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UBC Theses and Dissertations

From custodial care to rehabilitation : the changing philosophy at Valleyview Hospital Josey, Kay 1965

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PROM CUSTODIAL CARE TO REHABILITATION: THE CHANGING PHILOSOPHY AT VALLEYVIEW HOSPITAL A Study o f Treatment F a c i l i t i e s D i s c h a r g e P l a n n i n g and Community Resources A v a i l a b l e f o r the P s y c h i a t r i c G e r i a t r i c P a t i e n t  by KAY JOSEY CLAYTON HERBERT TODD MOORHOUSE IGOR STARAK  Thesis Submitted i n P a r t i a l F u l f i l l m e n t of t h e Requirements f o r t h e Degree o f MASTER OF SOCIAL WORK i n t h e S c h o o l o f S o c i a l Work  A c c e p t e d as c o n f o r m i n g t o t h e s t a n d a r d r e q u i r e d f o r t h e degree o f Master o f S o c i a l Work  S c h o o l o f S o c i a l Work 1965 The U n i v e r s i t y  of B r i t i s h  Columbia  In the  requirements  British  for extensive he  cation without  of my  this  that  and  thesis in partial  by  degree at  the  study.  copying  granted  representatives.  this  advanced  agree  for reference  p u r p o s e s may his  f o r an  Columbia, I  available mission  presenting  the  of  permission.  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r 8, C a n a d a  Columbia,  make i t  f u r t h e r agree  that  freely per-  thesis for scholarly  o f my  I t i s understood  thesis for financial  written  I  of  U n i v e r s i t y of  Library shall  this  Head  the  fulfilment  Department  that.copying  gain  shall  not  or or  be  by publi-  allowed  ABSTRACT  In I960, the Home f o r the Aged, an i n s t i t u t i o n of the P r o v i n c e of B r i t i s h Columbia, underwent an o f f i c i a l name change to V a l l e y v i e w H o s p i t a l . The change i n name i n d i c a t e d a change i n the p h i l o s o p h y toward the treatment of the aged m e n t a l l y i l l person. T h i s change can be equated w i t h new knowledge about the p h y s i c a l , p s y c h o l o g i c a l and s o c i a l aspects of a g i n g . Formerly the program and the g o a l were r e l a t e d to c u s t o d i a l c a r e ; now, the program and the g o a l are r e l a t e d to treatment which w i l l r e s u l t i n the aged m e n t a l l y i l l p a t i e n t r e t u r n i n g to a l i v i n g arrangement i n the community t h a t i s most a p p r o p r i a t e to h i s needs. T h i s study, c i t e s the problems of aged people i n t h i s p r o v i n c e , w i t h p a r t i c u l a r r e f e r e n c e to problems o f mental illness. The p r o c e s s of admission to h o s p i t a l , treatment programs and d i s c h a r g e procedures, p a r t i c u l a r l y as they r e l a t e to the work of the S o c i a l S e r v i c e Department, are d e s c r i b e d . A g a i n s t t h i s background of procedures, the p a r t i c u l a r c r i t e r i a f o r d i s c h a r g e and r e h a b i l i t a t i o n p l a n n i n g , as r e l a t e d to the h o s p i t a l and to the r e s o u r c e s a v a i l a b l e i n the community are examined. P a r t i c u l a r p a t i e n t groups are noted i n r e l a t i o n s h i p to the p a r t i c u l a r resource r e q u i r e d to r e c e i v e them back i n t o community. The study r e v e a l s t h a t , although, u s i n g h o s p i t a l c r i t e r i a f o r d i s c h a r g e , a l a r g e number of p a t i e n t s c o u l d be appropr i a t e l y r e h a b i l i t a t e d , b u t s u f f i c i e n t community r e s o u r c e s , i n c l u d i n g f a m i l y c a r e , b o a r d i n g and n u r s i n g homes, are l a c k i n g f o r such p a t i e n t s . Furthermore, community a t t i t u d e s towards the aged m e n t a l l y i l l person have n o t changed to meet the new p h i l o s o p h y about t h e i r treatment i n V a l l e y v i e w H o s p i t a l . S i n c e correspondence r e v e a l e d t h a t V a l l e y v i e w H o s p i t a l i s unique amongst mental h o s p i t a l s f o r the aged on t h i s c o n t i n e n t , the study was of n e c e s s i t y a p i l o t one, and i s p r i m a r i l y d e s c r i p t i v e . However, the q u e s t i o n n a i r e method was used to gather d a t a about e x i s t i n g l i v i n g accommodation a v a i l a b l e to d i s c h a r g e d p a t i e n t s . F i n a l l y , the study o f f e r s some suggestions f o r improvement and expansion of community r e s o u r c e s , and of l e g i s l a t i o n c o n c e r n i n g them which, i f c a r r i e d out, would ensure, to a g r e a t e r extent, t h a t the p h i l o s o p h y o f treatment and r e h a b i l i t a t i o n , r a t h e r than c u s t o d i a l c a r e , c o u l d be translated into practice.  ACKNOWLEDGEMENTS  T h i s s t u d y has b e e n made p o s s i b l e t h r o u g h t h e u n s t i n t i n g c o o p e r a t i o n and s u g g e s t i o n s o f f e r e d b y many i n d i v i d u a l s . The w r i t e r s , t h e r e f o r e , wish t o o f f e r s i n c e r e thanks to those many p e o p l e who have g i v e n o f t h e i r a d v i c e and t i m e i n o r d e r to c l a r i f y p o i n t s from the i n c e p t i o n o f the study u n t i l t h e f i n a l d r a f t emerged. We w i s h , e s p e c i a l l y , t o a c k n o w l e d g e t h e g e n e r o u s s e r v i c e s o f o u r t h e s i s a d v i s o r , M i s s F r a n c e s A. M c C u b b i n , S c h o o l o f S o c i a l Work, U n i v e r s i t y o f B r i t i s h C o l u m b i a , whose a b i d i n g f a i t h i n and k n o w l e d g e o f t h e aged, s t i m u l a t e d and g u i d e d u s t h r o u g h o u t t h e p r e p a r a t i o n and f i n a l w r i t i n g o f the s t u d y . To D r . J o h n W a l s h , M e d i c a l S u p e r i n t e n d e n t and Mr. L i n d s a y McCormick, S u p e r v i s o r , S o c i a l S e r v i c e Department a t V a l l e y v i e w H o s p i t a l , we w i s h t o e x t e n d o u r t h a n k s f o r t h e i r k i n d assistance. But f o r t h e i r encouragement a t t h e i n c e p t i o n o f t h e s t u d y , t h i s s t u d y may n o t have b e e n p o s s i b l e . Throughout, t h e y have r e m a i n e d a p p r o a c h a b l e when t h e i r h e l p was n e e d e d . Mr. A. I . S m i t h , B u s i n e s s Manager a t V a l l e y v i e w H o s p i t a l has a l s o b e e n m o s t g e n e r o u s o f h i s t i m e and s u g g e s t i o n s throughout the study. M r s . P. W h i t e o f W e l f a r e I n s t i t u t i o n s and Mr. A. R o s e , I n s p e c t o r o f H o s p i t a l s c l a r i f i e d many p o i n t s f o r u s . We w i s h t o e x t e n d o u r t h a n k s t o them. And t o M r s . J . D. A r c h e r , we s a y thank y o u f o r h e r u n f a i l i n g c h e e r f u l n e s s , humour, and t h e t y p i n g o f t h i s s t u d y during her evening hours. F i n a l l y , we w i s h t o a c k n o w l e d g e t h e k i n d n e s s o f many o t h e r i n d i v i d u a l s : t h e s t a f f and p a t i e n t s a t V a l l e y v i e w H o s p i t a l who were w i l l i n g t o t a l k a b o u t t h e i r e x p e r i e n c e w i t h i n t h e h o s p i t a l ; t h e owners a n d o p e r a t o r s o f v a r i o u s b o a r d i n g and n u r s i n g homes who spoke w i t h a c a n d o r and o p e n n e s s about t h e i r p r o b l e m s i n o f f e r i n g a s e r v i c e t o t h e e l d e r l y while t r y i n g to earn a l i v i n g . To t h e s e i n d i v i d u a l s we s a y t h a n k y o u .  TABLE Chapter I .  Problems  OP  CONTENTS  and P o t e n t i a l s o f A g i n g  Introduction. G e n e r a l Problems o f Aging. P o t e n t i a l s of Aging. G e n e r a l Problems o f Aging i n B r i t i s h Columbia. Psychiatric Disorders Among t h e A g i n g i n B r i t i s h C o l u m b i a . Chapter I I .  S c o p e and M e t h o d o f S t u d y  Valleyview Hospital, Geographical L o c a t i o n and D e s c r i p t i o n . T h e Changed P h i l o s o p h y Toward t h e Aged. The S c o p e o f t h e S t u d y . The Method o f S t u d y a n d S o u r c e s o f D a t a . Chapter  III.  A d m i s s i o n , T r e a t m e n t and S e l e c t i o n of P a t i e n t s f o r Discharge.  Admission. Treatment Facilities. Treatment Toward R e h a b i l i t a t i o n . Factors Considered i n D i s c h a r g e . P a t i e n t S e l e c t i o n f o r /Discharge. Chapter  IV.  Discharge C r i t e r i a Resources.  and Community  Discharge R e l a t e d to Resources. V a l l e y v i e w H o s p i t a l C r i t e r i a as R e l a t e d t o R e s o u r c e s . Discharge. Follow-up S e r v i c e s . C h a p t e r V.  Analysis  o f Study  and C o n c l u s i o n s .  Case I l l u s t r a t i o n s . C o n c l u s i o n s and Resources. Valleyview Hospital Discharge C r i t e r i a . Recommendations. Future Research. Appendices:  A. B. C. D.  Bibliography Letters N u r s i n g Form B o a r d i n g and N u r s i n g Home Questionnaire  TABLES IN THE TEXT  Total April  Patients i n Residence, 1, 1963.  Number o f D i s c h a r g e s Made t o E a c h of t h e Resources D u r i n g t h e F i s c a l  Year  196U-65.  Breakdown o f P a t i e n t P o p u l a t i o n by Ward on M a r c h 3 1 , 1965.  PROM CUSTODIAL CARE TO REHABILITATION: THE CHANGING PHILOSOPHY AT VALLEYVIEW HOSPITAL A Study o f Treatment F a c i l i t i e s Discharge Planning and Community Resources A v a i l a b l e f o r the P s y c h i a t r i c G e r i a t r i c P a t i e n t  CHAPTER  I  PROBLEMS AND POTENTIALS OF AGING  Introduction Aging i s a universal process. and gradual.  I t i s a process both slow  I t i s a process which cannot be halted except  by the death of the i n d i v i d u a l . Even with t h i s i n e v i t a b i l i t y , aging has d i f f e r e n t meanings within various human s o c i e t i e s , and the way In which the i n d i v i d u a l prepares f o r his aged period i s p a r t i a l l y decided by the culture i n which he has developed.  The c l a s s i c a l Greek  considered old age as an "unmitigated misfortune" since "many are the i l l s that invade the heart"  1  i n o l d age. On the other  hand, the peasants, i n the high valleys of the Andean regions of  Ecuador, Peru, and B o l i v i a , a f t e r a l i f e of hard t o i l to  gain a subsistence l i v i n g , looked to old age as a time when the aged one assumed a respect and honour not accorded during the e a r l i e r part of l i f e .  This respect and honour i s also given  to  the aged members of the St. Lawrence Island Eskimo whose  1  Slater, P h i l i p E. "Cultural Attitudes Toward the Aged." G e r i a t r i c s , v o l . 18, number k, (April, 1 9 6 3 ) , p.308 Holmberg, A l l a n R. "Age i n the Andes." Aging and Leisure. Oxford University Press, New York, 1961, p . 8 6 - 9 0  2 i s l a n d home i s i n the Bearing Alaska  and  Sea,  w i t h i n s i g h t of S i b e r i a .  expect the aged one  hundred m i l e s  from  These Eskimos, however,  t o c a r r y out tasks which are w i t h i n h i s  c a p a c i t i e s f o r t h e i r philosophy life  one  of l i f e ,  "work i s l i f e  and  i s work", a p p l i e s t o a l l members of t h a t c u l t u r e .  the Eskimos work as long as p o s s i b l e , the Japanese and aged assume new  r o l e s of contemplation and  leisure.  While  1  Burmese  In  the  Japanese case, the aged i n d i v i d u a l r e c e i v e s marked r e s p e c t  2 from other  age groups i n s i d e and  o u t s i d e the f a m i l y .  The  same  r e s p e c t h o l d s t r u e f o r the Burmese aged i n d i v i d u a l , although one  group r e c e i v e s s p e c i a l deference as  tranquility".  "those who  eat i n  T h i s group i s i n r e c e i p t of pensions.3  B a s i c a l l y , t h e r e f o r e , the a t t i t u d e s toward aging f i v e c u l t u r e s c i t e d , w i t h the p o s s i b l e e x c e p t i o n  i n the  of the  Ancient  Greeks, are i n d i r e c t c o n t r a s t t o the a t t i t u d e s which are d i r e c t e d toward the aged i n Canadian s o c i e t y . suggests t h a t the  " c u l t u r e of the modern western world i s  of a c t i o n . . . . A c t i o n ment (and)  ( i s our) means of mastery over our  our means of s e l f e x p r e s s i o n  fulfillment."  One  Charlotte Buhler  as w e l l as  one  environ-  self  of the r e s u l t s of t h i s a t t i t u d e i s a l a c k  k o f time f o r contemplation.  I t i s , then, no  s u r p r i s e to l e a r n  t h a t the aged have l i t t l e wish f o r contemplation s i n c e "people Hughes, Charles C. "The Concept of Time i n the Middle Years: The S t . Lawrence I s l a n d Eskimos." Aging and L e i s u r e . p . 9 " " 9 5 Smith, Robert J . "Japan: The L a t e r Years of L i f e and the Concept of Time.". Aging and L e i s u r e , p . 9 5 - 1 0 0 3 Ruston, C o l l e e n . ' "The L a t e r Years of L i f e and the Use of Time Among the Burmanese." Aging and L e i s u r e , p . 1 0 0 - 1 0 3 1  1  ^  "Meaningful L i v i n g i n the Mature Y e a r s . "  P.3^9  •  Aging and  '  Leisure.  3 who a r e not a c t i v e a r e made t o f e e l u s e l e s s and even worthless".  1  Prom t h i s a t t i t u d e , s p r i n g s many of the d i f f i c u l t i e s  which the aged experience i n Canada. Now a q u e s t i o n a r i s e s .  What i s aging?  Perhaps, Leonard  Z. Breen has g i v e n the best answer when he d e c l a r e s t h a t : "For t h i s w r i t e r aging i s a process of change; i t i s not a state of being. I t i s dynamic. Aging i s not adjustment, p h y s i c a l s t r u c t u r e , or s o c i a l d i s s a t i s faction. I t i s i t s e l f a process without i n h e r e n t q u a l i t i e s of goodness and badness. T h i s continuous change, I s what we i n g e n e r a l may understand as 'aging'.  2  Aging and the i n d i v i d u a l have a u n i t y . a g i n g becomes p a r t o f the l i f e l o n g processes change and e v o l u t i o n .  Prom t h i s i d e a , of development,  A l l these processes a r e known t o  happen s i m u l t a n e o u s l y with r e s p e c t t o a s i n g l e  individual  and a t d i f f e r e n t r a t e s w i t h i n and among i n d i v i d u a l s . p o i n t s suggest  These  t h a t work with the aged should i n c l u d e under-  s t a n d i n g o f the past experience and maturation To l e a v e t h i s important  of the i n d i v i d u a l .  aspect out of the t o t a l c o n s i d e r a t i o n  would c r e a t e a d i s t o r t i o n which would r e s u l t i n f a u l t y when attempting  reasoning  t o e x p l a i n the a c t i o n s o f a g i v e n aged  i n d i v i d u a l a t a g i v e n p o i n t i n time. Perhaps t h i s i s where the d i f f i c u l t y l i e s i n the g e n e r a l Canadian a t t i t u d e .  So o f t e n i t i s e a s i e r t o i g n o r e the  I b i d , p.350 "The Aging I n d i v i d u a l . " The Handbook o f S o c i a l Gerontology, e d i t o r : C l a r k T i b b i t t s , U n i v e r s i t y of Chicago p r e s s , Chicago,  i 9 6 0 , p.147  4 i n d i v i d u a l sufferings of the aged person while understanding the  general problems of the aged group.  As a r e s u l t , fewer  services are supplied to the aged group even though the aged people have thoughts, feelings and impressions which have been sharpened by the struggles of l i f e .  I t might even be suggested  that the aged i n d i v i d u a l i s open to a greater number of problems as a d i r e c t r e s u l t of the c u l t u r a l demands of Canadian Society. In any case, the aged group must either receive equal treatment i n the supplying of services, or be considered as a minority group with a l l of the lack of understanding, stereotyping and prejudice that such a term implies. As more aged individuals swell the Canadian population, there w i l l grow a stronger demand f o r services i n a l l aspects of l i v i n g from increased pensions to more, and more adequate housing and l i v i n g arrangements.  A projection of the aged  population numbers i s suggested by Dr. Schevenger.  He declares  there w i l l be more than two m i l l i o n Canadians over the age of s i x t y - f i v e by I 9 8 O .  1  This does not seem to indicate any change  i n the l i f e span of the i n d i v i d u a l , only a greater number of "people...living...out t h e i r expected l i f e span". can  Thus, i t  be expected, as the aged population increases, the demands  from t h i s group f o r more services w i l l become more i n s i s t e n t . Gn the one hand, the aged population increases while, on the 1  2  other hand, Canadians, i n general, seem to maintain a somewhat "How Shall the Aging L i f e . " Canadian Welfare, v o l . 4 0 , number 5 , (September / October, 1 9 6 4 ) , p.208 Towards Better Understanding of the Aged. Seminar at Aspen, Colorado, September, 1958, p.10  5 negative view of o l d age. held?  Why should such a negative view be  Might the answer l i e i n the way our society i s geared to  action?  Sustained action requires the v i t a l i t y of youth, and  so i t i s assumed that the o l d person cannot offer much to society because he lacks the v i t a l i t y and quickness of youth. Such an attitude i s an unfortunately narrow one. the  Although  aged may lack a sustained v i t a l i t y , they are able to offer  many other useful contributions to Canadian society.  Accumu-  lated l i f e experience and the reasoned decisions which can accompany such l i f e experience, hint at the usefulness, the productivity, of older people which remain untapped by Canadian communities. Perhaps the negative view can be traced to another general difficulty  f o r the aged.  In the past f i f t y years, at least,  great changes have advanced Canada i n many d i f f e r e n t ways, f o r example, i n d u s t r i a l i z a t i o n .  So great are the changes that  a v i s i t o r from f i f t y years ago would scarcely recognize h i s country.  