r the Aged, as a whole, since the Vernon u n i t houses only men. Unfortunately, f i g u r e s regarding c u l t u r a l o r i g i n concerning p a t i e n t population are not a v a i l a b l e . However, i t i s the Medical Superintendent's opinion that approximately e i g h t - f i v e percent of the t o t a l p a t i e n t population are of B r i t i s h o r i g i n which i s r e f l e c t e d i n the group selected f o r study. - 37 -As might be expected from a group of this age, ten of the group were widows or widowers and only five of the twenty-four were married. Two of the remaining nine patients had been separated or divorced from their spouse and the remaining seven were single. Thus, for one reason or another, nineteen of our group of twenty-four patients had no marital partner which, at the age of 70 or over contributes heavily to further personal isolation. In keeping with policy that the Port Coquitlam unit services people of the Lower Mainland area, ALT, the patients i n our sample group had resided i n the Vancouver Island or Lower Mainland area prior to their admission to the Homes for the Aged. The patients ranged i n age between 70 and 88 years and were f a i r l y evently distributed within these years. The average age was approximately 77 years. Although the majority of the group (nine of the twenty-four) were between the ages of 78 and 82 years, there was a con-siderable "scatter" i n aged. For example, three of the patients were between 70 and 74 years of age and ranged between 84 and 88 years. Similar information about the total population of the institution i s not available, as the figures about age are traditionally grouped into ten year periods (i.e. 70-80, 80-90) rather than the two year intervals which have been used for c l a r i t y i n discussing the sample group. There was considerable variation regarding the length of time (from 6 months -24 years) that members of the group had spent i n the Hbmes for the Aged. - 38 -TABLE 3. The length of stay of a group of 2A pa t i e n t s at the Homes f o r the Aged* Port Coquitlam* 1958. Length of Stay Male Female T o t a l 1 year 2 2 1 - 2 years 2 A 6 2 - 5 years 2 3 5 5 - 1 0 years 2 2 A 10 / years 2 3 5 TOTAL 10 U 2A Although the average length of stay was about 5§- years, t h i s f i g u r e i s somewhat misleading as the group indi c a t e d a f a i r l y even spread throughout a l l the entire population regarding length of stay are not a v a i l a b l e , but i t i s assumed through the experience and observations of the c l i n i c a l team that the sample group i s f a i r l y representative. I t i s a l s o i n t e r e s t i n g to note that out of the twenty-four men and women i n our group* only two in d i c a t e d a h i s t o r y of previous p s y c h i a t r i c h o s p i t a l i z a t i o n . - 39 -The other twenty-two, according to the information a v a i l a b l e , had not been h o s p i t a l i z e d f o r p s y c h i a t r i c i l l n e s s p r i o r to t h e i r admission to the P r o v i n c i a l Mental Hospital and subsequent t r a n s f e r to the Homes f o r the Aged, or admission to the Homes f o r the Aged a f t e r assessment at the P r o v i n c i a l Mental H o s p i t a l as a "guest". One would conclude that many of the patients who had been i n h o s p i t a l f o r over ten years had been e i t h e r viewed as having chronic p s y c h i a t r i c i l l n e s s e s or had not been considered f o r discharge because of l a c k of resources i n the outside community. I t i s extremely d i f f i c u l t to make any meaningful c l a s s i f i c a t i o n of the p s y c h i a t r i c disorders with which patients were diagnosed. An a r b i t r a r y c l a s s i f i c a t i o n (Table A) does i l l u s t r a t e t h a t a l l twenty-four patients have an organic element i n t h e i r i l l n e s s e s which are accompanied f o r the most part with some behavioural or psychotic r e a c t i o n . - AO -TABLE A. The diagnosis of a group of twenty-four patients at the Homes for the Aged* Fort Coquitlam, 1958* Illness Number 1. Senile Brain Disease (a) With qualifying phrase— Depressive Features (2) Psychosis (3) (b) Without qualifying phrase (7) 12 2. Cerebral Arteriosclerosis (a) With qualifying phrase-Reactive depression (l) Behavioural reaction (l) (b) Without qualifying phrase (3) 5 3. Chronic Brain Syndrome (a) Due to Cerebral Arteriosclerosis (6) (b) With Senile Brain Disease (l) 7 TOTAL i 2 4 Information about the resident population of the Homes for thej Aged regarding illnesses i s not available. However* published s t a t i s t i c s re-i garding f i r s t admissions according to diagnosis indicate that over 95% of f i r s t admissions to the Port Coquitlam unit are diagnosed i n one of the three (l) ! categories i n the above table. j (1) B r i t i s h Columbia, Report of the Mental Health Services* Queen's Printer Victo r i a , 1958 P L 119, Table 3. - 41 -In summary, the sample group of twenty-four patients i s , from the information a v a i l a b l e , f a i r l y representative of the pa t i e n t population as a whole i n the Port Coquitlam u n i t of the Homes f o r the Aged. In terms of the "average" a t y p i c a l p a t i e n t within the group i s seventy-seven years of age and has been i n h o s p i t a l between f i v e and s i x years. He i s o f B r i t i s h e x t r a c t i o n , a Protestant and sin g l e . He s u f f e r s from an organic i l l n e s s which i s accompanied by changes i n h i s thinking and behaviour. There are many needs which the c l i n i c a l caseworker has to consider when a s s i s t i n g these patients i n t h e i r discharge from a p r o t e c t i v e i n -s t i t u t i o n a l s e t t i n g to that o f the outside community. In one the f u l f i l -lment of these needs i s the r e s p o n s i b i l i t y of the i n s t i t u t i o n . In the other* the former p a t i e n t , as a c i t i z e n , must take some i n i t i a t i v e and r e s p o n s i b i l i t y i n f i n d i n g and using the resources which the community provides. Patients l e a v i n g the Homes f o r the Aged have heightened d i f f i c u l t y i n t h i s regard because of the length of time they have spent i n h o s p i t a l and handicaps to adjustment added by t h e i r age. During t h i s lengthy period o f h o s p i t a l i z a t i o n one would expect, because of the dependency f o s t e r e d upon pa t i e n t s i n any i n s t i t u t i o n a l s e t t i n g , some diminution of these p a t i e n t s ' a b i l i t y to look a f t e r themselves, i n ad d i t i o n to t h i s l o s s , one would a l s o expect a d r a s t i c weakening o f community t i e s , that i s , some l o s s i n r e l a t i o n s h i p s with f r i e n d s and fa m i l y , i n community a f f a i r s and i n community resources. Coupled with the problems accrued from h o s p i t a l i z a t i o n are those of s o c i a l and community i s o l a t i o n , p h y s i c a l f r a i l i t y and a tendency toward ps y c h o l o g i c a l r i g i d i t y . A l l these must be considered i n any discharge plan-ning. - A2 -CHAPTER I I I NEEDS AND RESOURCES IN DISCHARGE PLANNING Since i t would be d i f f i c u l t , i f not impossible, to assess every i n d i v i d u a l need within the group, some common needs w i l l be examined i n terms of the patient's p o t e n t i a l i n being considered f o r discharge to community. The preceding considerations suggest that two broad categories must be taken into account. F i r s t there are the needs d i r e c t l y r e l a t e d to the p a t i e n t ' s period of h o s p i t a l i z a t i o n and which must be met some other way i n community to preserve the well-being of the patien t . The areas chosen f o r assessment included* Medical needs ( f o r example, the need f o r furt h e r treatment of p h y s i c a l ailments; f o r s p e c i a l d i e t s or vitamin therapy); p s y c h i a t r i c casework or counselling needs (pharmacological therapy, psychotherapy or supportive casework are some of the ways of meeting these needs that were included i n t h i s category)* The need f o r personal supervision, (that i s the need f o r guidance from f r i e n d s or r e l a t i v e s i n coping with day-to-day problems); and housing needs (the s p e c i a l aspects of housing accommodation required f o r the older person, such as a sheltered boarding home or a housekeeping room close to community r e c r e a t i o n f a c i l i t i e s ) . The second group o f needs selected are more s p e c i f i c a l l y r e l a t e d to the pati e n t ' s adjustment i n the outside community and f o r which the patient u s u a l l y has some resources to meet these needs. - 43 Since i t i s the caseworker's function to a s s i s t the p a t i e n t to use his own personal strength as much as p o s s i b l e , the f o l l o w i n g f a c t o r s were considered resources which he can use to f a c i l i t a t e h i s adjustment i n community. Those f a c t o r s assessed were* p h y s i c a l a b i l i t y , f i n a n c i a l and m a t e r i a l resources, s o c i a l , r e c r e a t i o n a l and r e l i g i o u s i n t e r e s t s , the number and i n t e r e s t of f a m i l y and f r i e n d s and the patient's motivation f o r discharge. I t i s apparent, however, that i f the p a t i e n t lacks any of these, the community w i l l have to provide f o r these lacks and these f a c t o r s w i l l therefore become needs. P s y c h i a t r i c . Casework and Medical Needs Of primary concern to the s o c i a l worker i n any i n s t i t u t i o n a l s e t t i n g of t h i s nature i s the need f o r extending h o s p i t a l services a f t e r discharge or i n providing services i n community r e l a t e d to the patient's h o s p i t a l i z a t i o n or h i s need f o r post-discharge treatment. Often the success of the p a t i e n t ' s attempt to re-adjust i n the outside community depends on the extension of casework services or psycho-therapy to him from people with whom he i s f a m i l i a r and f e e l s he can t r u s t . He may need to continue with prescribed d i e t s or medication to maintain h i s p h y s i c a l or mental health and require support and encouragement t o do so. An attempt was made by the c l i n i c a l team t o assess the patient's p s y c h i a t r i c , casework and medical needs i n terms of t h e i r s o c i a l i m p l i c a t i o n s . For example, any patient r e q u i r i n g frequent and constant medical supervision would of necessity have to l i v e i n close proximity to a medical doctor or medical f a c i l i t i e s . - u TABLE 5. The need f o r casework counselling and psychotherapy of a group of 24 patients of the Homes f o r the Aged, Fort CoQuitlanu 1958.  