These changes were hastened by the Great Depression  of the 1 9 3 0 ' s and by two World Wars.  As a r e s u l t , the present  aged group has passed through a period of rapid changes which has forced them to make a t r a n s i t i o n from the l i f e of t h e i r past experience, that i s , farms, small towns, a more leisured pace of l i f e , to a l i f e which i s c h i e f l y spent i n urban areas with the crowds, t r a f f i c and a fast pace of l i f e .  The  t r a n s i t i o n seems to have l e f t the present aged population i l l prepared to meet the new demands of modern Canadian society.  6 I n t h i s sense, the present n e g a t i v e view of the aged may  be  justified. N e v e r t h e l e s s , whether condemnation or p i t y i s g i v e n t o the aged group, t h e r e remain many problems which the aged i n d i v i d u a l f a c e s when he must make t h i s t r a n s i t i o n . of t h i s d i f f i c u l t y ,  In l i g h t  i t seems wise to d i s c u s s b r i e f l y a  few  o f these problems, always b e a r i n g i n mind t h a t , although problems are e v i d e n t , t h e r e remains another of a g i n g .  these  s i d e : the p o t e n t i a l s  T h i s balanced view i s e s s e n t i a l because aging i s not  a t o t a l problem a r e a .  I t a l s o r e t a i n s a promise which t h i s  s o c i e t y has not y e t c o n s i d e r e d of v a l u e t o any g r e a t degree. There f o l l o w s , then, a b r i e f d i s c u s s i o n of these problems; absence of c l e a r l y d e f i n e d r o l e s , i s o l a t i o n ,  economic  i n s u f f i c i e n c y , r e t i r e m e n t , and h e a l t h .  General Problems of Aging (l)  Absence of C l e a r l y Defined R o l e s . In g e n e r a l , the aged i n d i v i d u a l has no guide  t o i n d i c a t e the r o l e s to be assumed a f t e r the age Cavan (et a l ) o u t l i n e s t h i s  of  lines  sixty-five.  difficulty:  "The s o c i e t a l p a t t e r n f a i l s t o d e f i n e c l e a r l y what the r o l e of the o l d person i s w i t h r e f e r e n c e t o other age groups or w i t h i n the o l d groups. T h i s f a i l u r e i s e s p e c i a l l y marked i n the case of the o l d man, whose r o l e was previously closely related to h i s F o r purpose of t h i s t h e s i s , the age of s i x t y - f i v e has been s e l e c t e d as the b e g i n n i n g of t h a t time i n l i f e known as the aged p e r i o d .  7 employment and his position as chief wage earner i n the family. For the old married woman, the s h i f t of r o l e i s less marked. In f a c t , such a s h i f t may never be necessary i f she i s able to maintain her position as manager of her house." 1  This absence of c l e a r l y defined r o l e s f o r the aged reinforces the f a c t that Canadian society expects very l i t t l e i n the way of a contribution from the aged i n d i v i d u a l .  Gn the  other hand, action i s stressed as an e s s e n t i a l ingredient to contentment and success.  I t i s not surprising,  therefore,  that the aged i n d i v i d u a l gains the strong impression that he i s useless and worthless and cannot contribute country.  any s k i l l to his  I t might be speculated that t h i s basic  conflict  causes many of the emotional problems i n old age. (2)  Isolation Each i n d i v i d u a l needs i n t e r a c t i o n with other  i n d i v i d u a l s for both support and mental stimulation. health can only be maintained i f s a t i s f y i n g  Mental  interpersonal  r e l a t i o n s h i p s are available f o r everyone. This i s especially true f o r the aged who face inevitable readjustment d i f f i c u l t i e s as loved ones die, or move away or r e t i r e and as loss of health threatens. under these conditions,  To make new friends  might prove to be an overwhelming  s t r a i n which the e l d e r l y person i s unable to t o l e r a t e .  Then  again, there might be resentment toward younger age groups. 1  Cavan, Ruth S.; Burgess, E. W.; Havighurst, R. S.; and Goldhamer, H. "Personal Adjustment i n Old Age." p.23, reported by. Williams, Richard H. "changing Status, Roles, and Relationships." Handbook on Social Gerontology, p.276  8 These issues could drive the aged i n d i v i d u a l into a sense of i s o l a t i o n heightened by loneliness. (3)  Economic Insufficiency An adequate income i s essential to meet the d a i l y  maintenance needs of each i n d i v i d u a l .  Prom income the  i n d i v i d u a l i s able to provide adequate food, housing, clothing, medical attention and recreation. If these ideas regarding income are applied to the aged, i t can be r e a d i l y seen how anxiety and stress are created i n the i n d i v i d u a l aged person who must exist on an inadequate income.  Coupled with the fact that physical and psychological  reserves may be low, such stress can be so overwhelming that breakdown of various types can r e s u l t . problem i n t h i s  Williams sums up the  way: "Thus, i n general, older people seem to be notably disadvantaged i n terms of wealth or i n t h e i r command over scarce means. This, i n turn, placed r e s t r i c t i o n s on the type of s o c i a l systems i n which they can p a r t i c i p a t e . However, i t must be remembered that t h i s problem tends to be cumulative with others and to be acutely concentrated i n c e r t a i n groups. When i t i s combined with poor health, loss of power, prestige and recognition through loss of employment, and loss of emotional response through death of a spouse and friends, the problem can indeed become acute." 1  Williams, Richard H. "Changing Status, Roles and Relationships." Handbook on S o c i a l Gerontology, p.280  9 (k)  Retirement The  problem of r e t i r e m e n t i n Canadian s o c i e t y  continues t o r e c e i v e a g r e a t d e a l of c r i t i c a l a t t e n t i o n from many q u a r t e r s . in  The reason f o r t h i s can be found, perhaps,  the f a c t t h a t r e t i r e m e n t a f f e c t s v i r t u a l l y every  man  and woman and,  t h e r e f o r e , poses a t h r e a t to the  i n d i v i d u a l ' s known way retirement  employed  of l i f e .  As Dr. Tyhurst  notes,  i n v o l v e s change or t r a n s i t i o n , bereavement or g r i e f ,  l o s s of a c t i v i t y , degree of s o c i a l i s o l a t i o n , l o s s of income and  changes i n s o c i a l s t a t u s . Since r e t i r e m e n t may  a c t i v e t o a l e i s u r e l y way  1  f o r c e an aged i n d i v i d u a l from an of l i f e ,  an a l r e a d y t h r e a t e n i n g s i t u a t i o n . l e i s u r e time?  a c o m p l i c a t i o n i s added t o How  w i l l the person  use h i s  T h i s q u e s t i o n must be asked and answered, i f  p o s s i b l e , by the i n d i v i d u a l about t o r e t i r e .  I f he i s f o r -  tunate enough t o r e t i r e t o other work, i t can be presumed t h a t his  adjustment w i l l not be g r e a t , f o r h i s whole way  i n c l u d i n g t r a i n i n g , i s geared toward a l i f e U n f o r t u n a t e l y , those who  r e t i r e to a l i f e  of  life,  of work.  of l e i s u r e  without  p r e p a r a t i o n are f a c e d with g r e a t adjustments f o r which t h e i r life  work and e d u c a t i o n gave them l i t t l e p r e p a r a t i o n .  l a t t e r group may  s u f f e r emotional  problems.  Because r e t i r e m e n t poses such an emotional might be a need f o r r e t i r e m e n t 1  This  strain,  counselling to help  there  the  Tyhurst, J . S. "Retirement". Neurologic and P s y c h i a t r i c Aspects of the D i s o r d e r s of A g i n g . ( e d s . ) Joseph E. Moore (et a l ) , v o l . XXXV of the A s s o c i a t i o n f o r Research i n Nervous and Mental D i s o r d e r s , W i l l i a m s and W i l k i n s , B a l t i more, 1955, p.237-242  10 I n d i v i d u a l t o p l a n c a r e f u l l y f o r . t h e day he l e a v e s h i s work. How such a program would be prepared and whether p r o f e s s i o n a l l y t r a i n e d p e r s o n n e l would be needed i s beyond the scope of t h i s thesis.  N e v e r t h e l e s s , the a d o p t i o n o f such a program might  pay d i v i d e n d s through r e d u c t i o n of s t r e s s and a n x i e t y a s s o c i a t e d with retirement. develop t h i s (5)  Some day, Canadians may have t o c o n s i d e r and  idea.  Health There have been many advances and d i s c o v e r i e s i n the  field  of medicine.  These have r e s u l t e d i n a good h e a l t h  s t a n d a r d f o r most people i n Canada; they have r e s u l t e d i n lower death r a t e s among b a b i e s ; they have r e s u l t e d i n more e l d e r l y people l i v i n g l o n g e r .  But many of t h e areas i n  medicine which have not advanced a r e i n those v e r y areas o f i l l n e s s which plague i n d i v i d u a l s as they grow o l d e r . suggested, t h e r e f o r e ,  It i s  that:  "Medical advances by and l a r g e have been b e n e f i c i a l i n t h e f i e l d of a c t i v e b a c t e r i a l a i l m e n t such as Smallpox, D i p t h e r i a , and Cholera, Pneumonia and Menning i t i s - but c h r o n i c rheumatism, d e g e n e r a t i v e d i s e a s e s of the h e a r t and b l o o d v e s s e l s and s e n i l e mental d i s o r d e r s have remained untouched by modern d i s c o v e r i e s and w i t h l a r g e numbers of o l d people i n the community t h e i r t o t a l i n c i d e n c e i s h i g h e r than ever." 1  H e a l t h , t h e r e f o r e , can become a problem of c o n s i d e r a b l e Andrews, C. T. "The Problems of the Aged." S o c i a l Problems. A Canadian P r o f i l e .  11 c o n c e r n t o t h e aged p e r s o n .  I t i s a t t h i s p e r i o d i n l i f e when  he i s more s u s c e p t i b l e t o the d e g e n e r a t i v e d i s e a s e s , b o t h p h y s i c a l and m e n t a l .  To f a c e t h e p r o s p e c t o f r e c o v e r i n g from  an i l l n e s s which has a f f e c t e d t h e p e r s o n a d v e r s e l y , can cause p s y c h o l o g i c a l d i s t u r b a n c e s of v a r y i n g s e v e r i t y . be combatted  How  t h e s e can  depends p a r t l y on t h e s k i l l of t h e m e d i c a l d o c t o r  and p a r t l y on t h e amount of p h y s i c a l r e s e r v e s which t h e o l d e r i n d i v i d u a l can draw on a t t h e time of h i s i l l n e s s .  Also, i t  has been suggested t h a t " o l d p e o p l e a r e more d e p r e s s e d  and  d i s t u r b e d by i l l n e s s t h a n younger p e o p l e because of t h e i r d i m i n i s h e d body r e s e r v e s and because o f our s o c i e t y ' s emphasis on y o u t h . "  1  Many o t h e r problems  can f a c e t h e aged i n d i v i d u a l , r a n g i n g  from f e a r and u n c e r t a i n t y of t h e f u t u r e t o d i f f i c u l t i e s w i t h relatives.  N e v e r t h e l e s s , t h e a g i n g p r o c e s s cannot  c o n s i d e r e d i n t o t a l as a problem p e r i o d . problems  be  I t i s granted that  can e x i s t , as b r i e f l y d i s c u s s e d above, and as amply  e x p l o r e d i n the growing amount of l i t e r a t u r e on the s u b j e c t . But t h e r e i s a g r a d u a l i n c r e a s e i n emphasis upon a g i n g as a p e r i o d of p o t e n t i a l s .  T h i s more b a l a n c e d v i e w o f a g i n g  s u g g e s t s t h a t a new p h i l o s o p h y i s b e g i n n i n g t o permeate t h e f i e l d of g e r o n t o l o g y . ^ 1  2  Bonner, Judy (ed) The Word i s Hope. An I n s t i t u t e on R e h a b i l i t a t i o n of t h e A g i n g , A u s t i n , Texas, 1961, P«5 G e r o n t o l o g y , i n t h i s sense, r e f e r s t o the s t u d y of o l d p e r s o n s as suggested by E n g l i s h , Horace B. and E n g l i s h , Ava C. A Comprehensive D i c t i o n a r y of. P s y c h o l o g i c a l and Psychoa n a l y t i c a l Terms. Longman, Green & Co., New York, 1958.  12  P o t e n t i a l s of Aging As knowledge i n c r e a s e s , t h e r e i s an i n c r e a s i n g awareness o f the p o t e n t i a l s of a g i n g .  T h i s i s , perhaps, best noted i n  the wealth of l i t e r a t u r e r a n g i n g from the "popular" w r i t i n g s t o l a r g e c o m p i l a t i o n s o f present day knowledge about  aging.  J o u r n a l s a r e devoted t o the s u b j e c t and cover every aspect o f a g i n g from m e d i c a l s t u d i e s t o s o c i o l o g i c a l and a n t h r o p o l o g i c a l data.  T h i s accumulation of knowledge i n the l i t e r a t u r e  strongly  suggests the waste i n a l l o w i n g the aged p o p u l a t i o n t o underproduce  i n a myriad o f ways f o r themselves  and hence f o r  society. Much o f t h i s knowledge i s beginning t o r e a c h the g e n e r a l p u b l i c who a r e b e g i n n i n g t o respond through the development of c l u b s f o r e l d e r l y people i n v a r i o u s communities, as a means of r e l i e v i n g the sense of i s o l a t i o n experienced by the aged as l o v e d ones and c l o s e f r i e n d s d i e .  A better step i n t h i s  d i r e c t i o n might be seen i n the f u n c t i o n a l community c e n t r e s which o f f e r multipurpose a c t i v i t i e s f o r most age groups. type of development holds a promise  This  o f communication between  the v a r i o u s age groups and l a t e r may be a means of welding the experience o f age w i t h the v i t a l i t y o f youth.  A further  b e n e f i t c o u l d be found i n the development of new r o l e s f o r the aged w i t h i n these c e n t r e s through the aged a c t i n g as l e a d e r s f o r some of t h e c h i l d r e n ' s and young a d u l t s '  groups.  Other s i g n s o f p u b l i c i n t e r e s t a r e evidenced i n the g r a d u a l i n c r e a s e i n pensions, and w i t h the pensions approp-  13 r i a t e l y planned In r e l a t i o n t o the c o s t - o f - l i v i n g income d e f i c i e n c i e s may  index,  disappear t o a l a r g e extent.  of course, means b e t t e r food,  This,  enough c l o t h i n g and more adequate  housing, a l l of which would r e s u l t i n a b e t t e r l e v e l of good h e a l t h and  wellbeing.  These changed a t t i t u d e s on the p a r t of the p u b l i c suggest a more p o s i t i v e p h i l o s o p h y senses.  of aging which the aged group  T h i s encourages the e l d e r l y t o b e g i n wondering about  the growing o p p o r t u n i t i e s f o r l e a v i n g t h e i r mark on  society.  Kenneth Duncan emphasizes t h a t the "aged seem i n c r e a s i n g l y t o conclude t h a t age means o p p o r t u n i t y the c r e a t i o n of a new  to undertake f o r themselves  place i n s o c i e t y . "  t h a t people want t o h e l p ,  1  He goes on t o argue  t h e r e f o r e , the aged must somehow  " c a p i t a l i z e on t h i s unprecedented i n t e r e s t and h e l p , while i t e x i s t s . "  willingness  2  In s p i t e of t h i s e v i d e n t  i n t e r e s t i n the aging,  r e t a i n s a fundamental ambivalence toward the aged.  society On the  hand, they are seen as f i g u r e s of a u t h o r i t y while on the hand, they are viewed as dependent and  might be a swing toward the former view, y e a r s ahead, i t i s not i n c o n c e i v a b l e  2 3  other  that  " i n the  there  immediate  t h a t the o l d e r person  be more f u l l y equated with a u t h o r i t y . " 3  may  What t h i s means i n  "Modern S o c i e t i e s A t t i t u d e Toward A g i n g . " v o l . 18, number 8, (August, 1 9 6 3 ) , p.635 . 1  one  childlike individuals.  A f t e r p o i n t i n g t h i s out, Jerome Kaplan d e c l a r e s  1  to  Geriatrics.  Loc. c i t . "New T h e o r i e s A f f e c t i n g G e r i a t r i c S o c i a l I n s t i t u t i o n s . " G e r i a t r i c s , v o l . 17, number 3 , (March, 19^2), p.171  Ik terms of the Canadian c u l t u r e i s i m p o s s i b l e t o p r e d i c t today. The aged i n d i v i d u a l does have c e r t a i n advantages when compared the  w i t h the younger age groups.  As an example,  consider  f a c t t h a t the aged have r e l a t i v e l y f r e e time f o l l o w i n g  t h e i r retirement.  One of the q u e s t i o n s which the r e t i r i n g  person must c o n s i d e r i s what he plans to do with h i s time f o l l o w i n g the f i n a l day of h i s work.  I t i s suggested t h a t aged  i n d i v i d u a l s can c a p i t a l i z e on the f r e e time and use i t t o t h e i r own  c o n s t r u c t i v e advantage, i n c l u d i n g the development of  meaningful hobbies, the change t o new work, or i n any other c o n s t r u c t i v e way which w i l l s a t i s f y the aged i n d i v i d u a l .  Once  t h i s s a t i s f y i n g a c t i v i t y i s found f o r the r e t i r e m e n t years^ the aged i n d i v i d u a l can remain a contented, s a t i s f i e d  citizen.  T h i s aspect a l s o has d i r e c t i m p l i c a t i o n s f o r b e t t e r mental health.  The aged i n d i v i d u a l who keeps a c t i v e , as the c u l t u r e  demands, continues t o have an i n t e r e s t i n l i f e .  One survey  even suggested t h a t an a c t i v e i n t e r e s t i n community l i f e  aids  the  aged i n d i v i d u a l t o remain h e a l t h i e r m e n t a l l y than i s usual  for  the p o p u l a t i o n as a whole. Still,  1  i n s p i t e of these p o t e n t i a l s , the aged must  continue t o f a c e f o r some time the pervading community tude t h a t the aged, i n g e n e r a l , have reached t h e i r y e a r s and a r e , t h e r e f o r e , of l i t t l e  use t o s o c i e t y .  