Extent o f Need D e s c r i p t i o n Number 1. Frequent & Intensive. P a t i e n t requires weekly 10 or twice weekly contacts *• by a caseworker and/or p s y c h i a t r i s t i n order to i n t e r p r e t or to support the p a t i e n t i n dealing with h i s adjustment to f a m i l y or f r i e n d s or i n using medical, s o c i a l * r e c r e a t i o n a l or r e l i g i o u s resources* 2. Supportive & Br?.ef. Monthly or bi-monthly con- 7 t a c t s of a b r i e f supportive nature by the p s y c h i a t r i s t or caseworker to a s s i s t the p a t i e n t i n coping with any occasional d i f f i c u l t i e s or to observe and t r e a t any signs of permanent mal-adjustment i n i t s begin-ning stages. 3. Occasional & Preventative . Occasional supportive contacts 7 of a routine nature based upon a request by the p a t i e n t or those i n con-t a c t with them or a t the convenience of the case-worker with the focus on observing and t r e a t i n g any beginnings o f mal-adaptive behaviour. TOTAL 24 - U5 -The p s y c h i a t r i c and counselling needs were assessed together, so that the focus on the need f o r casework serv i c e s would remain on the patient's p s y c h i a t r i c condition. That i s , to maintain the gains in treatment which the patient made during h o s p i t a l i z a t i o n and enable him to use resources i n community to keep up health. Thus casework a c t i v i t y around s p e c i f i c areas such as discharge planning or unforeseen events in the patient's readjustment i n community were not included. " P s y c h i a t r i c s e r v i c e s " implied the use of psychotherapy and the p r e s c r i b i n g of t r a n q u i l i z e r s and other drugs r e l a t e d to maintaining mental health of the p a t i e n t . Excluded were the more intensive somatic therapies such as electroshook treatment or surgery. - 4 6 -I t i s not s u r p r i s i n g to note (Table 5) that ten of the twenty-four patients, according to the assessment of the c l i n i c a l team, need frequent and intensive follow-up care on a weekly or twice weekly ba s i s . I t i s i n t e r e s t i n g that the majority of the group do not require counselling o f t h i s i n t e n s i t y . Rather b r i e f and occasional contacts would seem to be adequate. These r e s u l t s , however, do imply that follow-up care i s required by the majority of the patient group i n order to maintain t h e i r present l e v e l of mental health and would indicate that i f these patients were discharged, some post-discharge treatment f a c i l i t i e s would be e s s e n t i a l . These f a c i l i t i e s should include, according to the r e s u l t s of t h i s assessment, the services of a caseworker to provide the support and encouragement some of these people need. As i n the case of p s y c h i a t r i c treatment and casework counselling needs most people as they grow older require more frequent medical examinations and treatment. Many are r e s t r i c t e d to s p e c i a l d i e t s or have to take d a i l y medication. The c l i n i c a l team assessed the medical needs of t h i s group of twenty-four patients i n order t o determine wiether or not these could be met i n the community. - 47 -TABLE 6 . The extent of medical needs of a group of twenty-four p a t i e n t s i n the Homes f o r the Aged, Port Coquitlam, 1958- , Extent of Need Des c r i p t i o n Number 1. Constant Supervision. Patient i s required to maintain schedules i n taking medicines and to maintain regular (weekly) or f o r t n i g h t l y ) contact with the medical doctor and/or P u b l i c Health Nurse. 6 2 . Regular Supervision. P a t i e n t i s required to maintain regular medical schedules, but requires no more than p e r i o d i c checkups with the medical doctor or P u b l i c Health Nurse. 10 3 . Occasional Supervision. Required to maintain no more than normal medical schedules (vitamins, etc.,) and occasional checkups with the family doctor or Pu b l i c Health Nurse. 8 TOTAL , . , . 24 - A& -I t w i l l be noted (Table 6) that no attempt was made to assess the s p e c i f i c needs of each patie n t . Rather the extent of each patient's medical needs were examined i n terms of the demand these patients t t would make f o r medical care i n the community. In the opinion of the c l i n i c a l team, eighteen of the group of twenty-four require only regular or occasional supervision so that the majority of the patients would have l i t t l e d i f f i c u l t y i n obtaining s u i t a b l e accommodation since the demands they would make f o r care would not be too a t y p i c a l f o r persons now i n the community of a s i m i l a r age group. There was a s i g n i f i c a n t c o r r e l a t i o n between the extent o f need f o r medical, p s y c h i a t r i c and counselling services and the patient's length o f stay. For example, i t was observed that s i x of the ten patients who had been i n h o s p i t a l f o r l e s s than two years required "frequent" p s y c h i a t r i c or casework counselling services whereas only one out of f i v e of the group having l i v e d i n h o s p i t a l over ten years required s i m i l a r services. The remaining four patients staying over ten years required only "supportive and occasional s e r v i c e s . " These f i n d i n g s would indi c a t e that the s o c i a l worker would have t o help the pat i e n t who has remained f o r a r e l a t i v e l y short time on an intensive b a s i s to f i n d and use the medical and other services provided i n the patient's community. - 49 -Housing Needs The p r o v i s i o n of su i t a b l e housing accommodation f o r older people i s a major problem i n most communities i n North America at the present time. As previously outlined (Chapter I) during the past few decades older people have become separated from theprimary f a m i l y group and thus have been forced to seek separate housing accommodation. Newer housing u n i t s constructed f o r a smaller fami l y do not provide f o r other than immediate f a m i l y members. Coupled with t h i s l a c k of space i n the modern home i s the d i f f i c u l t y that older people sometimes have i n looking a f t e r themselves without assistance from others so that they often are unable to provide for themselves i n a su i t e or l i g h t housekeeping room and have to seek a home where they can be p a r t i a l l y looked a f t e r by others. The c l i n i c a l team assessed the selected patient group i n terms of how these people could adjust i n the various types of housing found i n the community at the present time. Each p a t i e n t was evaluated by the c l i n i c a l team i n terms o f his or her adjustment on the ward. That i s , the patient's a b i l i t y to look a f t e r h i s own personal hygiene, g e t t i n g along with other patients and a b i l i t y to assume some r e s p o n s i b i l i t y f o r cleaning up the ward and making beds, to mention a few examples. I t should be added that the pati e n t ' s behavior was reviewed over a period of several months i n order to obtain some idea of his consistency. I t i s rather s u r p r i s i n g to note (Table 7) that t h i r t e e n of the twenty-four patients required only a "board and room" type of residence rather than the more sheltered type of housing which i s provided i n the community. Two of the patients who required "sheltered boarding home care", i n the opinion of the c l i n i c a l team would have been better suited to a nursing home i n view of t h e i r severe p h y s i c a l handicaps. These two pati e n t s , both women, would require assistance i n almost a l l a c t i v i t y such as getting up f o r meals, going t o the bathroom, etc. although they d i d not require constant medical or p s y c h i a t r i c care. Of the three remaining patients r e q u i r i n g the "sheltered boarding home" two needed t h i s type of housing because of t h e i r i n a b i l i t y to climb s t a i r s , otherwise t h e i r p h y s i c a l and emotional condition was good. These two patients would require housing s i m i l a r to that of any person with a severe heart condition r e s t r i c t i n g t h e i r p h y s i c a l a c t i v i t y . I t would seem s i g n i f i c a n t that most o f the group could get along i n a "board and room" type of residence i n view of the lengthy time most of the patients have spent i n the h o s p i t a l where f u l l i n s t i t u t i o n a l care i s provided. That i s , one would wonder i f a long period of h o s p i t a l i z a t i o n would not r e s u l t i n a dependency on f u l l y i n s t i t u t i o n a l care. Perhaps the answer to t h i s question i s that the aim of the h o s p i t a l s t a f f i s to help the patient as much ; - 51 -possible maintain his or her optimal l e v e l of functioning. One of the methods the nursing s t a f f employ ( e s p e c i a l l y when the amount of s t a f f a v a i l a b l e to care f o r these patients i s considered) i s that of encourag-ing the patient to look a f t e r himself as mueh as he i s able. In addition, he i s encouraged to help i n looking a f t e r others or i n performing other duties around the ward such as cleaning, serving food or other a c t i v i t i e s i • not unlike those required to maintain a normal household. Although the r e s u l t s of t h i s assessment imply that most patients do not appear to require a sheltered type of housing, a s o c i a l worker would have to bear i n mind that t h i s study was conducted i n a s e t t i n g where sheltered care, although not n e c e s s a r i l y requirecd by most of the people i n the group, was however implied. Also i t must be remembered that there i s a ready opportunity f o r each p a t i e n t t o f i n d support and acceptance through h i s fellow patients and the s t a f f i n performing any duties around the ward. These considerations do not n e c e s s a r i l y i n v a l i d a t e the conclusions but might indi c a t e that s i m i l a r r e l a t i o n s h i p s may be necessary to the patient l i v i n g i n a home where board and room are provided, and should be a matter of consideration i n the s o c i a l worker's planning i n providing housing f o r the patients as represented by t h i s group. I t would not seem too s u r p r i s i n g that only two patients were capable of r e s i d i n g i n a s u i t e or l i g h t house-keeping room i n view of the age and r e s u l t a n t p h y s i c a l i n f i r m i t i e s of most of these p a t i e n t s . - 52 -Personal Supervision Most older people, because of t h e i r i n c a p a c i t i e s , need some minor guidance or help i n coping with day-to-day problems that younger age groups would have l i t t l e d i f f i c u l t y i n handling. For example, an older person often needs some advice or encouragement keeping w i t h i n a budget, i n answering correspondence or i n maintaining contacts with f r i e n d s or r e l a t i v e s . Although the pat i e n t s i n the groups were assessed i n terms of t h e i r need f o r p r o f e s s i o n a l p s y c h i a t r i c and casework counselling services, the c l i n i c a l team was aware of the need of most of the pat i e n t group f o r occasional, informal and instructured guidance. This evaluation was obtained c h i e f l y from the nursing s t a f f , who have the opportunity to observe the patient's reactions t o f r u s t r a t i o n s during the twenty-four hours of the day and the amount of help they need from other patients or s t a f f . / - 53 -TABLE 7 An assessment of the type of housing needed by a group of twenty-four patients i n the Homes for the Aged, Port Cqqujtlam. 1958. Type of Home Pescr^ption Number 1. Sheltered Boarding Home Patient requires: private room on ground floor close to f a c i l i t i e s without being required to climb stai r s . Home i s i n close prox-imity to medical and/or psychiatric resources. 5 2. BoardjLne Home Care Patient requires social and rec-reational f a c i l i t i e s i n the home, but i s capable of climbing stairs and i n caring for personal house-hold needs. K 3. Board and Room Patient i s able to make f u l l use of household f a c i l i t i e s i n caring for personal hygeine. Social and recreational f a c i l i t i e s are needed within close proximity (within 3 or L blocks). 13 A. Supervised Lieht Housekeeping F a c i l i t i e s Patient i s capable of maintaining li g h t housekeeping room with occasional guidance and super-vision. Needs only normal access to social and recreational f a c i l -i t i e s . 1 5. Suite or Lieht Housekeeping Room Patient i s capable of l i v i n g i n and managing a suite or l i g h t housekeeping room without super-vision. Needs no more than normal social outlets. 1 TOTAL 24 - 54 -TABLE 8 The Amount of Personal Supervision Required by a Group of 24. Patients i n the Homes f o r the Aged. Port Coquitlam. 1958. . Extent of Need Descr i p t i o n Number 1* F u l l Supervision Patient requires constant supervision i n a l l phases of personal care ( i . e . s a n i t a t i o n , meals, etc.) and needs support and encouragement i n making use of r e c r e a t i o n a l and s o c i a l f a c i l i t i e s and i n a l l other phases of a c t i v i t y 5 2. L i g h t Supervision P a t i e n t o c c a s i o n a l l y requires some guidance i n keeping with the in c a p a c i t i e s of old age. This would include occasional support and encouragement i n using community resources, In housekeeping, e t c . 17 3. No Supervision P a t i e n t i s able to fu n c t i o n adequately i n community and at home with no guidance or supervision, i s w e l l motiva-ted and capable of using s o c i a l , r e c r e a t i o n a l and r e l i g i o u s a c t i v i t i e s and i s completely independent i n performing normal household "functions. 2 TOTAL i. 24 - 55 -Most of the twenty-four p a t i e n t s , while not r e q u i r i n g constant supervision do require occasional guidance (Table 8). The social^worker would therefore be w e l l advised to make c e r t a i n that the patient had someone i n the community who could provide a f a i r l y consistent contact f (such as a r e l a t i v e or landlord) and f o r whom the patient had s u f f i c i e n t respect to accept his guidance or counsel. P h y s i c a l A b i l i t y One of the most valuable resources the older person has (as with any age group) i s the a b i l i t y to perform the v a r i e t y of p h y s i c a l a c t i v i t i e s e s s e n t i a l i n maintaining a healthy adjustment. Some ph y s i c a l a b i l i t y i s required to carry on almost any a c t i v i t y , and i n the case of the older person, t h i s resource becomes more valuable to him as he r e a l i z e s that h i s powers are beginning to wane. In some cases, taking care of one's own personal hygiene requires tremendous exertion. Others may have the a b i l i t y to enjoy strenuous a c t i v i t i e s i n t h e i r l e i s u r e time* l e i s u r e time which increases with older age because of the l o s s of employment and the narrowing of s o c i a l contacts. The c l i n i c a l team, i n assessing the patient group, evaluated each patient's behavior i n terms o f the m o b i l i t y and stamina he manifested i n h i s ward behavior. The scope of a c t i v i t i e s provided i n the h o s p i t a l o f f e r s ample opportunity f o r the patient's involvement and consequently his p h y s i c a l a b i l i t y i s e a s i l y measurable. There i s work to be done i n the wards or on the h o s p i t a l grounds r e q u i r i n g various l e v e l s of strength and stamina and other organized r e c r e a t i o n (bowling, dancing) and informal a c t i v i t i e s ( g o l f i n g , f i s h i n g ) are a l s o a v a i l a b l e to the patient and provide a ready index of h i s a b i l i t i e s . - 56 -TABLE 9 The p h y s i c a l a b i l i t y of a group of twenty-four patients i n the Home f o r the Aged, F o r t Coqujtlam. ¥?5& Extent of Need D e s c r i p t i o n Number 1. Cons i s t e n t l y Active P a t i e n t i s able to maintain a 5 normal stream of p h y s i c a l a c t -i v i t y i n keeping with the f r a i l t i e s of old age. Pat i e n t i s a b l e to do l i g h t work (such as j a n i t o r i a l d u t ies, watchman, etc.) with a minimum of absent-eeism or p a r t i c i p a t e moderately i n such a c t i v i t i e s i n g o l f , dancing, etc* 2, Moderately Active O c c a s i o n a l l y able to p a r t i c i p a t e In such a c t i v i t i e s as l i s t e d 7 above i n c l u d i n g l i g h t work on a casual or part-time bas i s . P a t i e n t i s c o n s i s t e n t l y able, however, to enjoy such moderate a c t i v i t y as h i k i n g , f i s h i n g , e t c . , and to involve himself i n spec-* t a t o r sports. 3, R e s t r i c t e d Unable to p a r t i c i p a t e i n any 7 a c t i v i t i e s other than walking or spectator a c t i v i t i e s . P a t i e n t i s , however, s u f f i c i e n t l y mobile to look a f t e r personal needs i n the home and to moderately par-t i c i p a t e i n such p h y s i c a l act-i v i t i e s as found i n the normal household. A. P a r t i a l l y Handicapped Pat i e n t i s mobile only to the exr 3 of c a r i n g f o r h i s own personal needs i n the home such as going f o r meals, going to the bathroom, e t c . Occ a s i o n a l l y goes out on s p e c i a l occasions or f o r p e r i o d i c v i s i t s with f r i e n d s or r e l a t i v e s , e t c . 