takes i s s u e with t h i s i d e a when he argues t h a t : 1  Bonner, Judy  (ed) The Word i s Hope, p.5  atti-  declining Tibbitts  15 "ideas abound t h a t a person undergoes growth u n t i l middle age then g r a d u a l l y d e c l i n e s i n a l l f a c u l t i e s u n t i l death. (This i s ) not n e c e s s a r i l y t r u e . (There a r e ) d i f f e r e n t q u a l i t i e s of (the) human organism (which) have d i f f e r e n t r a t e s of a c h i e v i n g the prime l e v e l , e.g. p h y s i c a l a b i l i t i e s may d e c l i n e . a f t e r middle age, y e t i n t e l l e c t u a l f u n c t i o n s may g r a d u a l l y i n c r e a s e u n t i l very o l d age." 1 The  two s i d e s o f aging d i s c u s s e d  so f a r , the problems and  p o t e n t i a l s , p l a c e the aged i n a new l i g h t . suggestion,  There i s a  a l s o , o f a t h r e e dimensional view, as s o c i e t y  begins t o c o n s i d e r how best t o a l l o w the aged t o take p a r t i n a c t i v e l i f e which adds g r e a t l y t o the r e s o u r c e s  o f Canada.  Perhaps T i b b i t t s concludes t h i s i d e a as w e l l as any w r i t e r when he suggests "that a p o p u l a t i o n with a s i z e a b l e p o r t i o n o f the persons s u r v i v i n g beyond t h e i r 6.5th b i r t h d a y preserves  mental  and p h y s i c a l a b i l i t i e s which add immeasurably t o the i n t e l l e c t u a l and m a t e r i a l wealth o f the community." Now t h a t b r i e f c o n s i d e r a t i o n has been g i v e n t o the problems and p o t e n t i a l s o f aging  i n g e n e r a l , the f o c u s can be narrowed  t o c o n s i d e r the aged i n the Province  of B r i t i s h  Columbia.  T i b b i t t s , C l a r k . " S o c i a l Gerontology." G e r i a t r i c s , v o l . 15, number 10, (October, i 9 6 0 ) , p . 7 0 9 . Loc. c i t .  i6  G e n e r a l Problems o f A g i n g i n B r i t i s h Columbia The Lower M a i n l a n d  1  and Vancouver I s l a n d i s b l e s s e d w i t h  a temperate c l i m a t e which encourages t h e growing o f f l o w e r s from F e b r u a r y  t o November.  seems t o draw p e o p l e ,  I t i s t h i s . t y p e o f c l i m a t e which  i n c l u d i n g t h e aged, t o t h i s  area.  S t a t i s t i c s seem t o p o i n t up t h i s a s s u m p t i o n a l t h o u g h t h e w r i t e r s a r e n o t aware o f any s t u d i e s t h a t p r o v i d e c o n c l u s i v e evidence. Vancouver I s l a n d has a p o p u l a t i o n o f 2 9 1 , 0 0 0 Lower M a i n l a n d has 8 6 6 , 2 0 0 p e o p l e .  2  while the  The t o t a l i s 1 , 1 5 7 , 2 0 0 .  By way o f comparison, Canada's t o t a l p o p u l a t i o n i s 1 8 , 2 3 8 , 2 0 0 and B r i t i s h Columbia's i s 1 , 6 2 9 , 0 0 0 . The aged p o p u l a t i o n o f s i x t y - f i v e and up a r e c o n s i d e r a b l y l e s s i n t h e t o t a l p o p u l a t i o n but they n e v e r t h e l e s s a significant  group o f p e o p l e .  Vancouver I s l a n d has 3 5 * 9  o f them w h i l e t h e Lower M a i n l a n d has 9 9 * 9 t o t a l o f 135,800 aged c i t i z e n s .  represent  0 0  0 0  w h i c h makes a  A g a i n , a s a means f o r  comparison, Canada has 1 , 3 9 2 , 1 0 0 aged and B r i t i s h Columbia has 165,600. 1  p  The Lower M a i n l a n d i n c l u d e s t h e F r a s e r R i v e r V a l l e y from Vancouver t o Hope and f r o m t h e U n i t e d S t a t e s B o r d e r t o t h e mountains on t h e n o r t h s i d e o f t h e F r a s e r R i v e r . The V a l l e y i s a p p r o x i m a t e l y 100 m i l e s l o n g by 15 m i l e s a t t h e w i d e s t p o i n t . Vancouver I s l a n d i s a p p r o x i m a t e l y iho m i l e s l o n g by 60 wide. A l l f i g u r e s a r e a p p r o x i m a t e and have been rounded o u t t o t h e n e a r e s t z e r o s f o r ease o f c a l c u l a t i o n . The f i g u r e s were o b t a i n e d from t h e Government o f Canada Census T r a c t s , 1961; B. C. Government's Department o f S o c i a l W e l f a r e Annual R e p o r t , 1964; and B. C. Government's Annual Budget, 1965.  IT When t h e s e f i g u r e s a r e a s s e s s e d and c a l c u l a t e d  into  p e r c e n t a g e s , ^ some i n t e r e s t i n g f a c t s a r e r e v e a l e d w i t h r e f e r e n c e t o t h e p o p u l a t i o n s p r e a d i n B r i t i s h Columbia. example, B r i t i s h Columbia's  For  general population i s eight percent  of Canada's p o p u l a t i o n . Y e t , s i x p e r c e n t o f t h a t e i g h t p e r c e n t r e s i d e i n t h e Lower M a i n l a n d and on Vancouver I s l a n d .  The  f i g u r e s a r e even more s t a r t l i n g when i t i s known t h a t t h i s s i x p e r c e n t r e p r e s e n t s seventy-one population of B r i t i s h  percent of the t o t a l  Columbia.  The aged p o p u l a t i o n assumes s i m i l a r  characteristics.  Twelve p e r c e n t o f Canada's aged p o p u l a t i o n r e s i d e i n B r i t i s h Columbia.  Of t h a t t w e l v e p e r c e n t , n i n e p e r c e n t l i v e w i t h i n  t h e Lower Mainland-Vancouver  Island area.  This nine percent  r e p r e s e n t s e i g h t y - t w o p e r c e n t o f B r i t i s h Columbia's population.  t o t a l aged  I n o t h e r words o n l y e i g h t e e n p e r c e n t o f t h e aged  l i v e o u t s i d e o f t h e Lower Mainland-Vancouver w i t h i n the boundries of B r i t i s h  I s l a n d a r e a and  Columbia.  These f i g u r e s prove i n t e r e s t i n g when a c o n t r a s t i s made between t h e aged p o p u l a t i o n and t h e t o t a l p o p u l a t i o n . F o r example, seven p e r c e n t o f t h e t o t a l Canadian p o p u l a t i o n i s s i x t y - f i v e and up whereas B r i t i s h Columbia's i s t e n percent of i t s t o t a l p o p u l a t i o n .  This  aged p o p u l a t i o n comparison  between t h e two f i g u r e s , t h a t i s seven p e r c e n t f o r Canada and t h e t e n p e r c e n t f o r B r i t i s h Columbia,  indicates the greater  p r o p o r t i o n o f aged i n B r i t i s h Columbia when compared t o t h e r e s t o f Canada. 1  A l l percentages a r e approximate.  18 Comparing the f i g u r e s f u r t h e r , r e v e a l s t h a t the Lower Mainland-Vancouver I s l a n d area has  e i g h t percent  p o p u l a t i o n as compared with the t e n percent p r o v i n c e of B r i t i s h Columbia. percent  f o r the whole  Thus, as r e v e a l e d , only  two  of the t o t a l aged p o p u l a t i o n l i v e s w i t h i n the border  of B r i t i s h Columbia and Island  of the aged  o u t s i d e the Lower Mainland-Vancouver  area.  What do these f i g u r e s r e v e a l ?  There i s a l a r g e r  propor-  t i o n of the aged p o p u l a t i o n i n the Lower Mainland-Vancouver I s l a n d area of B r i t i s h Columbia than i n the whole of Canada. I t would f o l l o w , then,  t h a t t h i s lower south-western  corner  of B r i t i s h Columbia has a l a r g e r p r o p o r t i o n of the problems of the aged such as: i s o l a t i o n , r e t i r e m e n t and h e a l t h .  economic  insufficiency,  I t f o l l o w s , too, t h a t the demand f o r  s e r v i c e s f o r the aged would be g r e a t e r than elsewhere. further result  A  would be an i n c r e a s e d demand f o r monetary a i d  from l o c a l governments. On the other hand, q u e s t i o n s remaining  e i g h t e e n percent  could be asked about the  of the t o t a l aged p o p u l a t i o n i n  the remainder of B r i t i s h Columbia.  Since t h e r e i s a l a r g e r  p o p u l a t i o n of younger age groups i n other c e n t r e s i n B r i t i s h Columbia, there may  be a g r e a t e r number of s e r v i c e s f o r  age groups r a t h e r than i n c l u d i n g the aged groups i n the service pattern.  And  these overall  again, the f i g u r e s c o u l d suggest a  s c a t t e r i n g of the aged p o p u l a t i o n with r e s u l t a n t i n c r e a s e d problems i n  isolation.  19 S i n c e B r i t i s h Columbia then has as r e s i d e n t s a h i g h p r o p o r t i o n of Canada's e l d e r l y people,  and  since i t i s  r e c o g n i z e d t h a t t h e r e are problems r e l a t e d t o o l d age, i t would f o l l o w t h a t mental i l l n e s s i n t h i s age  group would be  more p r e v a l e n t i n B r i t i s h Columbia than i n other p a r t s of Canada.  T h i s i s d i f f i c u l t t o document and,  i m p o s s i b l e to document i n d e t a i l .  i n f a c t , may  be  However, whether the  i n c i d e n c e of mental i l l n e s s can be documented or not,  the  f a c t remains t h a t many aged i n d i v i d u a l s do s u f f e r from mental i l l n e s s e s and are admitted  to Valleyview Hospital f o r t r e a t -  ment .  P s y c h i a t r i c D i s o r d e r s Among the Aging  in British  Columbia  P s y c h i a t r i c d i s o r d e r s among the aging, i n c l u d i n g the complex causes l e a d i n g t o these d i s o r d e r s , a r e not w e l l known t o or understood  by the g e n e r a l p u b l i c .  In f a c t , t h e r e  exists  c o n s i d e r a b l e f e a r of such i l l n e s s e s which these w r i t e r s have found p r e v a l e n t d u r i n g the t o u r s conducted f o r the p u b l i c at V a l l e y v i e w H o s p i t a l . r o o t e d i n a g e n e r a l ignorance  general  Much of t h i s f e a r might  about mental i l l n e s s but  be there  might be an added f a c t o r i n s o f a r as the mental i l l n e s s of the aged i s concerned. P s y c h i a t r y has developed  c o n s i d e r a b l e knowledge about  p s y c h i a t r i c i l l n e s s e s of the aged. developes and p r o g r e s s e s , causing c o n f u s i o n .  As t h i s knowledge  the names of the i l l n e s s e s change  To the person  unversed i n p s y c h i a t r i c  20 terminology such terms as " s e n i l e dementia" and t i c b r a i n d i s e a s e " are incomprehensible  and,  "arteriosclero-  hence f r i g h t e n i n g .  In view of t h i s c o n f u s i o n i n terminology another must be taken f o r the purposes  of t h i s t h e s i s .  approach  Rather  than  d e s c r i b i n g i n d e t a i l the v a r i o u s p s y c h i a t r i c d i s o r d e r s a s s o c i a t e d w i t h the aging process, the aged person's  illness  w i l l be c o n s i d e r e d from the S o c i a l Worker's p o i n t of view, t h a t i s , i n terms of i t s s o c i a l s i g n i f i c a n c e . aged person's symptoms?  breakdown?  How  d i d he r e a c t ?  What caused  the  What were the  What i s the person l i k e i n p e r s o n a l i t y ?  What i n  h i s background might have p a r t i c u l a r b e a r i n g on the present illness?  These and a myriad  of other s o c i a l q u e s t i o n s  asked  i n the l i g h t of the aged p a t i e n t ' s h i s t o r y o f f e r data t o the p s y c h i a t r i s t who  d i a g n o s i s the i l l n e s s .  T h i s d i a g n o s i s must  not d e t r a c t the S o c i a l Worker from the s o c i a l aspects of the patient.  These s o c i a l a s p e c t s make the aged p a t i e n t an  i n d i v i d u a l among aged i n d i v i d u a l s w i t h i n the h o s p i t a l To understand  a little  setting.  about the p s y c h i a t r i c d i s o r d e r s  among the aging, t h e r e must be a b e g i n n i n g somewhere. b e g i n n i n g must be found i n the causes.  This  Such i l l n e s s e s are  "induced by a complex of c h r o n i c poor p h y s i c a l h e a l t h , e n f o r c e d i d l e n e s s , reduced  income, l a c k of s o c i a l o u t l e t s  (social  obsolescence) and other emotional, p s y c h o l o g i c a l and environmental 1  s t r e s s e s p e c u l i a r t o o l d e r people i n our  culture."  Caufrey, Eugene A. and G o l d s t e i n , Marcus S. "The H e a l t h S t a t u s of Aging People." Handbook of S o c i a l . G e r o n t o l o g y . p.184 . .  21 Attached t o the understanding of the causes of these d i s o r d e r s , t h e r e must be as much understanding of the persona l i t y as p o s s i b l e . background  T h i s i n c l u d e s some knowledge of the  of the aged person who  i s m e n t a l l y i l l f o r should  "an aged person become m e n t a l l y i l l , h i s behaviour w i l l on h i s c h a r a c t e r throughout  life.  emotional problems throughout t i o n s of them i n advanced  A person who  life  years."  has  depend  had  w i l l evidence m u l t i p l i c a 1  I t i s w i t h i n an understanding of these two a s p e c t s , t h a t is,  the causes of the breakdown and the aged i n d i v i d u a l ' s  p e r s o n a l i t y , t h a t a d i a g n o s i s can be developed by the psychiatrist.  Prom t h i s d i a g n o s i s , treatment i s suggested.  S u c c e s s f u l treatment means t h a t the p a t i e n t i s r e t u r n e d t o a former l e v e l of good h e a l t h which i s a p p r o p r i a t e t o the p a r t i c u l a r age of the p a t i e n t .  Treatment  may  be s u c c e s s f u l f o r  " t h e r e i s evidence t o support the c l a i m t h a t , g i v e n a p p r o p r i a t e treatment and r e l i e f from major environmental s t r e s s , many aged p a t i e n t s can be r e s t o r e d t o a s t a t e of mental normal  f o r t h e i r age."  2  T h i s i s the hope a t V a l l e y v i e w H o s p i t a l .  To o f f e r  hope t o the p s y c h i a t r i c g e r i a t r i c p a t i e n t , 3 a team of  health  this  comprised  P s y c h i a t r i s t , M e d i c a l S t a f f , S o c i a l Workers, O c c u p a t i o n a l  T h e r a p i s t s , and other s t a f f a l l cooperate t o g i v e a s e r v i c e to  t h i s type of p a t i e n t of whom t h e r e are a g r e a t many.  1  The Word i s Hope,  2  Ibid,  3  Aged p s y c h i a t r i c a l l y i l l p a t i e n t .  p.5  p.184  For  22 example, V a l l e y v i e w H o s p i t a l had seven hundred and f o r t y - o n e p a t i e n t s i n r e s i d e n c e a t the end o f March 2>1, 1^6k,  1  There i s a growing b e l i e f t h a t t h e aged p s y c h i a t r i c p a t i e n t can respond Coupled  t o treatment  i f t h e treatment  i s g i v e n e a r l y enough.  w i t h t h i s b e l i e f , i s t h e b e l i e f t h a t mental h o s p i t a l s  f o r t h e aged should have "open door" p o l i c i e s t o a l l o w t h e ambulatory aged p a t i e n t t o come and go a t w i l l about t h e grounds o f the h o s p i t a l . custody  Also r e l a t e d , i s the b e l i e f that  i s not necessary f o r t h e aged p a t i e n t d u r i n g the  remainder o f h i s n a t u r a l l i f e .  As a r e s u l t  of these  f a i r l y r e c e n t i n o r i g i n , a l l the V a l l e y v i e w s t a f f  beliefs,  considers  t h a t a p a t i e n t should be d i s c h a r g e d from t h e h o s p i t a l as soon as he has made a s a t i s f a c t o r y response  t o treatment  appropriate  t o h i s age. No l o n g e r w i l l t h i s i n s t i t u t i o n a c t as a t o t a l custody  unit.  toward a g i n g .  A l l o f these p o i n t s suggest  a new p h i l o s o p h y  This philosophy i s r e f l e c t e d a t Valleyview  H o s p i t a l and w i l l be enlarged upon i n the succeeding  I j 6 k Annual Report. Mental B r i t i s h Columbia, p.10  chapters.  Health Services, Province of  CHAPTER  II  SCOPE AND METHOD OF STUDY  I n Chapter I some o f t h e problems and p o t e n t i a l s o f t h e aged p e r s o n , g e n e r a l l y , were examined; p a r t i c u l a r a t t e n t i o n was t h e n f o c u s e d on t h e m e n t a l l y i l l B r i t i s h Columbia. and  aged i n t h e P r o v i n c e o f  R e f e r e n c e was made t o V a l l e y v i e w H o s p i t a l ,  s i n c e t h e s t u d y i s concerned w i t h p a t i e n t s ' d i s c h a r g e  f r o m t h i s h o s p i t a l , a d e s c r i p t i o n o f i t w i l l p r o v i d e an a p p r o p r i a t e background a g a i n s t which t o p r e s e n t  t h e scope and  method o f t h e s t u d y .  Valleyview Hospital  V a l l e y v i e w H o s p i t a l i s s i t u a t e d twenty m i l e s e a s t o f Vancouver on t h e n o r t h s i d e o f t h e F r a s e r R i v e r about one m i l e beyond Crease C l i n i c and E s s o n d a l e M e n t a l H o s p i t a l .  The  grounds f r o n t on a busy highway which i s an a l t e r n a t i v e r o u t e i n t o t h e i n t e r i o r o f B r i t i s h Columbia. In general, Valleyview H o s p i t a l i s organized s e p a r a t e b u i l d i n g s l i n k e d t o g e t h e r by s p a c i o u s  into  lawns and w e l l  2k kept, parklike landscaping. admitting  The  largest building,  the  a r e a , i s f l a n k e d by seven o t h e r b u i l d i n g s .  These  b u i l d i n g s , p l a c e d as t h e y a r e on the s i d e o f a h i l l t o t a k e advantage of the view l o o k i n g for  the aged p a t i e n t s who  e a s t , a c t u a l l y pose many problems  must walk between b u i l d i n g s .  For  younger i n d i v i d u a l s , the h i l l s would not hamper movement but t o the e l d e r l y p e r s o n t h e y r e q u i r e e f f o r t beyond the  a g r e a t d e a l of s t r a i n  c a p a c i t i e s of many aged p e o p l e .  W i t h i n the a d m i t t i n g  b u i l d i n g are the d i a g n o s t i c  M e d i c a l , L a b o r a t o r y , X-Ray, and  others.  O c c u p a t i o n a l and R e c r e a t i o n a l  Therapy and  S i x o t h e r b u i l d i n g s house the p a t i e n t s . room and  There a r e two  services:  Rehabilitation  s e r v i c e s are p r o v i d e d a l s o i n t h i s b u i l d i n g and  small dinning  and  Social The  include Services.  s e v e n t h has  a  "Tuck Shop".  o t h e r h o s p i t a l s s i t u a t e d a t Vernon  and  T e r r a c e which a r e p a r t of the p s y c h i a t r i c g e r i a t r i c u n i t f o r the e l d e r l y m e n t a l l y i l l .  Dellview  a t Vernon and  Skeenaview  a t T e r r a c e are o n l y mentioned a t t h i s t i m e t o show the of the s e r v i c e s p r o v i d e d t o t h i s e l d e r l y group. w i l l not  i n c l u d e t h e s e two  extent  This study  hospitals since neither provides a  d i s c h a r g e s e r v i c e which i s our main a r e a o f f o c u s . The  MacLean t h e s i s  view H o s p i t a l . 