5. Severely Handicapped Pat i e n t i s p h y s i c a l l y able only to 2 p a r t i a l l y look a f t e r h i s own personal needs at home. - 57 -Extent of- Meed Des c r i p t i o n Nnmbp.r 5. Severely Handicapped May o c c a s i o n a l l y need some assistance to come f o r meals, etc., leaves home only r a r e l y and when absolutely necessary and i s always accompanied by an escort. 2 TOTAL 24 Although there seems to be l i t t l e information regarding the l e v e l of function of thosevin a s i m i l a r age group i n the outside community, one would suspect that t h i s p a t i e n t group i s not a t y p i c a l i n t h i s respect. I t i s a l s o i n t e r e s t i n g to note that there seemed to be no c o r r e l a t i o n between the patient's p h y s i c a l a b i l i t y and other f a c t o r s , such as h i s length of stay or diagnosis. A s i m i l a r " s c a t t e r " i s evident i n comparing each patient's phydcal a b i l i t y with h i s or her "medical, p s y c h i a t r i c and casework co u n s e l l i n g needs", although two patients who are p h y s i c a l "severely handicapped" require "constant" medical and p s y c h i a t r i c care. In terms of S o c i a l Work planning, t h i s p a t i e n t group indicates a wide range of p h y s i c a l a b i l i t y seemingly unrelated to other needs and resources found i n t h e i r respective communities as they ind i c a t e suf-f i c i e n t p h y s i c a l a b i l i t y to make use of these resources, even though, ( i n most cases), on a r e s t r i c t e d b a s i s . - 58 -F i n a n c i a l and M a t e r i a l Resources. Most people, as they approach older age have made some f i n a n c i a l p r o v i s i o n s f o r t h i s period i n t h e i r l i v e s . Because of the l o s s of a b i l i t y to be g a i n f u l l y employed or because of forced retirement schemes most f i n d themselves dependent on the f i n a n c i a l and material resources amassed during t h e i r e a r l i e r years such as income derived from investments, or pensions granted through former employment. A sizeable porportion o f the older age group however, have f i n a n c i a l d i f f i c u l t i e s . Some were unable to make provisions f o r o l d age and others who d i d , have found t h e i r savings depleted i n the l a s t decade because of the diminished value o f the d o l l a r through i n f l a t i o n . I t i s r e a d i l y apparent that f i n a n c i a l provisions are e s s e n t i a l i n planning f o r the discharge o f any p a t i e n t from h o s p i t a l . Money i s needed f o r c l o t h i n g , s h e l t e r and medical care, to mention only the bare n e c e s s i t i e s . In a d d i t i o n the older person often requires s p e c i a l f a c i l i t i e s f o r h i s care and may need more money than the average person to maintain himself. Because of the importance of these resources, the f i n a n c i a l and m a t e r i a l possessions of each patient were c a r e f u l l y assessed. I t was hoped t h a t t h i s evaluation would help the team determine the amount of f i n a n c i a l assistance those i n the group would require i f they were discharged to community. This assessment was made on the basis of information provided through h o s p i t a l records and i n two cases from interviews with the p a t i e n t to supplement t h i s information.. At the time a patient i s admitted to h o s p i t a l a statement i s taken by the business o f f i c e as t o what f i n a n c i a l and ma t e r i a l resources the pa t i e n t possesses. This d e s c r i p t i o n of the patient's estate i s f i l e d and i f no r e l a t i v e or responsible person e x i s t s i n the community t o administer the estate the o f f i c e of the O f f i c i a l Committee (a branch of the Attorney General's Department) assumes r e s p o n s i b i l i t y f o r administering the patient's a f f a i r s . There was some question about whether the pati e n t ' s resources and needs should not have been broken down i n terms of sums of money. I t was f e l t that such a survey would be extremely d i f f i c u l t to make i n that i t would be almost impossible to assess the estates of some of the patients i n terms of act u a l cash value. Also, i t was hoped that the c l i n i c a l team measure the pati e n t ' s resources i n terms of the patient's own concept of h i s s o c i a l f u nctioning. For example, one of the group, Patient A, was r e c e i v i n g an income of $750. monthly as a pension. P a t i e n t B could be r e c e i v i n g a $35. a month pension supplementary to the Federal Old Age Pension. P a t i e n t A would have d i f f i c u l t y i n considering the income of Patient B as even p a r t i a l l y sustaining. In other words, some attempt was made to evaluate the adequacy of the person's resources i n terms o f h i s own p a r t i c u l a r l e v e l of s o c i a l functioning, rather than making t h i s assessment e n t i r e l y i n terms of community standards. 60 -TABLE 10. The Financial and Material Resources of a Group of Twenty-four Patients in the Homes for the Aged, Port Coquitlam. 1958.  Extent of Need Description Number 1. Comfortably Self-Sustaining Patient has capital investment with a steady income and own home or money to buy own home and other material goods which enable him to li v e comfortably, Patient has enough resources so that he need not worry about anything other than outstanding expenses such as law suits, etc. 2 2. Completely Self-Sustaining The patient has some property, possibly own home, furniture, etc. Sufficient capital to buy property as well as a small income or resources in the form of investment, etc. 2 3. P a r t i a l l y Sustaining Patient has limited personal property such as furniture, etc. and some income (excluding Old Age Security). There i s a need, however, for some budget control and assistance in extra expenses ( i . e . medical expenses, glasses, dentures, etc.). 8 4. P a r t i a l l y Dependent Patient has some personal income of a limited nture to supplement Old Age Security or Old Age Assistance (in the case where Old Age Security cannot be granted). Patient has personal property of l i t t l e significance or value and i s dependent on welfare programmes for meeting expenses other than the bare necessities. 1 5. Completely Dependent Patient's personal property of an insignificant nature and has no income other than that provided through Government Pension or Welfare. 11 TOTAL «sj 24 - 61 -I t i s apparent (Table 10) that few of the patient groups can be considered completely f i n a n c i a l l y independent. The majority are e i t h e r p a r t i a l l y or completely dependent on f i n a n c i a l resources which can be provided through the community. A comparison of these r e s u l t s with the p a t i e n t ' s length of stay indicates that most patients remaining i n h o s p i t a l f o r extended periods of time have correspondingly l e s s resources to employ when they return to the community. There may be several reasons f o r t h i s condition. One reason could be that patients with more f i n a n c i a l and material resources through t h e i r own e f f o r t s and through the e f f o r t s of t h e i r r e l a t i v e s and f r i e n d s may be discharged or t r a n s f e r r e d to other p r i v a t e hospitals or nursing homes, lea v i n g those with no resources as the major part of those remaining over ten years. This would seem u n l i k e l y i n view of the extremely low discharge r a t e . A second reason f o r t h i s diminution of these resources may be due to charges l e v i e d on the patient's estate by the h o s p i t a l i n terms of payment f o r t h e i r care (#1.50 d a i l y ) . Although patients who q u a l i f y may receive the Federal Old Age Pension and contribute t h i s toward the cost of t h e i r h o s p i t a l i z a t i o n many of the patients remaining i n h o s p i t a l f o r a longer period than ten years may have had charges l e v i e d on t h e i r estate p r i o r to the time these pensions were granted. In a d d i t i o n , ( p a r t i a l l y because of the lack of services of a s o c i a l worker i n the Homes f o r the Aged) there have been some delays i n r e c e i v i n g the pension so that unfortunately the patient may have had' to pay f o r the cost of his h o s p i t a l i z a t i o n f o r some considerable time p r i o r to r e c e i v i n g i t . 'I 62 -Since the majority of t h i s p atient group w i l l require f i n a n c i a l assistance when they return to the community a great deal of a s o c i a l worker's time would be required i n terms of helping the p a t i e n t with f i n a n c i a l planning. This a c t i v i t y would i n f e r the assessment of each pati e n t ' s e l i g i b i l i t y f o r f i n a n c i a l assistance under the Old Age Pensions Act or other resources as provided within the framework of s o c i a l l e g i s l a t i o n as well as some m o b i l i z a t i o n of any e x i s t i n g resources that could be provided by e i t h e r f a m i l y or f r i e n d s to ease any possible f i n a n c i a l hardship. F i n a n c i a l planning f o r the older person represents a great many d i f f i c u l t i e s e s p e c i a l l y i n terms of the need i n some cases f o r s p e c i a l and more expensive housing or d i e t s and the occasional need f o r s p e c i a l r e c r e a t i o n a l a c t i v i t i e s or assistance i n transportation. In other words, i n c a p a c i t i e s created i n gorwing old often times r e s u l t i n the need f o r a t y p i c a l and more expensive resource i n order t h a t these people can maintain an optimal l e v e l of adjustment. The I n t e r e s t of Family and Friends The patient's contacts i n community represent f o r the most part r e l a t i o n s h i p s made p r i o r to his admission to h o s p i t a l and are to him not only a part of the outside community but a l s o a "bridge" from the h o s p i t a l where he wishes to return. F r i e nds and r e l a t i v e s , of course, perform many functions f o r the older person, functions which assume an even greater s i g n i f i c a n c e i n older years. - 63 -"....•Let i t never be forgotten that the key t o p h y s i c a l vigour i n so many old people l i e s i n t h e i r state of mind and that nothing so sur e l y saps the p h y s i c a l strength of old people than a complete l o s s of i n t e r e s t i n l i f e . . . I t behooves us to pay regard to those f a c t o r s i n the environment which can help to p r e c i p i t a t e t h i s p e c u l i a r mixture of sadness and apathy. Of these of course, by f a r the most t r a g i c and by (1) f a r the most important, i s loneliness.". -Interested people can perform a counselling, supportive and supervisory a c t i v i t y , and can also be used by the s o c i a l worker i n terms of a s s i s t i n g the pa t i e n t i n his planning or i n heightening the p a t i e n t 1 s l e v e l of i n t e r e s t and a c t i v i t y . The patient's contact with the outside community i s a c t i v e l y encouraged at the Homes f o r the Aged. There are d a i l y v i s i t i n g hours and evening v i s i t i n g p r i v i l e d g e s once a week. Evening v i s i t i n g i s sometimes somewhat r e s t r i c t e d because of thelack of extra s t a f f required f o r dealing with v i s i t o r s . In addition, any correspondence requesting information about the patient i s answered i n the hope that these interested p a r t i e s w i l l maintain contact. P a t i e n t s who are able to return to the community f o r short periods of time are encouraged t o take leave from the h o s p i t a l t o v i s i t f r i e n d s and r e l a t i v e s . Many cases various members of the h o s p i t a l (1) Report of the Third Congress of the International A s s o c i a t i o n of Gerontology, London, 1954* "Old Age and the Modern World. E. & S. Livingstone, Ltd., 1955. P.23. - 64 -personnel maintain contact with friends and r e l a t i v e s of patients, reporting any changes i n the patient f o r week-end leaves, e t c . The c l i n i c a l team surveyed the number of people who are interested i n the p a t i e n t and the extent of t h e i r i n t e r e s t . These two areas, that i s the extent and l e v e l of i n t e r e s t by others outside of h o s p i t a l were separately assessed, because, i n seme cases, patients may have a number of v i s i t o r s but these v i s i t o r s may not be too intere s t e d i n planning with the h o s p i t a l s t a f f f o r the care of the p a t i e n t or In the comfort of the patient during h i s stay i n the hospilaL. Information i s r e a d i l y a v a i l a b l e regarding the number of v i s i t o r s a patient may have. Each time a person comes to v i s i t a patient, h i s name and address are recorded i n the patient's v i s i t o r s book and t h i s f i l e i s kept i n the nurse's o f f i c e on the ward. In addition, a f i l e card .is kept up t o date regarding inquiries by interested p a r t i e s and t h i s a l s o i s kept i n the nurse's o f f i c e . Regarding correspondence about the patient, a l l such i n q u i r i e s and copies of r e p l i e s are recorded i n the patient's correspondence f i l e , so that the c l i n i c a l team was also able to evaluate the i n t e r e s t of f r i e n d s and r e l a t i v e s through t h e i r correspondence. - 65 -TABLE 11 The Quantity of Family and Friends of a Group of Twenty-Four Patients i n the Homes for the Aged, Port Coquitlam. 1958*  Extent of Need Description Number L. Large Circle The patient has retained a good number of ties in the community indicating a lengthy period of establishment in this community. Patient has a spouse or children and several long term acquaintances. 2 2. Moderate Circle Patient retains a group of relatives or friends in the one community. Has some close relatives and a few friends remaining. 4 3. Limited Circle Patient has a few close relatives and old friends in former community. 6 U Scattered & Remote Patient has some relatives or friends whose ties are not close and who are scattered i n various communities, has some old friends in former community. 10 5. None No relatives or friends in former or other communities. Patient i s completely alone and isolated. 2 TOTAL 24 - 66 -E v i d e n t l y most of the patients had a l i m i t e d c i r c l e of fr i e n d s or only scattered and remote contacts i n thecommunity. (Table 11). I t i s a l s o not s u r p r i s i n g to note that the patient's c i r c l e o f f r i e n d s tend to diminish a s h i s length of h o s p i t a l i z a t i o n increased. For example, f i v e of the ten patients having been i n h o s p i t a l f o r les s than two years had a large or moderate c i r c l e of f r i e n d s . Of those patients i n h o s p i t a l over f i v e years, eight of the nine people indicated a l i m i t e d or scattered c i r c l e of contacts. Although t h i s assessment r e f l e c t s the tendancy f o r a l l older persons to become s o c i a l l y i s o l a t e d , these r e s u l t s p a r t i c u l a r ^ show the added i s o l a t i o n of the older person i n an i n s t i t u t i o n . - 67 -TABLE 12 The Interest of the Family and/or Friends ..of a group of Twenty-Four Patients i n the Homes for the Aged, Port' Cocmltlam. 1958.  Extent of Need Description Number 1. Strong Patient has frequent visitors or correspondence from family or friends. Frequent inquiries are received of how the patient's condition i s . Patient i s granted leaves from hospital on a f a i r l y frequent basis to his friends or family. 8 2. Moderate Patient has friends or relatives who v i s i t or correspond on a casual basis and on holidays or festive occasions, ( i . e . birthdays, etc). Periodic inquiries are received about the patient and he i s allowed week-end leaves to v i s i t relatives or friends. 5 3. Casual Occasional v i s i t s by a few close friends or relatives and periodic inquiries regardingthe patient's condition. Patient i s granted leave from hospital on rare occasions (i . e . once or twice yearly) 4 4* Remote Annually or semi-annually on a social nature by one or two close friends. Patient goes out on leave only on very rare occasions. 3 5. None No friends or relatives v i s i t . No inquiries regarding patient. 4 TOTAL 24 - 68 -Motivation f o r Discharge The success or f a i l u r e of any patient's discharge i s dependent i n a large part upon h i s own motivation towards le a v i n g the h o s p i t a l . If he i s anxious to re t u r n to his former community, he i s quite often able to f a c i l i t a t e his own discharge by m o b i l i z i n g h i s own resources or i n seeking other resources outside of the h o s p i t a l . The patient's motivation a l s o influences the r o l e of the s o c i a l worker t o a great extent. E s s e n t i a l to the a c t i v i t i e s of a s o c i a l worker i s the r i g h t to s e l f determination by the c l i e n t (that i s , the help the c l i e n t t o help himself) and i f the c l i e n t lacks the desire t o involve himself i n planning with the worker, very l i t t l e progress w i l l be made. The c l i n i c a l team, aware of the importance o f t h i s area, assessed the p a t i e n t group to determine these patients l e v e l of motivation i n terms of wishing to leave the h o s p i t a l . These patients were evaluated according to t h e i r w i l l i n g n e s s to leave the h o s p i t a l , i n c l u d i n g t h e i r expressed views. Evaluating the group presented several d i f f i c u l t i e s to the team. For example, several patients who indicated a good p o t e n t i a l f o r adjustment had never expressed and willingness or d e s i r e to leave the h o s p i t a l . Other p a t i e n t s , when they were disturbed, would request discharge from h o s p i t a l p r i m a r i l y because they were seeking some s o l u t i o n f o r t h e i r f e e l i n g s of upset and a g i t a t i o n . This survey therefore of necessity had to include , not only the patient's own expressed wishes about leaving the ho s p i t a l but some idea of his p o t e n t i a l f o r discharge i n terms of his medical and p s y c h i a t r i c c ondition. - 6 9 -The r e s u l t s of this assessment would indicate that a S o c i a l Worker could be of considerable help to most of these p a t i e n t s i n making discharge plans. I t i s d i f f i c u l t to p r e d i c t what r e s u l t s would occur i f a supportive type of r e l a t i o n s h i p was established with some of the pat i e n t ' s r e l a t i v e s . One would f e e l that the e f f o r t s of a case-worker i n t h i s regard would produce very b e n e f i c i a l r e s u l t s by the i n t e r p r e t a t i o n of the patient's i l l n e s s t o them, support to the family i n terms of follow-up care when the patient was discharged, or through the m o b i l i z a t i o n of resources a v a i l a b l e through the r e l a t i v e s or fri e n d s to a s s i s t the patient i n h i s return home and i n maintaining him once discharged. C e r t a i n l y the assessment does in d i c a t e considerable weakening of community t i e s , as t h e i r stay i n h o s p i t a l lengthens. 