1  1  has  o u t l i n e d the h i s t o r y of V a l l e y -  A l t h o u g h t h e r e i s no need t o r e i t e r a t e  the  MacLean, Jean E t h e l . A d m i s s i o n P o l i c y f o r an I n s t i t u t i o n f o r the S e n i l e . T h e s i s s u b m i t t e d i n P a r t i a l F u l f i l l m e n t of the r e q u i r e m e n t s f o r the Degree M a s t e r of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia, 1962, p.22-27  25 h i s t o r y , i t i s w o r t h n o t i n g t h a t as t h e h i s t o r y o f V a l l e y v i e w has e v o l v e d , t h e r e has a l s o e v o l v e d a p h i l o s o p h y toward t h e a g i n g .  D r . John Walsh, t h e M e d i c a l  Superintendent  at V a l l e y v i e w H o s p i t a l , explained h i s ideas w i t h the authors i n a p e r s o n a l i n t e r v i e w about t h e p h i l o s o p h y a t t h e i n s t i t u t i o n . He noted t h a t s o c i e t y , i n g e n e r a l , wants t o p u t t h e aged away. P r e v i o u s l y , many e l d e r l y p s y c h i a t r i c p a t i e n t s were sent t o t h e Home f o r t h e Aged b u t when t h i s i n s t i t u t i o n became known as V a l l e y v i e w H o s p i t a l i n January, i 9 6 0 , t h e change o f name r e f l e c t e d adequate e x p e r i e n c e and f a c i l i t i e s t o r e t u r n t h e aged t o t h e i r normal environment, t h a t i s , t h e community.  Today, as  Dr. Walsh s u g g e s t s , V a l l e y v i e w " r e c e i v e s (the m e n t a l l y i l l  aged)  i n o r d e r t o h e l p them over t h e i r p r e s e n t d i f f i c u l t i e s o r c r i s i s o r e p i s o d e and l e t them c a r r y on as b e f o r e . " I n h i s c o n c l u d i n g remarks, D r . Walsh s t r o n g l y emphasized t h a t " r e c o g n i t i o n o f s o c i a l and p s y c h o l o g i c a l f a c t o r s  contrib-  u t i n g t o p s y c h i a t r i c i l l n e s s i n t h e aged i s p r o b a b l y t h e most i m p o r t a n t advance made i n r e c e n t y e a r s .  This recognition  means t h a t t h e p a t i e n t i s t r e a t e d u s i n g m e d i c a l , s o c i a l and s c i e n t i f i c knowledge.  Recovery i s a good p r o s p e c t .  I n other  words, we a r e f o l l o w i n g t h r o u g h on what i s known." Such views i m p l y a change o f p h i l o s o p h y a t V a l l e y v i e w and suggest a j u s t i f i c a t i o n f o r t h e many changes which have t a k e n place.  F o r example, t h e r e has been a change from c u s t o d i a l  c a r e t o a c t i v e t r e a t m e n t ; f r o m l o c k e d doors t o t h e "open door" p o l i c y ; from t h e almost t o t a l s e g r e g a t i o n o f t h e sexes i n  26 b u i l d i n g s t o t h e mixed w a r d s .  1  I n a d d i t i o n , the idea that  most p a t i e n t s can be r e t u r n e d t o t h e community, i s , perhaps, t h e g r e a t e s t change t o be developed  at Valleyview Hospital.  I n t h e f o l l o w i n g T a b l e , t h e changed p h i l o s o p h y a t V a l l e y v i e w H o s p i t a l can be seen i n c o n c r e t e  TABLE  form.  I  . __ MALE  FEMALE  TOTAL  T o t a l P a t i e n t s i n Residence A p r i l 1, 1963  252  T o t a l Admissions  188  141  329  T o t a l Under Care  458  636  1,094  T o t a l Separations *  181  172  353  (Discharged i n P u l l )  (10)  (9)  (123)  (125)  (248)  Net I n c r e a s e o r Decrease  +25  -13  +12  T o t a l P a t i e n t s i n Residence March 3 1 , 1964  277  464  (Died)  729  S e p a r a t i o n means d i s c h a r g e s through d e a t h s , probation, e t c .  (19)  7  4i  transfers,  1964 Annual R e p o r t , M e n t a l H e a l t h S e r v i c e s , P r o v i n c e o f B r i t i s h Columbia, p.122  The mixed wards a l l o w t h e m i n g l i n g o f sexes d u r i n g t h e day a l t h o u g h s l e e p i n g q u a r t e r s a r e p l a c e d a t o p p o s i t e ends of t h e b u i l d i n g and a r e s e p a r a t e d from each o t h e r .  27 T h i s c h a r t a l s o suggests t h a t a b e g i n n i n g movement o f p a t i e n t s t o t h e community i s t a k i n g p l a c e .  Although the  number o f d i s c h a r g e s a r e s m a l l d u r i n g t h e F i s c a l Year, 1,  1963* t o March 31,  196^,  I t suggests t h e growing  April  importance  o f t h e S o c i a l S e r v i c e Department i n p r e p a r i n g t h e p a t i e n t f o r d i s c h a r g e and i n s e e k i n g t h e n e c e s s a r y r e s o u r c e s t o r e c e i v e t h e p a t i e n t i n t h e community.  With the expansion of t h i s r o l e  o f t h e S o c i a l S e r v i c e Department, a study o f t h e e f f e c t i v e n e s s o f t h e Department i n terms o f d i s c h a r g e procedure  and t h e  problems t h e Department must f a c e i n i t s e f f o r t s t o d i s c h a r g e p a t i e n t s seems, i m p o r t a n t .  The f o c u s o f t h i s s t u d y , t h e n , i s  on t h e r o l e o f t h e S o c i a l Worker w i t h i n t h e h o s p i t a l and, i n p a r t i c u l a r , w i t h i n t h e p r o c e s s o f d i s c h a r g e o f p a t i e n t s back to  t h e community. In  o r d e r t o l e a r n whether o t h e r i n s t i t u t i o n s shared t h e  p h i l o s o p h y r e g a r d i n g t h e m e n t a l l y i l l aged as i t i s r e f l e c t e d a t V a l l e y v i e w H o s p i t a l , l e t t e r s were s e n t t o a p p r o p r i a t e n a t i o n a l department i n Canada, Great B r i t a i n and t h e U n i t e d States.  The r e p l i e s i n d i c a t e t h a t no s i m i l a r  institutions  e x i s t i n these c o u n t r i e s , w i t h the p o s s i b l e exception of V i l l a S e l i c i n i a G e r i a t r i c H o s p i t a l , Jackson, L o u i s i a n a .  The l e t t e r  f r o m Washington, D. C , d e c l a r e d t h a t " t h e V i l l a i s r e p o r t e d t o have g e r i a t r i c wards o f good r e p u t e .  T h e i r main o b j e c t i v e  i s t o r e l i e v e t h e p r e s s u r e upon p s y c h i a t r i c throughout  institutions  L o u i s i a n a , and improve t h e c a r e o f t h e g e r i a t r i c  p a t i e n t who does n o t r e q u i r e e x t e n s i v e p s y c h i a t r i c ization."  (See A p p e n d i x B.)  hospital-  Whether t h i s means t h a t a  28 s i m i l a r p h i l o s o p h y has been developed difficult  to  i n Louisiana i s  determine.  The assumption, t h e r e f o r e , i s t h a t V a l l e y v i e w H o s p i t a l i s a unique i n s t i t u t i o n and t h a t any study of v a r i o u s aspects of the work of the i n s t i t u t i o n would not only be h e l p f u l t o the institution itself,  but would, to some extent, p r o v i d e f u r t h e r  knowledge about the aged. C e r t a i n p o i n t s have been o u t l i n e d above i n order to emphasize the need of a study around the a s p e c t s of d i s c h a r g e from V a l l e y v i e w H o s p i t a l .  F i r s t , a p o s i t i v e philosophy,  emphasizes the many p o t e n t i a l s of the aged group, has the h o s p i t a l and enabled a c t i v e treatment aged p a t i e n t w i t h the thought  pervaded  of the m e n t a l l y i l l  t h a t e v e n t u a l l y the aged  can be d i s c h a r g e d from the h o s p i t a l .  which  Secondly,  Table  person I  i n d i c a t e s a s m a l l number of d i s c h a r g e s as a d i s t i n c t s i g n of the i n c r e a s i n g e f f e c t i v e n e s s of the new  philosophy.  Thirdly,  V a l l e y v i e w H o s p i t a l appears t o be a unique i n s t i t u t i o n w i t h a s p e c i a l focus on the p s y c h i a t r i c g e r i a t r i c p a t i e n t , h i s t r e a t ment, and probable r e t u r n t o the community. i n d i c a t e the reasons  me  Scope pf the  These p o i n t s  f o r a study such as t h i s a t t h i s  time.  study  P r i m a r i l y , t h i s study must remain as a d e s c r i p t i v e  one.  No p r e v i o u s s t u d i e s have been completed i n the area of d i s c h a r g e and the r e l a t e d r e s o u r c e s w i t h the r e s u l t t h a t an overview  is  29 needed a t t h i s time t o i n d i c a t e some of the s p e c i f i c problems which the S o c i a l Worker must f a c e each time a p a t i e n t i s discharged. treatment another;  To say t h a t the h o s p i t a l i s o r i e n t e d toward  and d i s c h a r g e answers one q u e s t i o n but r a i s e s i s the community ready t o r e c e i v e t h e p a t i e n t ?  Our  study w i l l attempt t o answer the l a t t e r q u e s t i o n . Although a theory of d i s c h a r g e may s t a t e t h a t a l l p a t i e n t s are p o s s i b l e d i s c h a r g e p r o s p e c t s , i n p r a c t i s e c e r t a i n problems a r i s e which a r e p a r t l y a t t r i b u t a b l e t o the types of r e s o u r c e s or l a c k of r e s o u r c e s i n the community, and p a r t l y  attributable  t o the stages of r e c o v e r y t o which a p a t i e n t has advanced. I f the community i s not ready t o r e c e i v e the p a t i e n t , what other a l t e r n a t i v e s must the S o c i a l Worker seek t o e f f e c t the discharge?  By g a i n i n g such an overview,  perhaps, other r e s e a r c h  s t u d i e s might be i n d i c a t e d which might a s s i s t the h o s p i t a l S o c i a l Worker toward an understanding  of the community i n i t s  r o l e as the r e c e i v e r of the p a t i e n t . The study i s l i m i t e d t o the study o f V a l l e y v i e w H o s p i t a l i n the Lower Mainland  of B r i t i s h Columbia i n order t o determine  whether the r e s o u r c e s f o r the p s y c h i a t r i c g e r i a t r i c p a t i e n t a r e adequate t o r e c e i v e these p a t i e n t s upon d i s c h a r g e .  It i s  proposed t o examine the present c r i t e r i a of d i s c h a r g e as i t i s s e t a g a i n s t the a v a i l a b l e community r e s o u r c e s . criteria unrealistic? point of discharge?  Is t h i s  Does each p a t i e n t a c t u a l l y r e a c h the I f a p a t i e n t i s deemed d i s c h a r g e a b l e , a r e  t h e r e adequate r e s o u r c e s t o r e c e i v e him?  An attempt w i l l be  30 made t o answer such q u e s t i o n s as t h e s e . w i l l be an attempt  In a d d i t i o n , t h e r e  t o view r e a l i s t i c a l l y some o f the gaps i n  the e x i s t i n g c r i t e r i a o f d i s c h a r g e and the e x i s t i n g for  r e c e p t i o n o f these p a t i e n t s i n the community.  criteria In t h i s way,  a demonstration o f l i m i t a t i o n s i n the c r i t e r i a may pave the way toward an adequate d i s c h a r g e p o l i c y based on adequate r e s o u r c e s . The t o t a l p a t i e n t group w i l l be i n c l u d e d i n the study but w i l l be d i v i d e d i n t o two groups,  those who p r o g r e s s t o the  p o i n t o f d i s c h a r g e and those who must remain for  various reasons.  F u r t h e r , f o r purposes  i n c u s t o d i a l care o f t h i s study no  age l i m i t a t i o n i s s e t because admission t o V a l l e y v i e w H o s p i t a l takes i n t o account v a r i o u s f a c t o r s a s s o c i a t e d w i t h the aging process.  There a r e a t p r e s e n t , t h e r e f o r e , some p a t i e n t s i n  V a l l e y v i e w H o s p i t a l who a r e below the age of s i x t y - f i v e .  To  a r b i t r a r l y s e t age s i x t y - f i v e as the admission age t o V a l l e y view H o s p i t a l would prevent t h i s s m a l l group from o b t a i n i n g the treatment V a l l e y v i e w o f f e r s .  The Method o f Study T h i s study examines the c r i t e r i a o f d i s c h a r g e a g a i n s t the community r e s o u r c e s .  To understand  these c r i t e r i a ,  i t is  n e c e s s a r y t o a n a l y z e the process of admission t o h o s p i t a l and a l s o the treatment p r o c e s s . of  the d i s c h a r g e c r i t e r i a  With t h i s backdrop,  an e v a l u a t i o n  can be developed both i n terms o f  the h o s p i t a l and i n terms o f the community.  31 F o r t h i s s t u d y , s t a t i s t i c s have been a n a l y z e d f o r t h e p a s t y e a r t e r m i n a t i n g on March 3 1 , 1965, t h e end o f t h e j u s t past F i s c a l Year.  P a r t i c u l a r a t t e n t i o n has been p a i d t o t h e  d i s c h a r g e s t a t i s t i c s and t h e r a t e o f p a t i e n t r e t u r n  statistics  t o suggest t h e weaknesses i n t h e d i s c h a r g e c r i t e r i a . A q u e s t i o n n a i r e was developed t o a s s e s s c e r t a i n randomly s e l e c t e d b o a r d i n g and n u r s i n g homes i n t h e Lower M a i n l a n d i n t h e hope t h a t t h i s method might h e l p i n an u n d e r s t a n d i n g o f t h e a t t i t u d e s w h i c h t h o s e p e o p l e managing t h e s e r e s o u r c e s may have toward t h e aged p s y c h i a t r i c a l l y i l l  patient.  C e r t a i n s e l e c t e d cases have been s t u d i e d t o i l l u s t r a t e b o t h s u c c e s s f u l placements  i n t h e community and problems i n  d i s c h a r g e t o t h e community. Case h i s t o r i e s have been s e l e c t e d t o i l l u s t r a t e as much of t h e p r o c e d u r e i n t h e h o s p i t a l as p o s s i b l e . The s o u r c e s o f d a t a have been many and v a r i e d .  The  V a l l e y v i e w H o s p i t a l S t a f f have p r o v i d e d much i n f o r m a t i o n o f v a l u e which o t h e r w i s e might have remained of t h i s s t u d y .  unknown f o r purposes  The same h e l p was extended by randomly s e l e c t e d  b o a r d i n g and n u r s i n g homes from Vancouver C i t y t h r o u g h t o Abbotsford.  To o b t a i n some i n f o r m a t i o n about o t h e r p o s s i b l e  i n s t i t u t i o n s s i m i l a r t o V a l l e y v i e w H o s p i t a l i n Canada, Great B r i t a i n and t h e U n i t e d S t a t e s , l e t t e r s were sent a s k i n g f o r information.  Other s o u r c e s o f i n f o r m a t i o n have been: M e n t a l  H e a l t h R e p o r t s , M e n t a l H e a l t h A c t s and Census R e p o r t s .  32 W i t h i n t h i s chapter, changing p h i l o s o p h y has been noted as an important aspect i n b r i n g i n g about many o f t h e changes within Valleyview Hospital.  One change of utmost  importance  was suggested i n t h e name change from t h e Home f o r the Aged t o the p r e s e n t name.  T h i s change i s suggested i n the concept  V a l l e y v i e w ' s prime f o c u s i s on treatment o f t h e p s y c h i a t r i c g e r i a t r i c p a t i e n t , not on c u s t o d i a l c a r e .  With t h i s f o c u s  i n mind, Chapter I I I w i l l d i s c u s s t h e admission procedures and treatment p r o c e s s e s .  that  CHAPTER  III  ADMISSION, TREATMENT, AND OF PATIENTS FOR  SELECTION  DISCHARGE  1  I t i s l o g i c a l , b e f o r e examining d i s c h a r g e c r i t e r i a , examine some of the ways i n which the changing  to  philosophy  a f f e c t s the treatment  of the p s y c h i a t r i c g e r i a t r i c p a t i e n t i n  Valleyview Hospital.  T r a n s i t i o n from c u s t o d i a l care t o r e -  h a b i l i t a t i o n and d i s c h a r g e t o the community i s the b a s i s of the present  "open door" p h i l o s o p h y i n V a l l e y v i e w .  T h i s "open door*'  p h i l o s o p h y : ( l ) e l i m i n a t e d the p a t i e n t w a i t i n g l i s t which t h e two  hundred mark i n 1 9 6 2 ;  2  (2)  created heterosexual  neared (mixed)  wards which house male and female p a t i e n t s i n the same q u a r t e r s and engaging i n common treatment a d d i t i o n a l " s h o r t term" treatment  a c t i v i t i e s ; ( 3 ) provided  an  s e r v i c e f o r p a t i e n t s who  are  a b l e to s t a y at home, but o c c a s i o n a l l y r e q u i r e a s h o r t s t a y l o n g e r than t h r e e months) i n V a l l e y v i e w H o s p i t a l ; and  (k)  (no  pro-  v i d e d more s o c i a l work s t a f f t o p r o v i d e b e t t e r s e r v i c e i n d i s c h a r g i n g p a t i e n t s from V a l l e y v i e w H o s p i t a l . T h i s chapter i s focused p r i m a r i l y on the p s y c h i a t r i c i a t r i c patient. admission 1  2  ger-  His progress i s examined from the time of  t o V a l l e y v i e w H o s p i t a l t o h i s e v e n t u a l placement  on  For Pre-Admission see: MacLean, J . E t h e l , "Admissions P o l i c y f o r an I n s t i t u t i o n f o r the S e n i l e . " M.S.W..Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1962. Ibid p.20  3* one  o f the treatment wards.  F i n a l l y , when t h e p a t i e n t  success-  f u l l y responds t o the s p e c i a l i z e d treatment i n the h o s p i t a l , he  i s prepared f o r d i s c h a r g e .  The d i s c h a r g e c r i t e r i a and the  r e s o u r c e s a v a i l a b l e i n the community w i l l be examined i n the following  chapter.  ADMISSION As  soon as the p s y c h i a t r i c g e r i a t r i c p a t i e n t i s admitted  t o the V a l l e y v i e w  H o s p i t a l h i s r e h a b i l i t a t i o n treatment b e g i n s .  I n t h e examination room the p h y s i c i a n meets the p a t i e n t f o r the first  time.  As a standard procedure a t admission t o the  h o s p i t a l , the p h y s i c i a n performs a complete p h y s i c a l and mental examination.  I n a d d i t i o n , he compiles a s h o r t medical and  s o c i a l h i s t o r y o f the p a t i e n t which he may o b t a i n from one o r s e v e r a l o f the f o l l o w i n g 1.  sources:  The p a t i e n t h i m s e l f  - i f the mental  condition  i s s t a b l e enough. 2.  The r e l a t i v e s - i f they have a r r i v e d w i t h the p a t i e n t t o the h o s p i t a l .  