70 -TABLE 13 THE Level of Motivation of a Group of Twenty-Four Patients i n the Homes f o r the Aged at Port Coquitlam i n 1958  jevel of Motivation D e s c r i p t i o n Number i i g h P a t i e n t frequently and r e g u l a r l y has discussed and requested h i s discharge and indicates a w i l l i n g n e s s to involve himself i n planning. 5 lood P a t i e n t has expressed some wish to be discharged yet v a c c i l a t e s i n terms of h i s unwillingness to leave the protection of the h o s p i t a l and to face the d i f f i c u l t i e s involved i n preparing himself f o r discharge A F a i r Patient seldom expresses any wish to leave h o s p i t a l yet h i s adjustment on the ward indicates a p o t e n t i a l f o r mo b i l i z i n g his resources and as such could be a candidate f o r preparing f o r discharge. 9 Poor or None Pati e n t has expressed l i t t l e wish to leave h o s p i t a l and has made only a f a i r ward adjustment and indicates l i t t l e p o t e n t i a l f o r m o b i l i z i n g his own inner resources. TOTAL b 24 - 71 -The p a t i e n t group (Table 13) indicated a wide range of l e v e l s of motivation. F i f t e e n of the twenty-four were i n the " f a i r " to "poor" categories and the remaining nine seemed t o be eager to p a r t i c i p a t e i n any plans f o r discharge. I t should be noted that those of the group who had remained i n h o s p i t a l f o r a period of longer than f i v e years expressed the l e a s t w illingness to leave the i n s t i t u t i o n ; seven of these nine p a t i e n t s expressed no wish to leave h o s p i t a l even though the team considered them as good discharge p o s s i b i l i t i e s . On the other hand, s i x of the ten patients remaining i n h o s p i t a l l e s s than two years i n d i c a t e e i t h e r a "high" or "good"motivation. I t would seem then that the patient's highest motivation f o r discharge (at l e a s t i n t h i s patient group) occurs during the f i r s t and second year he i s i n h o s p i t a l . Perhaps t h i s i s the period of time that his communities t i e s are strongest and foremost i n his mind and h i s p s y c h i a t r i c condition has remitted to the extent that he f e e l s he would be able t o get along i n the community. A f t e r a two year period i n the i n s t i t u t i o n the patients would appear to accept h o s p i t a l i z a t i o n as a permanent plan rather than a means of improving t h e i r health so that they can return to t h e i r former type of l i v i n g . This l a c k of i n t e r e s t i n any other area than the h o s p i t a l would, of course, be heightened by the gradual withdrawal! - 72 -(1) of contacts with friends and r e l a t i v e s and also by the r e a l i z a t i o n of the patient that his needs are being met i n the i n s t i t u t i o n and i t would be d i f f i c u l t f o r him to change h i s way of l i v i n g that discharge to the community would demand. The above r e s u l t s have considerable implications to the s o c i a l worker concerned with a s s i s t i n g these patients i n t h e i r discharge. A l l of the patients, however, indicated that before they could be discharged they could benefit through s o c i a l work a c t i v i t y within one or more areas assessed. As was a n t i c i p a t e d those of the group who had remained In h o s p i t a l f o r an extended period of time experienced a weakening of t h e i r t i e s i n community and a stronger dependency on the i n s t i t u t i o n . Thus the job of the s o c i a l worker becomes more complex with these people i n that they have fewer resources to imply and l e s s w i l l i n g n e s s to consider the prospect of l e a v i n g h o s p i t a l . The r e s u l t s of the t o t a l assessment a l s o imply a need f o r casework a c t i v i t y with these patients both during the time they are i n h o s p i t a l and during a post-discharge period. (1) See Page 65 - 73 -I t would appear that considerable interview time would have to be spent preparing these patients to face the prospect of leaving h o s p i t a l , i n a s s e s s i n g t h e i r resources and the resources provided by the community i n order that the patient can enjoy the best possible adjustment. In addition, t h i s p a t i e n t group evidenced a need f o r extension of h o s p i t a l s e r v i c e s such as f u r t h e r counselling and medical care. The s o c i a l worker could p l a y a v i t a l r o l e i n t h i s regard as a "bridge" f o r the p a t i e n t between the h o s p i t a l and the community. - 74 CHAPTER IV SOCIAL WORK TREATMENT OF THE AGED PSYCHIATRICALLY ILL Summary and Assessment. At the beginning of t h i s study, the s o c i a l adjustment o f the aged was b r i e f l y o u t l i n e d . I t was concluded t h a t , f o r various reasons, older people are becoming an i s o l a t e d group and i t s members regarded by many i n the community as having the c h a r a c t e r i s t i c s common to t h i s group. Thus there i s a tendency f o r older people to be stereotyped as dependent people, incapable o f assuming the r e s p o n s i b i l i t y f o r t h e i r own care and happiness. A review of some of the a v a i l a b l e s t a t i s t i c s regarding the economic adjustment of the aging, revealed that not a l l aged people are dependent people. Many remain productive and s e l f s u staining even though they have become "aged" according to the d e f i n i t i o n imposed upon them through the implementation of forced retirement schemes and pension plans. Even though some remain independent, i t was pointed out that o l d e r people tend to become i l l more often and need a longer period of time to recover. H o s p i t a l s t a t i s t i c s f o r example, i n d i c a t e that a l a r g e r pro-p o r t i o n of the older aged group spend a longer time than any other age group. Although the c h r o n i c i t y of the older patients' i l l n e s s was acknowledged to be the major reason f o r lengthy h o s p i t a l i z a t i o n there was some question as to the influence of delays i n discharge as a r e s u l t of the l a c k of community f a c i l i t i e s t o care f o r these people during t h e i r convalescence. - 75 -A b r i e f assessment was made of some o f the newer trends i n psychiatry with respect to the treatment of the older person. I t was concluded that with the development of newer therapies and s p e c i a l t r e a t -ment f a c i l i t i e s f o r the care of the g e r i a t r i c p a t i e n t , many are responding to t h e i r h o s p i t a l i z a t i o n to the extent that many recover s u f f i c i e n t l y from t h e i r mental i l l n e s s to be considered ready f o r discharge. This trend i s r e f l e c t e d i n the B r i t i s h Columbia Homes f o r the Agedj which provide care f o r the aged person with mental i l l n e s s . A f t e r a b r i e f d e s c r i p t i o n of the development and the present programme of these i n s t i t u t i o n s , i t was concluded t h a t , although treatment consisted prim-a r i l y of c u s t o d i a l medical and nursing care, some of the patients respond to t h i s regime and are thus capable of l e a v i n g h o s p i t a l . •'•o achieve the purpose of t h i s study - to determine i f s o c i a l s ervices could make some c o n t r i b u t i o n i n helping some of these p a t i e n t s leave h o s p i t a l - i t was necessary to s e l e c t and define some of the areas i n which the s o c i a l worker would be a c t i v e with the p a t i e n t . In other words, the f i r s t task was to determine some of the needs of the p a t i e n t that would have to be considered i f he were planning to leave h o s p i t a l . In order to avoid the confusion of a long grouped i n t o two broad categories: ( l ) the patients' needs and (2) resources he could employ. Needs were defined a s those areas with which the p a t i e n t required help and emanated d i r e c t l y from h i s h o s p i t a l i z a t i o n . Those selected were medical, p s y c h i a t r i c and casework c o u n s e l l i n g , personal supervision and housing needs. Resources - those f a c t o r s which depended i n part on the possessions of the pa t i e n t - included p h y s i c a l a b i l i t i e s , f i n a n c i a l and material resources, s o c i a l , r e c r e a t i o n a l and r e l i g i o u s i n t e r e s t s and the patient's motivation f o r discharge. - 76 -Twenty-four p a t i e n t s from the Port Coquitlam u n i t of the Homes f o r the Aged were selected f o r the assessment. They had been i n h o s p i t a l f o r periods ranging from s i x months to twenty-three years. They were chosen by a routine sampling procedure from a l a r g e r group who were jusged to be medically and p s y c h i a t r i c a l l y s u i t a b l e f o r discharge. T h i s l a t t e r group had been determined by the medical and nursing s t a f f , who through the use of a questionnaire surveyed the e n t i r e p a t i e n t population i n order to i d e n t i f y those patients w e l l enough to leave the h o s p i t a l . Although the r e s u l t s of the assessment o f the group selected f o r study (accomplished p r i m a r i l y through the use of r a t i n g s c a l e s ) , i n -dicated that the needs and resources of the group v a r i e d considerably, i t was evident that a l l of these p a t i e n t s could b e n e f i t from the as-sistance of a s o c i a l worker i n one or more of the areas evaluated. There were some i n d i c a t i o n s that the p a t i e n t ' s length of stay had a considerable e f f e c t upon the type of s o c i a l work a c t i v i t y they use. Those remaining i n h o s p i t a l f o r a period of l e s s than two years had u s u a l l y retained some resources i n t h e i r former community which could be mobilized to a s s i s t them i n discharge. On the other hand, the majority of t h i s group indi c a t e d they would need an extension of h o s p i t a l services i f they were discharged. That i s most of these people would require e i t h e r p s y c h i a t r i c , casework or medical follow-up care i n order to maintain the gains they had made i n treatment. 77 -The motivation of these people to leave h o s p i t a l was good, perhaps because of the maintenance o f strong community t i e s , which was a l s o evidenced i n the assessment. Those patients who had remained i n h o s p i t a l f o r a longer p e r i o d of time, indicated l e s s need f o r medical or c o u n s e l l i n g s e r v i c e s y e t had l i t t l e i n the way of s o c i a l resources, such as wide s o c i a l contacts i n t h e i r former community, or f i n a n c i a l and material possessions. This group also evidenced l e s s motivation f o r discharge and seemed to regard t h e i r h o s p i t a l i z a t i o n as a permanent l i v i n g arrangement. There was no s i g n i f i c a n t c o r r e l a t i o n with patient's p h y s i c a l a b i l i t y or s o c i a l recreations and r e l i g i o u s i n t e r e s t s i n terms of t h e i r length of stay. As previously mentioned the r e s u l t of the assessment o f each o f the selected needs and resources indicated that a s o c i a l worker could make some co n t r i b u t i o n i n discharge planning with each p a t i e n t . This period i n h i s h o s p i t a l i z a t i o n , however, represents only one part of the patient's total treatment programme. In a d d i t i o n to assessing the patient's needs and personal resources the s o c i a l worker would have t o include a survey of community resources i n order to determine how the p a t i e n t could meet h i s needs most e f f e c t i v e l y . This study therefore reviews only one aspect of possible s o c i a l service contributions during p a r t of the patient's i n s t i t u t i o n a l i z a t i o n . Further studies would have to b e undertaken i n order to determine more f u l l y how a s o c i a l worker could a s s i s t the aged p a t i e n t h o s p i t a l i z e d f o r mental i l l n e s s * - 78 -A T r a n s i t i o n Period. T h i s study would seem to i n d i c a t e not only t h a t the p a t i e n t group would b e n e f i t by the s e r v i c e s of a sodS.al worker, but a l s o a t r a n s i t i o n period has r e s u l t e d i n the increase i n the p s y c h i a t r i c t r e a t -a b i l i t y of older persons. The treatment program of t h i s i n s t i t u t i o n ( p r i m a r i l y custodial) has r e f l e c t e d the common concept o f mental i l l n e s s i n the older personleing associated with c h r o n i c i t y and the r e s u l t a n t poor prognosis. However, p a r a l l e l i n g the growing awareness i n other areas of a newer more o p t i m i s t i c outlook the s t a f f of the Homes f o r the Aged have indi c a t e d that many patients could be returned to t h e i r community a f t e r suitable treatment. At the present time most of the separations from h o s p i t a l r e s u l t from the death of the p a t i e n t j very few patients a r e returned to t h e i r homes or are discharged to private h o s p i t a l s or boarding homes. At the same time, there i s a growing l i s t o f people awaiting admission to t h i s i n s t i t u t i o n r e s u l t i n g i n increasing pressure by the community f o r these f a c i l i t i e s . There i s a need therefore, to i n s t i t u t e an active program i n the h o s p i t a l focussed on h e l p i n g p a t i e n t s , who are w e l l enough to return to the community. The r e s u l t s of the study i n d i c a t e t h a t s o c i a l service a c t i v i t y would be e s s e n t i a l i f such a programme were i n i t i a t e d . The problem of dealing with over-crowding i n the f a c i l i t i e s f o r the aged i s not unique to the Province of B.C. A study of the needs of o l d e r and c h r o n i c a l l y i l l persons i n Ottawa completed under the d i r e c t i o n of Miss Marjory Bradford i n d i c a t e d s i m i l a r problems i n that C i t y . - 79 -In commenting on the results of the committee's survey of institutional (1) facilities for the aged Miss Bradford pointed out: "The present over-loading of nearly a l l institutions, and much excess stay of older patients in hospital, are partly a problem of bottlenecks for which not one, but many new channels must be opened. One of these is a social work services associated with a l l institutiohs;:and hospitals, to help the right people in, help the right people out, and work on patient and family problems in between. No institution dealing with human l i f e in sickness and trouble fails to run into such difficulty, or achfeves its highest pinnacle of usefulness without such a facilitating service.11 The number of patients who are ready for discharge increased significantly as a result of a more active psychiatric treatment programme within mental hospitals. Recently the results of an accelerated programme in a state (2) hospital at Camarillo, California was published. The author summarized the results as follows: "Since 1952, we have given more than 26,000 electric treatments to over 600 patients between the aged of sixty and ninety-two. We have been able to send on convalescent leave more than 200 patients, twenty-eight of whom had been on the most disturbed geriatric female ward in our hospital. (1) Bradford, Miss Marjorie, A study of the Needs of Older and  Chronically i l l persons in the City of Ottawa, publi shed by the Council of the Corporation of the City of Ottawa, 1954« P» 5* (2 ) Geriatric Mental Patients and How we can help Them» Geriatrics? Devoted to Diseases and Processes of Aging. Volume 14, February 1959* Lancet Publications Incorporated, Minneapolis, Minn., U.S.A. - 80 -Before i n s t i t u t i o n of t h i s form of therapy, p r a c t i c a l l y no one from t h i s ward o f 100 patients had been able to go on convalescent leave. However, a l l of these patients are now able to go to the d i n i n g room, none require intramuscular sedation, and none are i n r e s t r a i n t . F o r t y per cent are able to go on short home v i s i t s or have r i d i n g permission with t h e i r r e l a t i v e s . I t i s r e a d i l y apparent that such a programme would involve a great deal more contact between the p a t i e n t and h i s outside community than i n now i n evidence a t the Homes f o r the Aged i n Port Coquitlam. S o c i a l work a c t i v i t y i n such a programme would a l s o no doubt show considerable a c c e l e r a t i o n . I t i s i n t e r e s t i n g to note that the medical and nursing s t a f f of the Port Coquitlam s e t t i n g eagerly p a r t i c i p a t e d i n the study of the p a t i e n t group. They offered many suggestions and ideas as to how f u r t h e r information could be obtained and what other needs could be assessed. The question they most often asked was "when w i l l there be a s o c i a l s e rvice department active i n the h o s p i t a l ? " Although the members of the c l i n i c a l team have evidenced t h e i r w i llingness to work with patients toward discharge, there remains the problem of the older person being accepted i n the community. These people, i n a d d i t i o n to being o l d , have had a mental i l l n e s s and some w i l l no doubt face added r e j e c t i o n by t h e i r f r i e n d s because of t h i s coupled with the a t t i t u d e of the community the older person has to face a shortage of es-s e n t i a l resources such as suitable housing accommodation and r e c r e a t i o n a l centres. - 81 Thus the s o c i a l worker would l i k e l y f i n d himself very much involved i n making a thorough assessment of e x i s t i n g resources and perhaps i n dev-eloping f u r t h e r f a c i l i t i e s i n community to help these people. There are i n d i c a t i o n s of concern i n t h i s regard i n many com-munities at the present time. In Vancouver f o r example the Community Chest and Council S o c i a l Planning Section have r e c e n t l y completed