3.  The p o l i c e o f f i c e r s - i f they have brought the p a t i e n t t o the h o s p i t a l .  4.  The ambulance attendants and nurse - i f no one e l s e accompanied the p a t i e n t t o the h o s p i t a l .  I f , i n the o p i n i o n a  of the examining p h y s i c i a n ,  need f o r f u r t h e r background i n f o r m a t i o n  may r e q u e s t the V a l l e y v i e w  there i s  on the p a t i e n t , he  H o s p i t a l S o c i a l Worker t o o b t a i n  35 a more d e t a i l e d s o c i a l h i s t o r y . it:  ( l ) from other agencies  agencies  The S o c i a l Worker may o b t a i n  i n t h e community; (2) from v a r i o u s  throughout the province;  (3) f r o m o t h e r h o s p i t a l s  where t h e p a t i e n t has had t r e a t m e n t  a t some o t h e r p e r i o d o f  time. At t h e end o f t h e g e n e r a l e x a m i n a t i o n  by t h e V a l l e y v i e w  H o s p i t a l p h y s i c i a n , t h e p a t i e n t i s p l a c e d f o r o b s e r v a t i o n on the admission Building.  ward which i s s i t u a t e d i n t h e main V a l l e y v i e w  The o b s e r v a t i o n c o n s i s t s o f a s s e s s i n g t h e p a t i e n t ' s  s o c i a l behaviour  on t h e ward, h i s mental c o n d i t i o n , and h i s  physical condition.  A l l necessary  l a b o r a t o r y t e s t s are per-  formed ( b l o o d , X-Ray, and o t h e r s ) and c o n t i n u e d treatment  i s given.  rehabilitation  The p a t i e n t remains on t h e a d m i s s i o n  f o r one week and i s l a t e r i n t r o d u c e d t o t h e t r e a t m e n t The  treatment  ward  team.  team convenes, as a r u l e , every Tuesday  morning - t h i s m e e t i n g i s c a l l e d "The Case C o n f e r e n c e " .  The Treatment Team The  Treatment Team c o n s i s t s o f t h e p r i n c i p a l s t a f f members  f r o m t h e v a r i o u s s p e c i a l i z e d departments i n V a l l e y v i e w H o s p i t a l . I t i s headed by t h e M e d i c a l S u p e r i n t e n d e n t  and i t s r o l e i s t o  e s t a b l i s h and p u t i n t o e f f e c t t h e r e h a b i l i t a t i o n p l a n t h a t i s b e s t s u i t e d t o each p a t i e n t . The (a)  team members' f u n c t i o n s a r e as f o l l o w s : The M e d i c a l S u p e r i n t e n d e n t  - as mentioned above -  i s t h e chairman o f t h e t r e a t m e n t  team.  He  i n t r o d u c e s t h e p a t i e n t t o t h e o t h e r members and  36 p e r s o n a l l y i n t e r v i e w s him i n order t o r e - e v a l u a t e his  affective capacities.  Superintendent  At t h i s time the M e d i c a l  encourages the p a t i e n t t o express h i s  p e r s o n a l concerns and problems. (b) S t a f f p h y s i c i a n s - a l l f o u r p h y s i c i a n s take p a r t i n the conference. to  Here the examining p h y s i c i a n  the team the p a t i e n t ' s medical  presents  h i s t o r y , the r e s u l t s  from l a b o r a t o r y t e s t s and reads the p a t i e n t ' s s o c i a l history.  Finally,  the p h y s i c i a n proposes the  d i a g n o s i s and makes recommendations r e g a r d i n g the treatment needed i n order t o r e h a b i l i t a t e and eventu a l l y d i s c h a r g e the p a t i e n t .  I f the p a t i e n t has made  s u f f i c i e n t improvement i n the past week, the team makes a d e c i s i o n f o r immediate (c) Nursing  discharge.  S u p e r v i s o r s and Charge Nurses.  Nurse a t t h i s p o i n t i s requested  to give a d e t a i l e d  d e s c r i p t i o n of the p a t i e n t ' s every the time t h a t he was f i r s t  admitted  nurse evaluates any s i g n i f i c a n t  The Charge  day c o n d i t i o n from on the ward.  The  changes of the past  week and d i s c u s s e s the p a t i e n t ' s adjustment t o the hospital  situation.  (d) O c c u p a t i o n a l  T h e r a p i s t and R e c r e a t i o n a l T h e r a p i s t -  the r e p r e s e n t a t i v e s of these departments examine and make recommendations concerning to  the p a t i e n t ' s a b i l i t y  take f u l l advantage o f the v a r i o u s  Occupational  Therapy and R e c r e a t i o n a l Therapy a c t i v i t i e s i n the  37 hospital.  They a l s o i n d i c a t e ways i n which these  a c t i v i t i e s may enhance the p a t i e n t ' s r e h a b i l i t a t i o n and  discharge  possibilities.  1  (e) The S o c i a l Worker - the S o c i a l Worker's r o l e a t the Case Conference has many purposes: 1. He may be r e q u e s t e d t o p r o v i d e d e t a i l e d s o c i a l assessment o f the p a t i e n t . 2. He may r e c e i v e a d i r e c t r e f e r r a l from the team t o d i s c h a r g e the p a t i e n t . 3.  He may make recommendations r e g a r d i n g  the resources  a v a i l a b l e i n the community. 4.  He may be a s s i g n e d t o the p a t i e n t f o r p r o v i s i o n o f casework s e r v i c e s d u r i n g i n Valleyview  the p a t i e n t ' s  stay  Hospital.  Purpose of t h e Case Conference The  purpose of the Case Conference i s t o decide on a  cooperative  r e h a b i l i t a t i n g g o a l of treatment f o r each p a t i e n t  admitted t o V a l l e y v i e w  Hospital.  Ultimately  enable the p a t i e n t t o be discharged i s e s t a b l i s h e d i n three  t h i s goal i s to  t o the community.  The g o a l  steps:  1.  The p a t i e n t i s assessed i n d i v i d u a l l y .  2.  He i s i n t r o d u c e d  t o each member o f the Treatment  Team. 3. 1  The Treatment Team f i n a l i z e s the p a t i e n t ' s  transfer  Some o f these a c t i v i t i e s a r e woodwork, p a i n t i n g , k n i t t i n g , bingo, sing-songs, movies.  38 from the admission ward t o the l e v e l of treatment b e s t s u i t e d f o r h i s diagnosed mental and  physical  condition. The p a t i e n t ' s e v a l u a t i o n or assessment, based on a d e t a i l e d c l i n i c a l  therefore, i s  examination and d i a g n o s i s of h i s  somatic c o n d i t i o n , d e t e r m i n a t i o n of h i s f u n c t i o n a l p o t e n t i a l ities  and the degree of h i s i n t e l l e c t u a l d e t e r i o r a t i o n .  the e n t i r e team p a r t i c i p a t e s i n t h i s assessment,  Since  i t is  c o n s i d e r e d the f i r s t s t e p i n i n t r o d u c i n g the p a t i e n t t o the therapeutic a c t i v i t y . complete  Therapy  i s planned a f t e r t h e r e i s a  understanding of the dynamics of the d i s o r d e r and  a f f e c t i v e and i n t e l l e c t u a l p o t e n t i a l of the p a t i e n t .  the  Since  the most important t h e r a p e u t i c e f f o r t s are d i r e c t e d towards the p r e p a r a t i o n of the p a t i e n t f o r f u l f i l l m e n t of h i s f u t u r e s o c i a l r o l e i n the community, he i s t r a n s f e r r e d t o the r i a t e treatment f a c i l i t y t h e r e t h a t he w i l l  a v a i l a b l e i n the h o s p i t a l .  approp-  It i s  be helped t o develop h i s remaining a f f e c t i v e  and i n t e l l e c t u a l c a p a b i l i t i e s and s o c i a l  potentialities.  F u r t h e r treatment on each ward i s d i r e c t e d a t r e o r i e n t a t i o n t o the f u t u r e environment mental Therapy,  i n the community, by way  Group T h e r a p y ,  1  Physiotherapy, P o d i a t r y ,  R e c r e a t i o n a l Therapy and O c c u p a t i o n a l Therapy. Therapy  i s aimed mainly at r e a c t i v a t i o n  manual s k i l l s . 1  of E n v i r o n -  Occupational  and improvement of  S i n c e a l l work i n O c c u p a t i o n a l Therapy i s  By group therapy we mean a l l a c t i v i t i e s performed i n groups - i n V a l l e y v i e w H o s p i t a l s o c i a l group therapy was done on a study b a s i s i n 1962 and was v e r y s u c c e s s f u l .  39 performed i n groups, i t a l s o a i d s r e s o c i a l i z a t i o r i " " and communication among p a t i e n t s engaged i n manual p r o j e c t s .  TREATMENT FACILITIES In accordance w i t h the Treatment Team's d e c i s i o n , the p a t i e n t i s t r a n s f e r r e d t o one o f the f o l l o w i n g f a c i l i t i e s of Valleyview 1.  Infirmary The  treatment  Hospital.  Wards  p a t i e n t s who a r e t r a n s f e r r e d here, i n a d d i t i o n t o  t h e i r mental c o n d i t i o n , need complete bed care and maximum nursing  attention.  The v a r i o u s  physical  disabilities  encountered here, range from t o t a l p a r a l y s i s t o p e r i o d i c a l i n c a p a c i t a t i n g cerebro-vascular  strokes.  wards a r e d i s c h a r g e d  homes, p r o v i d i n g they respond  to nursing  P a t i e n t s from these  s u c c e s s f u l l y t o treatment o f t h e i r mental i l l n e s s t o the extent t h a t they can be accepted f o r n u r s i n g  home care i n t h e  community. 2.  Closed  Wards  These wards a r e d i v i d e d i n t o separate male and female quarters.  P a t i e n t s who a r e t r a n s f e r r e d - h e r e  a r e predominantly  ambulant, but need c l o s e s u p e r v i s i o n because o f extreme mental confusion,  wandering and seemingly i r r e v e r s i b l e i n t e l l e c t u a l  deterioration.  Here t h e r e a r e a l s o s p e c i a l f a c i l i t i e s f o r  those p a t i e n t s who are i n need of c l o s e l y c o n t r o l l e d d i e t s , and *  who have s p e c i a l somatic problems.  Some p a t i e n t s here a r e  D e f i n i t i o n o f r e s o c i a l i z a t i o n : A process by which the human b e i n g a c q u i r e s the knowledge o f h i s group and l e a r n s the s o c i a l r o l e s appropriate to h i s p o s i t i o n i n i t .  ko s u f f e r i n g from c i r c u l a t o r y and c a r d i a c e n d o c r i n e d i s o r d e r s and r e s p i r a t o r y The  insufficiencies,  malfunctions.  Nurse's r o l e i n the r e h a b i l i t a t i o n o f the p a t i e n t on  the c l o s e d wards i s l i m i t e d t o r e a c t i v a t i o n o f t h e p a t i e n t ' s r e m a i n i n g p h y s i c a l and i n t e l l e c t u a l c a p a c i t i e s , s t a r t i n g a t the minimum l e v e l o f h i s a b i l i t i e s .  When t h e p a t i e n t responds  s u c c e s s f u l l y t o small t a s k s , f o r example, walking t o t h e d i n i n g room, s i t t i n g  a t t h e t a b l e , and f e e d i n g h i m s e l f , the  Nurse p r o g r e s s i v e l y i n c r e a s e s t h e p a t i e n t ' s  responsibilities.  They w i l l probably be always l i m i t e d i n n a t u r e , however. In t h e c l o s e d wards a r e encountered the l a r g e s t number o f p a t i e n t s who can e v e n t u a l l y be discharged are p r e s e n t l y no a p p r o p r i a t e community.  but f o r whom there  f a c i l i t i e s a v a i l a b l e i n the  As a r e s u l t , such p a t i e n t s stay i n h o s p i t a l  longer  than i s necessary and c o n s t i t u t e , t h e o r e t i c a l l y , one group of patients.  Another group of p a t i e n t s i n t h e c l o s e d wards may  never be d i s c h a r g e d  because of t h e i r extreme and p r o g r e s s i v e  mental and p h y s i c a l d e t e r i o r a t i o n . d e a l t w i t h more f u l l y 3«  and  i n Chapter IV.)  Open Wards or "Mixed Wards" The  (This s u b j e c t w i l l be  1  open wards occupy t h r e e b u i l d i n g s and house both men  women p a t i e n t s .  Some of the p a t i e n t s t r a n s f e r r e d here may  be a n t i c i p a t i n g the f i n a l  stages o f t h e i r d i s c h a r g e (as  recommended by the Treatment Team).  Others may r e q u i r e a  l o n g e r r e s o c i a l i z a t i o n p e r i o d b e f o r e being ready f o r 1  discharge  Mixed Ward - u n o f f i c i a l name g i v e n t o the wards t h a t house b o t h male and female p a t i e n t p o p u l a t i o n engaging i n common r e h a b i l i t a t i o n therapy. The wards a r e never l o c k e d by key and have u n l i m i t e d v i s i t i n g hours.  hi t o t h e community.  Here t h e p a t i e n t s a r e h e l p e d , encouraged  and m o t i v a t e d t o be s e l f - s u f f i c i e n t i n a l l a s p e c t s o f everyday life.  TREATMENT TOWARDS REHABILITATION The  fundamental r e h a b i l i t a t i o n p l a n I n V a l l e y v i e w  Hospital i s t o t r e a t the i n d i v i d u a l patient according  to his  o r h e r r e m a i n i n g c a p a b i l i t i e s , b o t h i n t e l l e c t u a l and a f f e c t i v e . The  p a t i e n t ' s assignment t o one o f t h e wards d e s c r i b e d  above  i s c a r e f u l l y p l a n n e d by t h e Treatment Team i n o r d e r t h a t a s t a b i l i z i n g environment may be p r o v i d e d  i n h o s p i t a l t o prevent  the slow-down o r f u r t h e r d e t e r i o r a t i o n o f t h e p a t i e n t ' s mental and  physical capacities.  (See F a c t o r s C o n s i d e r e d i n D i s c h a r g e  P l a n n i n g , p. h"^.). The  problems o f p h y s i c a l d e t e r i o r a t i o n a r e d e a l t w i t h by  engaging t h e p a t i e n t i n r o u t i n e d a i l y a c t i v i t i e s o f e l e m e n t a r y n a t u r e which a r e aimed a t r e t r a i n i n g t h e p a t i e n t i n such r o u t i n e s as bedroom, d i n i n g room and t o i l e t h a b i t s .  This  r e t r a i n i n g i n the elementary d a i l y r o u t i n e i s introduced g r a d u a l l y t o t h e p a t i e n t by competent n u r s i n g s t a f f a t r e g u l a r intervals. The  patient's i n t e l l e c t u a l  m a i n t a i n e d and,  (mental) c a p a c i t i e s a r e  where p o s s i b l e , improved by t h e a d m i n i s t r a t i o n  o f p s y c h o g e n i c drugs which a r e p r e s c r i b e d by t h e h o s p i t a l s t a f f of physicians.  Drug Therapy i s n o t s u f f i c i e n t i n i t s e l f  t o r e s t o r e and m a i n t a i n potentialities.  t h e p a t i e n t ' s m e n t a l arid i n t e l l e c t u a l  The p a t i e n t r e q u i r e s , i n a d d i t i o n ,  constant  42 motivation.  M o t i v a t i o n i s regarded  H o s p i t a l s t a f f as the process  by the V a l l e y v i e w  o f o r g a n i z a t i o n which g i v e s  s e l f - d i r e c t i o n and guides t h e a c t i v i t i e s o f t h e person involved. one  There a r e e s s e n t i a l l y two components of m o t i v a t i o n :  i s some degree o f d i s c o m f o r t about h i s present c o n d i t i o n ;  the other i s some degree o f hope or some g o a l sought t o be worth a c h i e v i n g by t h e p a t i e n t .  In V a l l e y v i e w H o s p i t a l , t h e  g o a l i s d i s c h a r g e t o the community. i s motivated  The p a t i e n t , t h e r e f o r e ,  t o achieve h i s g o a l by v a r i o u s a c t i v i t i e s on t h e  ward t h a t w i l l prepare  him, both p h y s i c a l l y and m e n t a l l y , f o r  h i s r e t u r n t o t h e community. The  p a t i e n t i s encouraged t o e s t a b l i s h f r i e n d s h i p s and  r e l a t i o n s h i p s w i t h members o f both sexes;  i s engaged i n a l l  types of group a c t i v i t i e s on t h e ward and i s encouraged t o take the i n i t i a t i v e f o r a t t e n d i n g t h e v a r i o u s o c c u p a t i o n a l and r e c r e a t i o n a l a c t i v i t i e s and r e l i g i o u s s e r v i c e s .  Such a  p a t i e n t has ground p r i v i l e g e s ; he may go i n and out of t h e ward a t any time,  e n t e r t a i n v i s i t o r s i n the V a l l e y v i e w "Tuck Shop"  and go on week-end l e a v e s with r e l a t i v e s and f r i e n d s .  Event-  u a l l y t h i s patient i s able to return either to s e l f - c a r e , t o f a m i l y care or t o any s u i t a b l e r e s t home or boarding home i n t h e community. M o t i v a t i o n of t h e p a t i e n t towards e v e n t u a l d i s c h a r g e i s a l s o t h e f u n c t i o n of t h e S o c i a l Worker.  Throughout t h e  p a t i e n t ' s s t a y i n V a l l e y v i e w H o s p i t a l , t h e S o c i a l Worker p r o v i d e s casework s e r v i c e s and a c t s as a l i a i s o n between t h e  t3 p a t i e n t , h i s f a m i l y and t h e community.  The S o c i a l Worker's  major r o l e , however, i s i n s e l e c t i o n and d i s c h a r g e p a t i e n t from V a l l e y v i e w  of the  Hospital.  FACTORS CONSIDERED IN DISCHARGE Although every p a t i e n t i n Valleyview H o s p i t a l i s considered  f o r discharge,  p r o v i d i n g t h a t he o r she responds  s u c c e s s f u l l y t o t r e a t m e n t , t h e r e a r e c e r t a i n d i s t i n c t groups i n the patient population.  These f a l l i n t o t h r e e  categories,  depending on t h e degree o f c a r e and s u p e r v i s i o n t h e y may r e q u i r e a t t h e time of discharge.  Each c a t e g o r y i s i l l u s t r a t e d  by a c t u a l cases i n Chapter V. (a)  The ambulant p s y c h i a t r i c g e r i a t r i c p a t i e n t who suffered a functional i l l n e s s associated with the aging process,  f o r example, a p s y c h o t i c  o r psycho-  neurotic r e a c t i o n with a s o c i a l or psychological s t r e s s as a b a s i s .  This person, given  proper  treatment a t V a l l e y v i e w H o s p i t a l , r e q u i r e s minimal care o r s u p e r v i s i o n , and i s a b l e t o f u n c t i o n s u c c e s s f u l l y i n any b o a r d i n g home o r r e s t home i n which he may be p l a c e d . Valleyview  A f t e r h i s treatment i n  H o s p i t a l , he i s l u c i d  (aware o f h i s  e n v i r o n m e n t ) , w e l l o r i e n t e d t o t i m e , p l a c e and p e r s o n , and o f t e n i s a b l e t o c a r e f o r h i m s e l f . (See Case H i s t o r y I , Chapter V.)  (b)  The  "in-between"  psychiatric geriatric  patient:-  T h i s p a t i e n t does not r e q u i r e complete n u r s i n g but needs c l o s e s u p e r v i s i o n and  s p e c i a l under-  standing  staff.  