two studies which included p u b l i c a t i o n of a hand book f o r f a m i l i e s faced with the care of older people at heme and .an evaluation of present mental heal t h services f o r the aged i n B r i t i s h Columbia. S i m i l a r concern has been shown i n the United States. For example, i n the state o f Ohio recommendations neve been made f o r f u r t h e r therapeutic resources i n the community to be concerned with post h o s p i t a l s o c i a l plan-ning f o r the g e r i a t r i c mental p a t i e n t . The author observed that "the (2) change from h o s p i t a l l i f e to community must be an uninterrupted process". The report o f the committee studying needs and resources i n the C i t y o f Ottawa f o r the older person included i n i t s recommendations expansion of such resources as casework services provided by public welfare agencies, h o s p i t a l s o c i a l s e r v i c e s , the use of v i s i t i n g home-makers and housekeeping aides, and more d i v e r s i f i e d housing accommodation to meet the p a r t i c u l a r (3) housing needs of t h i s group. (1) Planning Report 1958, S o c i a l Planning Section, Community Chest and Council of Greater Vancouver, March 1959* Pages 4,7. (2) Post H o s p i t a l Planning f o r G e r i a t r i c Mental P a t i e n t s , G e r i a t r i c s Devoted to Diseased and Processes of Aging. Volume 14, Number 3 . March 1959-Lancet P u b l i c a t i o n s Incorporated, Minneapolis, Minn. U.S.A. (3) Bradford, Miss Marjorie, A Study of the Need3 of Older and Chron- i c a l l y i l l persons i n the C i t y of Ottawa, the Council of the Corporation of the C i t y of Ottawa, 1954* Paged 71,75-- 82 -New Goals f o r S o c i a l Work Research. At the present time as already ind i c a t e d (Chapter I) there i s no s o c i a l service department i n the Homes f o r the Aged. Therefore, al" though t h e r e i s no body of information available o f past s o c i a l work a c t i v i t y i t i s hoped that f u r t h e r research i n the areas o f the need f o r , and f u n c t i o n o f , a s o c i a l service department could r e s u l t i n the establishment of a department of peak e f f i c i e n c y . In view o f the p r o b a b i l i t y that a s o c i a l work department w i l l be s e t up i n the near future, thexe i s a need f o r research i n two broad areas. F i r s t , d e f i n i t i v e assessments, perhaps along the l i n e s o f t h i s present study, should be made i n order to determine more f u l l y , the p o s s i b l e scope of a c t i v i t i e s of a s o c i a l worker i n these u n i t s . In other words, how the s o c i a l worker would function i n a l l areas of the t o t a l h o s p i t a l programme. Casework a c t i v i t i e s i n pre-admission services would merit some a n a l y s i s . As p r e v i o u s l y o u t l i n e d (Chapterl) a great deal of time i s spent by the h o s p i t a l s t a f f ( p a r t i c u l a r l y the Medical Superintendent) i n d e a l i n g with the problems of prospective p a t i e n t s , t h e i r f a m i l i e s and i n t e r e s t e d s o c i a l agencies i n order to temporarily sustain the p a t i e n t p r i o r to h i s coming to h o s p i t a l or i n making e f f e c t i v e alternate plans. I t would seem t h a t working with these people to help them employ community resources or give support and guidance to those c a r i n g f o r these disturbed e l d e r l y people could be competently handled by a s o c i a l worker knowledgeable of the s p e c i a l problems these people have. Other pre-admission a c t i v i t i e s which could be assessed include an evaluation of the need f o r s o c i a l information i n treatment planning and some evaluation o f the b e n e f i t s that could r e s u l t - 83 -from the i n t e r p r e t a t i o n of se r v i c e s to patients and t h e i r f a m i l i e s p r i o r to admission i n order to e n l i s t t h e i r cooperation i n treatment and pre-discharge planning. E n l i s t i n g casework help during the patient's treatment period (1) should a l s o be examined. There are many examples o f areas needing a n a l y s i s i n c l u d i n g the s p e c i a l problems the aged present i n casework treatment, maintaining community t i e s during prolonged h o s p i t a l i z a t i o n and helping the older person remain motivated f o r discharge. Further research i n pre-discharge planning and following up care would also be e s s e n t i a l . The present study represents only a begin-ning i n t h i s area. Other questions have to be answered such as: What s p e c i f i c resources are available to meet these patients' needs i n community and how could t h i s be accomplished most e f f e c t i v e l y ? What would be the caseworker's s p e c i f i c area of competence i n r e l a t i o n to other members of the C l i n i c a l team? The second major area - that of organizing the S o c i a l Service Department to provide the most e f f i c i e n t possible s e r v i c e 0 also merits considerable a t t e n t i o n i n terms of research. Assuming that the a c t i v i t i e s of the s o c i a l worker i n the h o s p i t a l were c l a r i f i e d : How could he f u n c t i o n most e f f e c t i v e l y ? For example, how could meaningful l i a i s o n s be made with other agencies and i n s t i t u t i o n s and what r e f e r r a l procedures would be used. ( l ) A qualative a n a l y s i s of casework services at the Crease C l i n i c o f Psychological Medicine, a p s y c h i a t r i c i n s t i t u t i o n i n B r i t i s h Columbia performed by Mr. E. Schlesinger i l l u s t r a t e s some o f the contributions a s o c i a l worker can make during a patient's h o s p i t a l i z a t i o n . Schlesinger, Ernest. S o c i a l Casework i n the Mental H o s p i t a l , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954-. - 8A -Providing f o r f u r t h e r research i s another important area i n planning an agency function. Through research, f u r t h e r knowledge i s gained with the r e s u l t that new and better ways of doing things are developed* r e s u l t i n g i n turn i n the g i v i n g of more se r v i c e to people which i s the fundemental goal of s o c i a l work. A standardized system o f rec-ording information, ( f o r example, r e f e r r a l systems and diagnostic summaries) as well as planned research programmes would contribute to an increased e f f i c i e n c y i n the S o c i a l Service Department. Present trends i n population gowth i n d i c a t e an even greater proportion of older people, as compared with other age groups, f o r the f u t u r e . An increased demand f o r p s y c h i a t r i c f a c i l i t i e s to t r e a t those of t h i s group would appear i n e v i t a b l e . At the same time, with the dev-elopment of newer therapies, the older person has an i n c r e a s i n g l y b e t t e r chance o f being discharged from a p s y c h i a t r i c i n s t i t u t i o n . A l l o f these developments w i l l b r i n g greater pressure on the community to provide f o r the discharge patient of older years and as a r e s u l t a l a r g e r demand f o r s o c i a l workers to help these people. - 85 -BIBLIOGRAPHY S p e c i f i c References Books: Gruenberg, Dr. Ernest M. and Kaufman, Dr. Ralph M., Charter f o r the  Aging, Report of the New York State Conference at Albany, New York, 1956. Shock, Nathan, Trends i n Gerontology, Stanford U n i v e r s i t y Press, Stanford, C a l i f o r n i a , 1957. A r t i c l e s , Reports and Other Studies: Bradford, Miss Marjorie, A Study of the Needs of Older and Ch r o n i c a l l y  111 Persons i n the Cit y of Ottawa, published by the Council of the Corporation of the C i t y o f Ottawa, 1954, P. 81. B r i t i s h Columbia, Annual Report of the Mental Health Services, Queens P r i n t e r s , V i c t o r i a , 1958. Canada, Mental Health Services i n Canada, Research D i v i s i o n , Department of National Health and Welfare, Ottawa, J u l y , 1954. Clark, Ricbar James. Care of the Mentally 111 i n B r i t i s h Columbia, Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1945. " G e r i a t r i c Mental Patients and How we can Help Them", G e r i a t r i c s , Volume 14, Number 2, February, 1959. "Post H o s p i t a l Planning f o r G e r i a t r i c Mental P a t i e n t s " , G e r i a t r i c s , Volume 13, Number 3, March, 1959. Report of the Th i r d Congress of the International A s s o c i a t i o n of Gerontology, London, 1954, Old Age and the Modern ?forld, E. and S. Livingstone Ltd., 1955. - 86 -General References Books: Hamilton, Gordon, Theory and P r a c t i c e of S o c i a l Case Work, Columbia U n i v e r s i t y Press, New York, 1951. Lowrey, Lawson G., Psychiatry f o r S o c i a l Workers, Columbia U n i v e r s i t y Press, New York, 1946. A r t i c l e s , Reports and Other Studies: Group for the Advancement of Psychiatry, "The P s y c h i a t r i c S o c i a l Worker i n the P s y c h i a t r i c H o s p i t a l , Report Number 2, January, 1948. Ross, Robert M., A Volunteer Programme for the Patients of a" Mental  H o s p i t a l , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1958. Schlesinger, Ernest. S o c i a l Casework i n the Mental H o s p i t a l , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954. 

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