from competent n u r s i n g  p a t i e n t ' s m e d i c a t i o n has  care,  This  to be s u p e r v i s e d  and  the  nurse must have an awareness of h i s changes of behaviour and h i s mental c o n d i t i o n which may f o r changes i n m e d i c a t i o n or s p e c i a l d i e t . p a t i e n t i s ambulatory but tends t o be and  disoriented.  The  Chapter (c)  The  Hospital.  "in-between" p a t i e n t in  (See Case H i s t o r y I I ,  V.)  p s y c h i a t r i c g e r i a t r i c p a t i e n t who  nursing  This  forgetful  c o n s t i t u t e s the major p a t i e n t p o p u l a t i o n Valleyview  call  care and  supervision:  needs f u l l  This patient i s  e i t h e r bedridden or i n a wheel c h a i r at a l l times. In a d d i t i o n t o h i s severe degree of mental i o r a t i o n , he a l s o s u f f e r s c h r o n i c d e t e r i o r a t i o n due p a t i e n t may  This  from V a l l e y v i e w  Hospital  when h i s mental c o n d i t i o n improves to the  extent  t h a t he w i l l not be d i s t u r b i n g t o o t h e r s .  (See  Case H i s t o r y I I I , Chapter In a d d i t i o n .to the above three p a t i e n t s who 1  physical  to the aging p r o c e s s .  be d i s c h a r g e d  deter-  w i l l not be d i s c h a r g e d  V.) categories, there from .Valleyview  T h i s i s an i n f o r m a l term used i n V a l l e y v i e w  are  Hospital  Hospital.  4  5  because of t h e i r c h r o n i c p h y s i c a l and mental s t a t u s . some respond  s u c c e s s f u l l y t o treatment  If  and a r e c o n s i d e r e d f o r  discharge, t h e i r stay i n Valleyview H o s p i t a l i s often prolonged because of c e r t a i n e x i s t i n g impediments t h a t make a l l attempts to d i s c h a r g e such a p a t i e n t time consuming usually, f u t i l e . 1.  and,  Some Of these impediments a r e :  The need of these p a t i e n t s f o r a s e l e c t e d and h i g h l y p r o t e c t i v e environment i n the community because of their limited capacities.  Resources t o meet  needs are almost n o n e x i s t e n t .  (See Chapter  such IV,  Section II.) 2.  Where s u i t a b l e accommodation i n the community i s l o c a t e d , i t i s more expensive accommodation.  than other types of  The reason f o r t h i s i s found i n the  g r e a t e r amount of s e r v i c e s and f a c i l i t i e s r e q u i r e d to 3.  care f o r these p a t i e n t s .  In order t o o b t a i n the a d d i t i o n a l a s s i s t a n c e r e q u i r e d for  the p a t i e n t i n t h i s type of accommodation, i t i s  necessary t o seek the c o o p e r a t i o n o f community S o c i a l Welfare Departments.  U n f o r t u n a t e l y , some departments  do not cooperate w i t h V a l l e y v i e w S o c i a l S e r v i c e . As a r e s u l t of the above impediments, much e f f o r t and i s r e q u i r e d from the S o c i a l Worker.  More important,  time  i s the  d e l a y i n d i s c h a r g e the p a t i e n t f a c e s as a r e s u l t of the above impediments.  T h i s d e l a y i s r e f l e c t e d i n the p a t i e n t who  has-  been prepared f o r d i s c h a r g e but i s unable t o l e a v e h o s p i t a l . (See Case H i s t o r y IV, Chapter  V.)  k6 The above impediments a r e a r e f l e c t i o n o f the broad  social  and p s y c h o l o g i c a l problems of today w i t h which the aging population i s faced i n general.  (See Chapter  I.)  H o s p i t a l attempts t o overcome these impediments.  Valleyview This i s  seen i n the p h i l o s o p h y which pervades the process of treatment, s e l e c t i o n and d i s c h a r g e o f the p a t i e n t s .  PATIENT SELECTION FOR DISCHARGE The  S o c i a l S e r v i c e Department o f V a l l e y v i e w H o s p i t a l  has developed  a l i a i s o n w i t h community agencies and has l o c a t e d  some s u i t a b l e r e s o u r c e s f o r the care of the d i s c h a r g e d p a t i e n t . However, t h i s s e l e c t i o n of boarding homes and n u r s i n g homes i s done i n a random way and a t the present time t h e r e a r e no s p e c i f i c , w e l l - f o r m u l a t e d c r i t e r i a a g a i n s t which t o measure resources.  N e i t h e r a r e there s p e c i f i c  c r i t e r i a within hospital  which can be used i n the s e l e c t i o n and r e f e r r a l of p a t i e n t s f o r discharge planning. The  s e l e c t i o n of p a t i e n t s f o r d i s c h a r g e p l a n n i n g i s on a  very informal b a s i s . developed  has been t e n t a t i v e l y  whereby t h r e e months from the date of admission, the  patient's f i l e  i s brought t o the a t t e n t i o n o f the S o c i a l  Service Supervisor. forward,  One procedure  The names of those p a t i e n t s a r e brought  who appear t o have responded t o treatment, as  i n d i c a t e d i n the medical r e c o r d s . the i n d i v i d u a l S o c i a l Worker.  These names a r e a s s i g n e d t o  The S o c i a l Worker, i n t u r n ,  c o n s u l t s the h o s p i t a l p h y s i c i a n f o r a f i n a l d e c i s i o n concern-  *7 i n g the p a t i e n t ' s s u c c e s s f u l response to treatment which would i n d i c a t e h i s r e a d i n e s s Three months was  f o r discharge  planning.  s e l e c t e d by the V a l l e y v i e w  s t a f f as a s u i t a b l e p e r i o d of time at which the p r o g r e s s may  be  evaluated.  Hospital patient's  However, there are many except-  i o n a l cases where p a t i e n t s responded to treatment i n Valleyview  H o s p i t a l before  the three month p e r i o d . .  Such  p a t i e n t s are s e l e c t e d p r i o r t o the three months p e r i o d r e f e r r e d by the a t t e n d i n g Department f o r d i s c h a r g e As  p h y s i c i a n t o the S o c i a l S e r v i c e planning.  the p h y s i c i a n h i m s e l f  cannot c o n s t a n t l y be aware of  a l l the p a t i e n t s a l l the time, i t was,  t h e r e f o r e , agreed  the Treatment Team members t h a t i t i s i n order f o r any them t o b r i n g t o the a t t e n t i o n of the p h y s i c i a n any who  The  H o s p i t a l i n order  not be  one  the  t h a t an e a r l y  overlooked.  above methods of s e l e c t i o n of p a t i e n t s has  certain  advantages; f o r example, the i n f o r m a l i t y of the r e f e r r a l p a t i e n t s e l i m i n a t e s the n e c e s s i t y f o r formal  there are disadvantages i n t h i s  procedure; i t c r e a t e s d u p l i c a t i o n , c o n f u s i o n , s e r v i c e s , disagreements and the p h y s i c i a n and  of  written  communication between departments w i t h i n V a l l e y v i e w Nevertheless,  of  This  procedure i s a c t i v e l y c a r r i e d out a t a l l times d u r i n g p a t i e n t ' s stay i n V a l l e y v i e w  by  patient  appears t o be a p o s s i b l e candidate f o r d i s c h a r g e .  response to treatment may  and  Hospital.  informal overlapping  of  a l a c k of c o o r d i n a t i o n between  the other Treatment Team members.  I t also.  48 allows go  f o r the o c c a s i o n a l p a t i e n t s u i t a b l e f o r d i s c h a r g e t o  unnoticed. The  p h y s i c i a n i n charge examines the r e f e r r e d p a t i e n t and  o f f i c i a l l y d e c l a r e s the p a t i e n t no longer hospital.  i n need t o remain i n  Then, with t h e c o n s u l t a t i o n of t h e S o c i a l Worker,  the p h y s i c i a n decides  whether the p a t i e n t may be discharged t o  s e l f - c a r e , f a m i l y care, n u r s i n g home care or boarding home care.  Prom then on the remaining p l a n n i n g  i s the r e s p o n s i b i l -  i t y of t h e S o c i a l Worker. The  S o c i a l Worker informs the V a l l e y v i e w  Business O f f i c e that discharge information other  concerning  i s being  Hospital  considered  and requests  t h e p a t i e n t ' s f i n a n c i a l s t a t u s and  a s s e t s t h a t a r e a v a i l a b l e t o support t h e p a t i e n t i n the  community.  The S o c i a l Worker a l s o gathers,  from t h e Head  Nurse on t h e ward, by way o f a w r i t t e n n u r s i n g information  concerning  assessment,  t h e p a t i e n t ' s everyday behaviour, h i s  mental and p h y s i c a l needs (see n u r s i n g assessment form, Appendix C).  In a d d i t i o n , t h e S o c i a l Worker o b t a i n s a one  month supply  of the r e q u i r e d medications p r e s c r i b e d by the  physician.  Other p e r t i n e n t i n f o r m a t i o n may be r e q u e s t e d from  the O c c u p a t i o n a l any  and R e c r e a t i o n a l Therapy Departments, or from  other person t h a t i s known t o be i n c l o s e contact w i t h t h e  patient.  T h i s person c o u l d be the Chaplain,  D e n t i s t , Beauty  P a r l o r Operator and a l s o i n t e r e s t e d f r i e n d s or r e l a t i v e s . S o c i a l Worker then contacts  a s e l e c t e d community  The  resource(s)  t o determine t h e s u i t a b i l i t y of p l a c i n g t h e p a t i e n t .  Having  4  9  completed t h e p r e l i m i n a r y work, the S o c i a l Worker c o n s u l t s the p h y s i c i a n a g a i n t o d i s c u s s the d i s c h a r g e p l a n and t o r e evaluate the patient's condition before discharge i s f i n a l i z e d . A f t e r t h e completion  of these plans a t the h o s p i t a l , the  p a t i e n t ' s f a m i l y i s contacted a g a i n and i n v o l v e d i n the f i n a l d e t a i l s of the discharge planning.  Some i n t e r p r e t a t i o n t o the  f a m i l y r e g a r d i n g the p a t i e n t ' s needs and c a p a b i l i t i e s i s o f t e n necessary.  Reassurance i s g i v e n t h a t the p a t i e n t may r e t u r n t o  the h o s p i t a l without  any f o r m a l c e r t i f i c a t i o n , when and i f h i s  c o n d i t i o n d e t e r i o r a t e s t o t h e extent t h a t he w i l l r e q u i r e f u r t h e r h o s p i t a l i z a t i o n and treatment  i n Valleyview H o s p i t a l .  1  The p a t i e n t h i m s e l f i s made aware o f t h e p l a n n i n g at a l l times.  He i s a c t i v e l y i n v o l v e d i n t h e o v e r a l l p l a n n i n g o f h i s  d i s c h a r g e by the S o c i a l Worker and the Nursing S t a f f on t h e ward.  Sometimes the p a t i e n t h i m s e l f i n i t i a t e s a r e q u e s t f o r  discharge.  I f h i s request i s r e a l i s t i c ,  the p a t i e n t i s g i v e n  a l l t h e support and a s s i s t a n c e from the S o c i a l Worker t o r e t u r n wherever he wishes i n the community. The f o l l o w i n g chapter w i l l examine i n d e t a i l t h e c r i t e r i a f o r d i s c h a r g e from V a l l e y v i e w H o s p i t a l I n comparison w i t h the r e s o u r c e s a v a i l a b l e i n t h e community.  Comparatively few p a t i e n t s r e t u r n t o h o s p i t a l - i n t h e F i s c a l Year of A p r i l 1, 1964, t o March 3 1 , 1965, out of l 4 3 d i s c h a r g e d , 12 r e t u r n e d - 8 from boarding homes, 3 from f a m i l y care, and one from n u r s i n g home. (See Chapter IV.) P a t i e n t s have been d i s c h a r g e d t o I t a l y , I n d i a , and Hong Kong.  CHAPTER  IV  DISCHARGE CRITERIA AND  Chapter  COMMUNITY RESOURCES  I presented i n g e n e r a l the "open door"  p h i l o s o p h y of V a l l e y v i e w H o s p i t a l ; Chapter  I I I demonstrated  the e f f e c t s of t h i s philosophy on treatment patients f o r discharge planning.  and r e f e r r a l of  Since the success of the  "open door" p h i l o s o p h y i s i n d i r e c t r e l a t i o n s h i p t o an  effect-  i v e d i s c h a r g e program, t h i s chapter w i l l examine the d i s c h a r g e program and process i n e f f e c t at V a l l e y v i e w H o s p i t a l at t h i s t ime.  Discharge R e l a t e d to Resources Although  the p h i l o s o p h y of V a l l e y v i e w H o s p i t a l may  a l l p a t i e n t s who  have responded to treatment  as d i s c h a r g e a b l e ,  d i s c h a r g e i t s e l f i s d i r e c t l y l i n k e d to the r e s o u r c e s i n community.  regard  available  The q u a l i t y and q u a n t i t y of the l a t t e r are major  f a c t o r s i n determining the extent of a d i s c h a r g e program. There are two reasons  for this.  In the f i r s t p l a c e , h o s p i t a l  p o l i c y must be p r a c t i c a l and workable a t V a l l e y v i e w H o s p i t a l as i n a l l h o s p i t a l s .  A d i s c h a r g e program cannot e x i s t i n a  t h e o r e t i c a l vacuum.  C o n s i d e r a t i o n must be g i v e n not only to  52 d e c i s i o n s about the s u i t a b i l i t y of a p a t i e n t f o r d i s c h a r g e but a l s o , and perhaps even more i m p o r t a n t l y ,  t o the t y p e of  p a t i e n t the community i s equipped and w i l l i n g t o r e c e i v e the h o s p i t a l .  Secondly, w i t h reference  community, one  must c o n s i d e r  t o the s i t u a t i o n i n  the d i f f e r e n c e s between p s y c h i a t r i c  g e r i a t r i c p a t i e n t s and younger m e n t a l l y planning  d i s c h a r g e w i t h and  ill  patients.  In  f o r younger p a t i e n t s the problems  o f resumming customary r o l e s and r e s p o n s i b i l i t i e s them i n the community must be c o n s i d e r e d The  from  and  awaiting  c a r e f u l l y examined.  problems of the aged have been p r e s e n t e d i n d e t a i l i n  Chapter I under the h e a d i n g s "Absence of R o l e s ,  Economic  I n s u f f i c i e n c y , R e t i r e m e n t and H e a l t h . "  These problems r e p r e s e n t  a l a c k of r o l e s and r e s p o n s i b i l i t i e s .  For p s y c h i a t r i c g e r i a t r i c  p a t i e n t s t h e b a s i c f a c t o r t o be c o n s i d e r e d I s the amount of c a r e and community.  i n discharge  planning  s u p e r v i s i o n they r e q u i r e w i t h i n  the  I t i s , therefore, necessary at t h i s point i n time,  t o a s s e s s what r e s o u r c e s a r e a v a i l a b l e w i t h i n the community i n order to determine c r i t e r i a f o r discharge from  Valleyview  Hospital.  The  Resources There a r e f o u r t y p e s of r e s o u r c e s a v a i l a b l e f o r  H o s p i t a l p a t i e n t s i n the community. (1)  Valleyview  They a r e :  F a m i l y ( i n c l u d i n g r e l a t i v e s and f r i e n d s ) and  self-  care. (2)  Licensed The  N u r s i n g Homes.  H o s p i t a l Act d e f i n e s  t h e s e i n the f o l l o w i n g  way:  53 "Licensed h o s p i t a l means a p r i v a t e h o s p i t a l i n r e s p e c t of which a l i c e n s e has been i s s u e d pursuant t o t h i s a c t which has not been revoked. 'Private H o s p i t a l ' or ' h o s p i t a l ' means a house i n which two or more p a t i e n t s , other than the spouse, parent, or c h i l d of the owner or operator t h e r e o f , are l i v i n g at the same time, and i n c l u d e s a n u r s i n g home or convalescent home...." (3)  L i c e n s e d Boarding Homes. The  l i c e n s i n g Act r e f e r s t o such a home (with  s p e c i f i c r e f e r e n c e t o the aged) as: "a b u i l d i n g or p a r t of a b u i l d i n g . . . c o n d u c t e d or operated by a person which i s used, i n whole or i n p a r t . . . ( c ) as a boarding home or other i n s t i t u t i o n wherein food or l o d g i n g together with care or a t t e n t i o n are f u r n i s h e d , with or without charge, f o r two or more persons who, on account o f age, i n f i r m i t y , p h y s i c a l or mental d e f e c t , or other d i s a b i l i t y , r e q u i r e the a t t e n t i o n or care, e x c e p t i n g a home maintained by a person t o whom , the inmates are r e l a t e d by marriage...." 2  The l a t e s t f i g u r e s a v a i l a b l e f o r the p r o v i n c e i n d i c a t e d 4,8^3 able).  l i c e n s e d beds f o r a d u l t s (the i n f i r m and the unemployWell over h a l f of these are l o c a t e d i n the Lower  Mainland-Vancouver I s l a n d area.3 H o s p i t a l Act, P a r t I I " P r i v a t e H o s p i t a l " , p a r a . 7,  (B.  C.)  Welfare I n s t i t u t i o n s L i c e n s i n g Act (Province of B r i t i s h Columbia), R.S. 19^8, C363, S e c t i o n 1, p a r a . 2 Welfare I n s t i t u t i o n s Annual Report 1963-6^ (telephone c o n v e r s a t i o n with Welfare I n s t i t u t e s , 635 B u r r a r d S t r e e t , Vancouver, B. C.)  5  (4)  4  L i c e n s e d " B o a r d i n g Homes S p e c i a l "  (of which two  e x i s t a t t h i s time w i t h a t o t a l bed c a p a c i t y o f fifty-eight).  These homes, w h i l e l i c e n s e d under  t h e same p r o v i s i o n s as " ( 3 ) L i c e n s e d B o a r d i n g Homes", have been p l a c e d i n a s e p a r a t e c a t e g o r y i n t h i s p r e s e n t a t i o n because o f t h e i r s p e c i a l a b i l i t y i n p r o v i d i n g care f o r the p s y c h i a t r i c g e r i a t r i c  patient.  F o r c l a r i t y t h e y s h a l l be r e f e r r e d t o as " B o a r d i n g Homes S p e c i a l " . I t i s o u r i n t e n t i o n t o examine each o f t h e r e s o u r c e s s e p a r a t e l y and i n d e t a i l i n t h e next s e c t i o n .  First, a brief  e x a m i n a t i o n w i l l be made o f s t a t i s t i c s which r e v e a l t h e r e s o u r c e s used i n t h e p a s t y e a r and t h e r e l a t i o n s h i p o f t h e s e t o t h e c a r e needs r e q u i r e d by p a t i e n t s i n h o s p i t a l .  TABLE  II  The number o f d i s c h a r g e s made t o each o f t h e r e s o u r c e s d u r i n g t h e F i s c a l Year 1964-65 ( A p r i l 1 t o March 3 1 ) .  TOTAL NUMBER  RESOURCES USED N u r s i n g Homes  55  39*  B o a r d i n g Homes  42  29*  9  6*  30  21*  7  5*  143  100*  " B o a r d i n g Homes S p e c i a l " Family Self-Care •»  PERCENTAGE  •  •  Total  -  ,  -  55  TABLE  III  A breakdown of p a t i e n t p o p u l a t i o n by ward on March 3 1 , 1 9 6 5 . Where p o s s i b l e , the comparable type o f r e s o u r c e r e q u i r e d i n t h e community i s g i v e n . 1  HOSPITAL WARD  COMPARABLE COMMUNITY RESOURCE  TOTAL NUMBER  PERCENTAGE  Infirmary  Nursing Homes  186  25^  Open  Boarding Homes, Family, Self-Care  176  23^  Closed  "Boarding Homes S p e c i a l "  176  23^  81  llfo  iho  l8j*  759  100$  Admitting  2  Closed "A"3  -  Total  The most obvious  f a c t e v i d e n t i n T a b l e I I I i s the t o t a l  number of p a t i e n t s r e q u i r i n g "Boarding Homes S p e c i a l " c a r e . T h i s i s a c o n s e r v a t i v e f i g u r e but i t i s s t i l l more than  double  the present c a p a c i t y i n t h e community. See Chapter I I I "Treatment F a c i l i t i e s " which d e s c r i b e s the wards i n d e t a i l . • For these p a t i e n t s t h e p o t e n t i a l need f o r community r e s o u r c e s have not y e t been determined. 3  These p a t i e n t s have not responded t o treatment. They r e q u i r e c u s t o d i a l care because of t h e i r extreme mental d e t e r i o r a t i o n and even on the c l o s e d wards i t i s necessary to segregate them from the other p a t i e n t s . T h e r e f o r e , any r e s o u r c e capable of a c c e p t i n g these p a t i e n t s c o u l d accommodate t h i s category o f p a t i e n t o n l y . Some p a t i e n t s , should they d e t e r i o r a t e p h y s i c a l l y , might be e l i g i b l e f o r n u r s i n g home placements but the m a j o r i t y w i l l remain i n hospital.  5  6  VALLEYVIEW CRITERIA AS RELATED TO THE RESOURCES !•  F a m i l y and S e l f - C a r e W h i l e t h e p r o v i n c i a l government s e t s s t a n d a r d s f o r board-  ing  and n u r s i n g homes t h e r e a r e no government s t a n d a r d s f o r , o r  p a r t i c u l a r community i n t e r e s t i n , f a m i l y c a r e o r s e l f - c a r e . The  c r i t e r i a f o r d i s c h a r g e t o t h i s r e s o u r c e a r e s e t by t h e  hospital. A.  Family A l t h o u g h twenty-one p e r c e n t o f a l l d i s c h a r g e s w i t h i n  t h e p a s t F i s c a l y e a r were f a m i l y p l a c e m e n t s , f o r the most p a r t t o a husband/wife  o r daughter, t h i s i s not c o n s i d e r e d  a major r e s o u r c e by the h o s p i t a l .  Much has been w r i t t e n  i n c u r r e n t l i t e r a t u r e on t h e changing n a t u r e of f a m i l y l i f e under such t o p i c s as " u r b a n i z a t i o n v s . r u r a l and "the n u c l e a r v s . t h e extended f a m i l y " .  living"  However,  i n t e r v i e w s w i t h many f a m i l i e s b o t h a t t h e time of a d m i s s i o n and a t t h e time of d i s c h a r g e have i n d i c a t e d two  primary  a r e a s which have c u r t a i l e d t h e number o f p o t e n t i a l discharges to f a m i l i e s .  The f i r s t i s t h e absence o f  w i t h i n t h e home or apartment  f o r t h e aged member.  space  The  second and more d e c i s i v e f a c t i s t h a t f a m i l i e s , p r i o r t o t h e p a t i e n t ' s a d m i s s i o n t o h o s p i t a l , had been endeavouring  t o cope, f o r v a r i o u s r e a s o n s and o f t e n f o r a p e r i o d  of up t o t e n y e a r s or more, w i t h a p a r e n t o r r e l a t i v e a c t u a l l y needed h o s p i t a l i z a t i o n f o r most o f t h a t t i m e . T h i s has o f t e n i n v o l v e d u n s u c c e s s f u l placements  with  who  57 v a r i o u s f a m i l y members, numerous emergencies a t a l l hours of the day or n i g h t , and u n s u c c e s s f u l attempts a t placement i n v a r i o u s boarding or n u r s i n g homes.  In a l l  such i n s t a n c e s , not o n l y the amount of time, but  the  amount of money and able.  Finally,  to h o s p i t a l .  emotional  s t r e s s have been c o n s i d e r -  i n sheer d e s p e r a t i o n , admission  Often, i n the past, t h i s has  i s sought  been  complicated by the h o s p i t a l ' s long w a i t i n g l i s t  which  o f t e n kept p r o s p e c t i v e p a t i e n t s w a i t i n g f o r p e r i o d s of up to a year or more.  Once the i n i t i a l  shock of  admission  w i t h i t s c e r t i f i c a t i o n of a parent i s over, f a m i l i e s are consoled by the care and treatment ing.  the p a t i e n t i s r e c e i v -  In many cases, and understandably  or p h y s i c a l energy i s l e f t ,  so, no  o n l y f e a r and  emotional  concern  the p o s s i b i l i t y of having to cope with the parent a g a i n i n the home.  When r e c o n c i l e d t o the d i s c h a r g e ,  o f t e n p r e f e r t o " l e t the experts handle not the new admission  once  Because of such experiences some  f a m i l y members s t r o n g l y r e s i s t the d i s c h a r g e of an f a m i l y member.  about  it".  elderly they  Whether or  "open door" p h i l o s o p h y with i t s i n c r e a s e d  and p o t e n t i a l f o r t a k i n g younger, l e s s  d e t e r i o r a t e d p a t i e n t s w i l l ever change the  circumstances  surrounding t h i s s i t u a t i o n i t i s perhaps too e a r l y to ascertain.  Nor  can one p r e d i c t what changes i n a t t i t u d e  toward r e s p o n s i b i l i t y f o r care of e l d e r l y f a m i l y members w i l l accompany changes i n s o c i e t y ' s view of the aged person.  58 The  C r i t e r i a f o r discharge 1.  t o the f a m i l y  Both the p a t i e n t and  are:  f a m i l y member ( or i n t e r e s t e d  f r i e n d s , r e l a t i v e s ) must be motivated toward  (desirous o f ) t h i s  type of placement. 2. and  F a m i l y members should be a b l e t o cope w i t h the mental  p h y s i c a l needs of the p a t i e n t by understanding what the  care needs are and  how  best t o meet them.  ( P a t i e n t s who  normally r e q u i r e twenty-four hour care and considered 3.  The  I s to say,  s u i t a b l e f o r discharge  t o the  would  s u p e r v i s i o n are  not  family.)  p a t i e n t must be o r i e n t e d t o person and the p a t i e n t must be aware of and  place.  a b l e to  That  recognize  the s i g n i f i c a n c e of meaningful people i n h i s l i f e .  He must  a l s o have some g e n e r a l  how  awareness o f where he  away other p l a c e s are i n r e l a t i o n t o h i s own one  time.  Not  i s and  far  l o c a t i o n at  any  infrequently psychiatric g e r i a t r i c patients  completely i n the past,  e.g.  c h i l d r e n are i d e n t i f i e d  as  s i b l i n g s , c h i l d r e n ' s home become the scene of t h e i r own hood, with accompanying i r r i t a t i o n s and  confusion.  i n d i c a t i o n s r e f l e c t a need f o r s p e c i a l care,  live  child-  Such  understanding  and  s u p e r v i s i o n by t r a i n e d persons. 4.  The  p a t i e n t must have some awareness of h i s own  a l and mental c a p a b i l i t i e s and  l i m i t a t i o n s , that i s , a  r e a l i s t i c r e c o g n i t i o n of h i s or her by age  and  health.  physic-  c a p a b i l i t i e s as l i m i t e d  Some examples would be:  realization  h i s or her memory i s not as good as i t used t o be;  that  an  awareness of the i n a b i l i t y to'perform the r o l e of breadwinner. F a i l u r e t o have t h i s awareness or acceptance can r e s u l t i n  59 v a r i o u s m a n i f e s t a t i o n s of h o s t i l i t y , p a r a n o i d d e l u s i o n s and depressions. 5.  Proper f a c i l i t i e s must e x i s t f o r the p a t i e n t w i t h i n t h e  home.  F o r example, the absence of s t a i r s f o r the p a t i e n t w i t h  a cardiac i n s u f f i c i e n c y . B.  Self-Care T h i s i s a form of placement where the p a t i e n t i s  d i s c h a r g e d on h i s / h e r own d e v i c e s , u s u a l l y t o t h e home vacated a t t h e time o f admission.  The T a b l e on page 5^  i n d i c a t e s t h e r a r i t y with which t h i s type o f placement i s made.  Not o n l y do few p a t i e n t s show such mental improve-  ment t h a t they can f u n c t i o n without  any s u p e r v i s i o n , but,  because of t h e age f a c t o r alone, d i s c h a r g e candidates a r e d i s c o u r a g e d from t h i n k i n g i n terms o f s e l f - c a r e .  Very  c a r e f u l c o n s i d e r a t i o n by both the M e d i c a l and S o c i a l S e r v i c e Departments i s g i v e n b e f o r e a placement o f t h i s nature i s made. The  c r i t e r i a f o r discharge to s e l f - c a r e are: 1.  O r i e n t e d i n a l l spheres  (time, p l a c e , p e r s o n ) .  In  o t h e r words, m e n t a l l y b r i g h t and a l e r t . 2.  Awareness and acceptance  physical  of t h e i r own mental and  capabilities.  3.  Memory - i n t a c t .  k.  A b i l i t y t o f u n c t i o n without s u p e r v i s i o n .  5.  M o t i v a t i o n - t h i s type of placement must be requested  by t h e p a t i e n t . 6.  I n t e r e s t e d f a m i l y member or f r i e n d i n the a r e a .  6o Someone who  would normally be i n touch w i t h the p a t i e n t by  telephone or i n person on a d a i l y b a s i s as a p r e c a u t i o n i n the event t h a t the p a t i e n t might s u f f e r from an a c c i d e n t or  illness  w i t h i n the home. The  study of each of the l i c e n s e d r e s o u r c e s i n community  w i l l b e g i n w i t h a s i m p l i f i e d c h a r t based Acts  1  and twenty-four  upon the  q u e s t i o n n a i r e s (Appendix  D)  licensing completed  by both boarding and n u r s i n g home s t a f f . The h o s p i t a l - s e t c r i t e r i a f o r d i s c h a r g e w i l l f o l l o w an examination 2.  of each r e s o u r c e .  L i c e n s e d Nursing Homes Nursing f a c i l i t i e s  - minimum-good bedside n u r s i n g c a r e .  P h y s i c a l f a c i l i t i e s - P r i v a t e rooms, s e m i - p r i v a t e and four-bed wards.  Lounges.  Staff Training  - Graduate nurse i n charge.  Supervision  - Twenty-four hour c a r e  Cost of Care  - P r i v a t e $ 1 0 . - l 6 . per day and  (three s h i f t s ) . up.  Welfare $205. per month (ward o n l y ) . P a t i e n t ' s degree of p h y s i c a l d e t e r i o r a t i o n - No  limit.  Nursing Homes v a r y i n the amount of n u r s i n g care they are prepared t o o f f e r .  The minimum requirement  i n the c h a r t i s "good bedside c a r e " .  facilities as  outlined  However, the m a j o r i t y  o f n u r s i n g homes b u i l t w i t h i n the past few y e a r s are modern1  2  H o s p i t a l Act, op. c i t . and Welfare I n s t i t u t i o n s L i c e n s i n g A c t , op. c i t . The O f f i c e of the I n s p e c t o r of H o s p i t a l s i s c u r r e n t l y p r e p a r i n g , f o r government acceptance and p u b l i c a t i o n , d e f i n i t i o n s c o v e r i n g such terms.  6i s t y l e d , one-storey b u i l d i n g s o f f e r i n g complete n u r s i n g facilities  (excluding surgery).  Private Hospitals.  They a r e u s u a l l y known as  I t i s t o these r e s o u r c e s t h a t V a l l e y v i e w  p a t i e n t s who r e q u i r e n u r s i n g care a r e d i s c h a r g e d as the s e r v i c e s and f a c i l i t i e s  o f f e r e d a r e comparable t o those  a b l e on the i n f i r m a r y wards w i t h i n V a l l e y v i e w  avail-  itself.  Nursing home placements have been very s u c c e s s f u l t o d a t e . There was only one r e t u r n t o h o s p i t a l i n the past F i s c a l Year and the demands of post d i s c h a r g e f o l l o w - u p i n t h i s area have been m i n i m a l . peated  One of the reasons  1  f o r t h i s has been the r e -  use o f those homes wherein s u c c e s s f u l d i s c h a r g e s have  a l r e a d y been made.  One home has accepted  over f o r t y p a t i e n t s  i n the past two years w i t h no r e t u r n s t o h o s p i t a l . The m a j o r i t y of n u r s i n g homes accept w e l f a r e p a t i e n t s , although t h i s i s not a l i c e n s i n g requirement.  However, the  number o f w e l f a r e beds i s l i m i t e d and t h i s p r e s e n t s a problem of  delay i n discharge.  a r e extremely  Welfare beds f o r V a l l e y v i e w p a t i e n t s  l i m i t e d i n number.  A second a r e a o f concern i n n u r s i n g home placements i s the f a c t t h a t while s u p e r v i s i o n i s g i v e n by Graduate Nurses, t h e r e i s no assurance nursing.  t h a t these nurses a r e experienced  The pre-admission  i n t a k e conferences  i n psychiatric  h i s t o r i e s and assessments made a t  of p a t i e n t s who have been admitted  from  n u r s i n g homes g i v e a f a i r l y r e l i a b l e p i c t u r e o f the c a l i b r e and nature of the s e r v i c e s g i v e n by the homes i n v o l v e d . 1  Returns t o h o s p i t a l w i l l "Discharge Follow-up".  be d i s c u s s e d under the s e c t i o n  62 There i s a l s o a shortage o f O c c u p a t i o n a l Therapy and R e c r e a t i o n a l Therapy i n n u r s i n g homes, although r e c o g n i t i o n of the need f o r Physiotherapy i s becoming more and more The  apparent.  c r i t e r i a of the h o s p i t a l f o r d i s c h a r g e t o a n u r s i n g home  are: 1.  The p a t i e n t must be p h y s i c a l l y i n need f o r n u r s i n g c a r e .  2.  The p a t i e n t must not be a d i s t u r b i n g i n f l u e n c e f o r other  patients. 3.  L i c e n s e d Boarding Homes Nursing f a c i l i t i e s  - none r e q u i r e d .  Physical f a c i l i t i e s  - Private, semi-private, three t o f o u r bed wards. service.  D i n i n g room or t r a y Lounges.  Staff Training  - none r e q u i r e d .  Supervision  - Day care (operator and/or owner or s t a f f member must be present i n t h e home a t a l l times.  P a t i e n t ' s degree o f physical deteriorationCost of Care  ambulatory.  - P r i v a t e $ 1 1 0 . - 2 5 0 . per month  (based  on g e n e r a l accommodation and care needs. Welfare  $95*  P  e r  month (ward o n l y ) .  Boarding homes, r e s t homes, guest houses or comfort homes, whichever t h e owners p r e f e r t o c a l l them, range i n d i v i d u a l l y from warm, comfortable "homes away from home" t o l i t t l e more than b a r r e n rooming houses. As i n d i c a t e d i n the o u t l i n e , no n u r s i n g f a c i l i t i e s a r e  63 required.  The p a t i e n t s have t h e i r i n d i v i d u a l d o c t o r s w i t h i n  the community and day care o n l y i s p r o v i d e d w i t h i n the b u i l d i n g a t a l l times.  U s u a l l y t h e o p e r a t o r and/or owner l i v e s  w i t h i n t h e home. A l l p a t i e n t s must be ambulatory.  Regardless  of how long  they have l i v e d i n t h e home, when a p a t i e n t ' s c o n d i t i o n and c a r e needs r e q u i r e c h r o n i c n u r s i n g care, t h e p a t i e n t must be moved t o a l i c e n s e d n u r s i n g home.  Those persons  with  temporary i l l n e s s e s , o f course, can remain i n the boarding home under t h e i r p h y s i c i a n ' s c a r e . Twenty-nine percent of p a t i e n t s d i s c h a r g e d w i t h i n the past F i s c a l Year were d i s c h a r g e d t o boarding homes.  Returns t o  h o s p i t a l from these placements w i l l be d i s c u s s e d l a t e r .  It i s  noted, however, t h a t boarding home placements tend t o be the most d i f f i c u l t and u n s t a b l e .  Such placements tend t o r e q u i r e  the c l o s e s t f o l l o w - u p care and a t t e n t i o n .  Some o f t h e reasons  f o r t h i s w i l l be d i s c u s s e d i n the f o l l o w i n g paragraphs. One  of the most d i f f i c u l t problems i n u s i n g boarding homes  as a r e s o u r c e i s the l a c k o f t r a i n e d s t a f f .  I t i s unfortunate  t h a t t h e r e g u l a t i o n s which g i v e such s t r i c t and d e t a i l e d a t t e n t i o n t o the p h y s i c a l aspects of the b u i l d i n g i t s e l f , do not go f u r t h e r t o p r o v i d e assurance t h a t candidates f o r l i c e n s e s have a working knowledge and understanding o f t h e p a t i e n t s who a r e e n t r u s t e d t o t h e i r c a r e .  Many, although  l i c e n s e d t o care f o r the aged, have no understanding  of the  needs and behaviour p a t t e r n s o f the p a t i e n t s who a r e s e n i l e . Others do t r y w i t h good i n t e n t i o n s , but, without  t r a i n i n g of  6k any  k i n d , they must r e l y only on t h e i r own  any  c l u e s they may  l e a r n , r i g h t l y or wrongly, from e x p e r i e n c e .  T h i s c r e a t e s a range of operators  from "the warden" who  s t i t u t e s a u t h o r i t y f o r knowledge t o the the use  of a u t h o r i t y of any k i n d .  understanding and  p e r s o n a l i t i e s and  " t i m i d one"  sub-  who  fears  Equally lacking i n r e a l i s t i c  c o n t r o l s , both types of o p e r a t o r s  fail.  Night courses have been o f f e r e d from time t o time to boarding home operators voluntary  by the H e a l t h and Welfare Department but on a  basis  only.  Another problem i n t h i s area i s the l i m i t e d amount of supervision. discussed  The  q u a l i t y of care and  i n the p r e c e d i n g  paragraph.  s u p e r v i s i o n w i l l be d i s c u s s e d . quite well during peak of c o n f u s i o n ,  s u p e r v i s i o n has  been  Here the amount of  Many aged p a t i e n t s can manage  the day w i t h minimum s u p e r v i s i o n but and,  their  i f they are so i n c l i n e d , tendency t o  wander, u s u a l l y comes at n i g h t .  Although the  regulations  r e q u i r e a s t a f f member i n the home at a l l times, t h i s does not mean t h a t they are on duty a t n i g h t but  only t h a t they must  be  s l e e p i n g i n the home. A t h i r d problem i s the p h y s i c a l l a y o u t of many of homes.  Converted o l d e r homes present  a problem i n the number  of s t a i r s between h i g h - c e i l i n g f l o o r s and t o the b u i l d i n g .  the  at the  entranceways  With a lounge and k i t c h e n f a c i l i t i e s ,  s l e e p i n g room i s a v a i l a b l e on the main f l o o r .  little  Most p a t i e n t s ,  t h e r e f o r e , must be a b l e t o climb a f l i g h t of s t a i r s , or at l e a s t , i f they are on the main f l o o r , handle the stairs.  outside  6 Another  problem  5  i s the l a c k o f o p p o r t u n i t i e s f o r  O c c u p a t i o n a l and R e c r e a t i o n a l a c t i v i t i e s . the country w i t h acreage around  Boarding homes i n  them have l e s s o f a problem  w i t h the l a t t e r but many p a t i e n t s , accustomed t o urban n a t u r a l l y wish t o r e t u r n t o f a m i l i a r  living,  surroundings.  As a n a t u r a l r e s u l t of these problems t h e r e a r e a number of vacant beds I n b o a r d i n g homes which a r e u n s u i t a b l e f o r V a l l e y v i e w p a t i e n t s because o f shortcomings  i n the q u a l i t y and  q u a n t i t y o f s u p e r v i s i o n , s t a b i l i z i n g t h e r a p e u t i c l i m i t s , or j u s t the p h y s i c a l l a y o u t of the home.  On t h e other hand, t h e r e  a r e p a t i e n t s ready f o r d i s c h a r g e t o boarding home f a c i l i t i e s who must await s u i t a b l e v a c a n c i e s . Based upon the c a p a b i l i t i e s and l i m i t a t i o n s of boarding homes which have been c i t e d , the h o s p i t a l has s e t the f o l l o w i n g c r i t e r i a f o r d i s c h a r g e t o such homes: 1.  O r i e n t e d t o p l a c e , person.  That i s t o say, s u f f i c i e n t l y  a l e r t m e n t a l l y t o c o r r e c t l y r e c o g n i z e t h e i r surroundings and the people w i t h whom they a r e l i v i n g . 2.  A b i l i t y t o e s t a b l i s h some degree  of r e l a t i o n s h i p , to  communicate, v e r b a l l y or otherwise, with t h e i r f e l l o w p a t i e n t s and w i t h 3.  staff.  Cooperative toward  t a k i n g m e d i c a t i o n and o b s e r v i n g the  b o a r d i n g home r e g u l a t i o n s . 4.  Desirous o f a placement  i n a b o a r d i n g home as opposed  to, f o r instance, s e l f - c a r e . 5.  Memory s a t i s f a c t o r y f o r r e c e n t and past events.  6.  Good s l e e p h a b i t s .  ( i . e . no h a b i t s t h a t would be  66 deemed p e c u l i a r o r d i s t u r b i n g t o o t h e r  guests.)  7.  Ambulatory.  8.  A b l e t o c a r e f o r p e r s o n a l needs w i t h minimum degree o f  supervision. 9.  I f d e l u s i o n a l , such d e l u s i o n s s h o u l d n o t be i n t e r f e r i n g  o r pose a t h r e a t t o s a f e t y o f p a t i e n t o r t o o t h e r s w i t h whom he w i l l be a s s o c i a t e d . The p h y s i c a l l i m i t a t i o n s o f p a t i e n t (e.g. a p a t i e n t w i t h a h e a r t c o n d i t i o n ) a r e c o n s i d e r e d on an i n d i v i d u a l b a s i s when s e l e c t i n g an a p p r o p r i a t e home.  The e x t e n t o f t h e p a t i e n t ' s  a c t i v i t y i n O c c u p a t i o n a l and R e c r e a t i o n a l Therapy i s h o s p i t a l i s compared w i t h what t h e i n d i v i d u a l home has t o o f f e r . example, a p a t i e n t who l i k e s g a r d e n i n g which has g a r d e n i n g k.  For  i s p l a c e d i n a home  facilities.  " B o a r d i n g Homes S p e c i a l " Nursing f a c i l i t i e s  - Emergency equipment (e.g.  Physical f a c i l i t i e s  - P r i v a t e , s e m i - p r i v a t e and t h r e e and f o u r - b e d wards. or t r a y s e r v i c e .  oxygen).  D i n i n g room  Lounges.  (Same  as s t a n d a r d b o a r d i n g home.) Staff Training  T r a i n e d p s y c h i a t r i c nurse i n charge and p r o v i d i n g s u p e r v i s i o n for  Supervision  a l l other  staff.  Twenty-four hour c a r e ( t h r e e shifts).  P a t i e n t ' s degree o f physical deterioration  Ambulatory (same as s t a n d a r d 'boarding homes).  6 Cost o f Care  7  - P r i v a t e $125.-250. based on care needs. Welfare  $95*  P  e r  month - a c c e p t -  ed on temporary, emergency b a s i s only. Although a c o n s e r v a t i v e estimate of twenty-three of  percent  our p a t i e n t s p r e s e n t l y q u a l i f y f o r t h i s type of placement  l e s s than t e n percent were p l a c e d i n such homes i n the l a s t F i s c a l Year.  Yet the two homes i n v o l v e d a r e c o n s t a n t l y f a c e d  w i t h vacant beds.  The reason i s p r i m a r i l y f i n a n c i a l .  As  o u t l i n e d i n the c h a r t the Welfare r a t e i s accepted on a temporary b a s i s o n l y .  T h i s f i n a n c i a l problem l i e s  i n the f a c t  t h a t these homes a r e not prepared t o o f f e r t h e type o f s e r v i c e they can g i v e on a w e l f a r e r a t e f o r boarding homes of month.  $95*  P  e r  To the present time, any i n c r e a s e i n the amount o f  b o a r d i n g home r a t e s f o r care needs has not been forthcoming from the Department o f W e l f a r e . With a s t a f f under the charge o f a t r a i n e d Nurse, p a t i e n t s a r e s u p e r v i s e d by a person w i t h t r a i n i n g and q u a l i f i c a t i o n s .  Psychiatric suitable  With twenty-four hour care they  have the amount o f s u p e r v i s i o n needed as w e l l . The major r o l e of such homes i n r e l a t i o n t o V a l l e y v i e w H o s p i t a l had been i n managing t e m p o r a r i l y w i t h  difficult  p a t i e n t s who were a w a i t i n g admission t o the h o s p i t a l . the e l i m i n a t i o n of the w a i t i n g l i s t ,  With  t h i s r o l e has v i r t u a l l y  disappeared. Because o f the s t a f f i n these homes, t h e i r  understanding,  68 t r a i n i n g and s p e c i a l a b i l i t y t o manage, c r i t e r i a  of Valleyview  H o s p i t a l f o r d i s c h a r g e t o such homes a r e : 1.  P a t i e n t must have ample p r i v a t e means o f support.  2.  P a t i e n t must be ambulatory.  (Licensing regulation.)  To date, these homes have been a b l e t o cope w i t h a l l p s y c h i a t r i c g e r i a t r i c problems and w i t h the c l o s e s u p e r v i s i o n p r o v i d e d by an i n t e r e s t e d community d o c t o r , have been a b l e t o p r o v i d e treatment  and t o s t a b i l i z e the c o n d i t i o n of many  p a t i e n t s who would otherwise have r e q u i r e d admission t o Valleyview Hospital. I t i s u n f o r t u n a t e , however, t h a t a p a t i e n t ' s f i n a n c i a l p o s i t i o n i s a determining f a c t o r i n whether he spends the remainder  of h i s l i f e i n a mental h o s p i t a l o r r e t u r n s t o a  b o a r d i n g home i n the community.  DISCHARGE In  order t o i n t r o d u c e and m a i n t a i n the "open door"  p h i l o s o p h y o f V a l l e y v i e w H o s p i t a l i t was necessary t o have support from such r e s o u r c e s i n community as v a r i o u s Welfare Departments, H e a l t h Departments, V i c t o r i a n Order M e d i c a l Doctors, and P o l i c e .  of Nurses,  I t was, and i s , necessary t o  a l l e v i a t e any concern they may have r e g a r d i n g d i s c h a r g e s o f p s y c h i a t r i c g e r i a t r i c p a t i e n t s back i n t o community, some of whose s o c i a l h i s t o r i e s i n d i c a t e long and f r e q u e n t of  involvement  the time and e f f o r t of many, i f not a l l , o f the a f o r e -  mentioned a g e n c i e s .  At the same time, b o a r d i n g home o p e r a t o r s ,  n u r s i n g home owners, and f a m i l i e s had t o be assured t h a t they  6 were not l e a v i n g themselves  9  open t o unwelcomed g r i e f w i t h a  d i s c h a r g e d p a t i e n t they c o u l d not handle and c o u l d not have removed without overcoming In  almost insurmountable o b s t a c l e s .  s h o r t , the e r a o f w a i t i n g l i s t s a t V a l l e y v i e w H o s p i t a l had  left  i t s mark and these people, agencies and groups, were  understandably c a u t i o u s about a g a i n assuming the care of a p a t i e n t t h i s h o s p i t a l c o n s i d e r s ready f o r d i s c h a r g e . In  order t o o f f e r assurance and support t o those i n the  community i n v o l v e d d i r e c t l y or i n d i r e c t l y w i t h d i s c h a r g e d p a t i e n t s , and t o the p a t i e n t s themselves, of  p r o b a t i o n was c r e a t e d .  an i n d e f i n i t e  form  I t allows a patient to r e t u r n to  h o s p i t a l , i f necessary, a t any time a f t e r d i s c h a r g e , q u i c k l y and without the need f o r r e c e r t i f i c a t i o n .  By i t s v e r y nature,  t h i s type o f p r o b a t i o n p r o v i d e s an easy flow back i n t o h o s p i t a l and,  i n t e r e s t i n g l y enough, has helped o p e r a t o r s , owners, and  f a m i l i e s t o cope with many more problems s i n c e they know t h a t the h o s p i t a l i s ready and w i l l i n g t o be of a s s i s t a n c e i f c a l l e d upon. U n f o r t u n a t e l y , t h e r e remain  some l o c a l Departments of  Welfare and n u r s i n g homes which a r e extremely r e l u c t a n t t o accept p a t i e n t s from V a l l e y v i e w H o s p i t a l under any c o n d i t i o n s . U s u a l l y these Welfare Departments r e g a r d committal to  be permanent.  o f t h e aged  With t h e i r own busy schedules, they r e s e n t  a p p l i c a t i o n s f o r the r e t u r n o f former a r e b e t t e r cared f o r i n h o s p i t a l .  c l i e n t s whom they  At the same time  the h o s p i t a l t o be prepared f o r admissions a t t i t u d e of the n u r s i n g homes would appear,  feel  they.expect  indefinitely.  The  f o r the most p a r t ,  70 to  r e f l e c t the age-old stigma of mental i l l n e s s , as w e l l as  an  outmoded p h i l o s o p h y r e g a r d i n g the care of the aged. There are two  other forms of d i s c h a r g e but these  seldom used a t t h i s time. 1.  Discharge  are  These are:  in Pull  I t must be used under the f o l l o w i n g c o n d i t i o n s : a) f o r v o l u n t a r y  admissions  b) f o r those d i s c h a r g e d t o addresses province.  o u t s i d e the  (e.g. I t a l y and A l b e r t a w i t h i n the past  F i s c a l Year.) 2.  Six-months P r o b a t i o n T h i s i s used i n cases of s e l f - c a r e or f a m i l y placement  at  the request of the p a t i e n t or f a m i l y members.  Depending  upon the adjustment the p a t i e n t makes t o h i s environment he or she w i l l ,  a t the end of the six-month p e r i o d , be  discharged i n f u l l  either  or t r a n s f e r r e d t o the i n d e f i n i t e form of  probation. N e i t h e r form of p r o b a t i o n i s meant t o be r e s t r i c t i v e i n any way a full  and,  should the f a m i l y wish i t , t h i s can be changed to  d i s c h a r g e a t any  An important  time.  aspect of d i s c h a r g e p l a n n i n g i s the r o l e of  the P u b l i c T r u s t e e .  Most persons  admitted  to Valleyview  H o s p i t a l w i l l , by the v e r y nature of t h e i r c o n d i t i o n , be c o n s i d e r e d " i n c a p a b l e of managing t h e i r own  affairs".  Where  the appointment of a "Quasi Committee" has not been made by Supreme Court p r i o r to admission  the  of such a p a t i e n t , a c t i o n i s  a u t o m a t i c a l l y taken t o d e s i g n a t e the P u b l i c T r u s t e e as  the  71 g u a r d i a n or "committee" of the p a t i e n t . The f u n c t i o n of the P u b l i c T r u s t e e i s ( i n a t r u s t c a p a c i t y ) to r e c e i v e and d i s b u r s e a l l monies on b e h a l f of the p a t i e n t ; t o r e c e i v e , h o l d , p r o t e c t and,  i f necessary,  sell  such p r o p e r t y or a s s e t s of a p a t i e n t , and t o i n v e s t monies i n approved  securities.  By the very nature of t h e i r c o n d i t i o n , the m a j o r i t y of p a t i e n t s w i l l be d i s c h a r g e d as " i n c a p a b l e of managing t h e i r own  affairs".  T h i s means t h a t the P u b l i c T r u s t e e must assume  r e s p o n s i b i l i t y f o r more and more p a t i e n t s .  (472  admissions  the F i s c a l Year 1964-65 a t V a l l e y v i e w H o s p i t a l a l o n e . ) Lack of s t a f f and, adequately  in  1  t h e r e f o r e , i n s u f f i c i e n t time to d e a l  w i t h the problems of i n d i v i d u a l p a t i e n t s has  r e s u l t e d i n d e l a y s both i n a c t u a l d i s c h a r g e s from h o s p i t a l  and  i n i n i t i a l payments t o o p e r a t o r s , owners, and p a t i e n t s a f t e r discharge. affected.  T h i s has  c r e a t e d undue s t r e s s and h a r d s h i p on  Such s t r e s s has  ment i n community and has  those  o f t e n hampered a p a t i e n t ' s a d j u s t complicated the post  discharge  f o l l o w - u p s e r v i c e from h o s p i t a l .  FOLLOW-UP SERVICES Those p a t i e n t s d i s c h a r g e d w i t h i n the Lower  Mainland  r e c e i v e f o l l o w - u p s e r v i c e s , a s s i s t a n c e , and a d v i c e where needed, from the S o c i a l Workers a t V a l l e y v i e w H o s p i t a l . remainder of the p r o v i n c e the Mental 1  In the  H e a l t h Centres have been  V a l l e y v i e w H o s p i t a l s t a t i s t i c s as yet  unpublished.  72 o f tremendous a s s i s t a n c e t o the p a t i e n t s and have kept V a l l e y v i e w H o s p i t a l i n touch w i t h the ..progress and adjustment of each p a t i e n t i n the community. Most of the l o c a l Department o f S o c i a l Welfare have cooperated with the h o s p i t a l S o c i a l S e r v i c e Department i n placement and f o l l o w - u p s e r v i c e s .  Many of these Departments  welcome the h o s p i t a l a s s i s t a n c e ; the Vancouver Department, however, p r e f e r s t o p r o v i d e these s e r v i c e s from t h e i r own agency t o w e l f a r e p a t i e n t s r e t u r n e d t o t h a t c i t y .  Although a  l a r g e m a j o r i t y o f p a t i e n t s a r e admitted from the Vancouver a r e a , the number of d i s c h a r g e s t o the C i t y a r e very s m a l l . N u r s i n g homes i n t h i s area a r e r e l u c t a n t t o accept V a l l e y v i e w H o s p i t a l p a t i e n t s , p a r t i c u l a r l y those i n r e c e i p t of government f i n a n c i a l a s s i s t a n c e and many delays a r e experienced i n p l a c i n g such p a t i e n t s i n b o a r d i n g homes because of the heavy demands f o r t h i s type o f placement. Although the r e t u r n s t o h o s p i t a l have been l e s s t e n percent placements),  than  ( s i x t y - o n e percent of t h i s from boarding home the demands f o r f o l l o w - u p e s p e c i a l l y i n boarding  home placements have been e x t e n s i v e .  The main reason f o r t h i s  has been t h e i n e x p e r i e n c e of o p e r a t o r s .  T h e i r l a c k o f under-  s t a n d i n g of the problems of t h e i r aged p a t i e n t s c r e a t e s a constant need f o r a s s i s t a n c e and a d v i c e from the h o s p i t a l workers.  U n f o r t u n a t e l y the S o c i a l Workers a r e o f t e n unable,  w i t h the demands on t h e i r time, t o g i v e as much h e l p t o each o p e r a t o r as r e q u i r e d . There have been f o u r f a m i l y , one n u r s i n g home, and e i g h t  73 b o a r d i n g home r e t u r n s t o h o s p i t a l o f those d i s c h a r g e d w i t h i n the F i s c a l Year 1 9 6 ^ - 6 5 .  1  This represents a t o t a l of t h i r t e e n  or nine percent o f d i s c h a r g e s .  One p a t i e n t readmitted  from a  b o a r d i n g home was d i s c h a r g e d a g a i n two weeks l a t e r t o another b o a r d i n g home and has a d j u s t e d w e l l i n the second home. r e a d m i s s i o n from a f a m i l y placement was depressed daughter's  over a  i l l n e s s but was a b l e t o r e t u r n t o the f a m i l y e i g h t  days l a t e r .  A second r e t u r n from f a m i l y was due t o sudden  physical deterioration. remaining  One  The p a t i e n t has s i n c e e x p i r e d .  The  t e n p a t i e n t s s u f f e r e d r e l a p s e s and were r e t u r n e d t o  h o s p i t a l because they had become management problems.  The s t a y  out o f h o s p i t a l ranged from t e n days ( f o r an a l c o h o l i c ) t o seven months. There i s one area where v a l u a b l e h e l p has been f o r t h coming, and, i n f a c t , has made d i s c h a r g e p o s s i b l e .  This i s  the s e r v i c e o f f e r e d by the V i c t o r i a n Order o f Nurses and P u b l i c H e a l t h Nurses.  D i a b e t i c p a t i e n t s have been d i s c h a r g e d  t o t h e i r homes, and boarding homes, because o f the w i l l i n g n e s s and  c o o p e r a t i o n o f these agencies t o p r o v i d e d a i l y  therapy.  insulin  One p a t i e n t has been out of h o s p i t a l two years  because of the a v a i l a b i l i t y o f t h i s  service.  T h i s chapter has presented some o f t h e problems and l i m i t a t i o n s inherent i n the resources p r e s e n t l y a v a i l a b l e i n community and the e f f e c t s o f these problems and l i m i t a t i o n s on the d i s c h a r g e c r i t e r i a of V a l l e y v i e w H o s p i t a l .  The next,  c o n c l u d i n g chapter w i l l present a summary, case h i s t o r i e s , the f i n d i n g s and recommendations of t h i s 1  Valleyview Hospital S t a t i s t i c s .  study.  CHAPTER  V  ANALYSIS OP STUDY AND CONCLUSIONS  There a r e ever i n c r e a s i n g demands from the,community f o r the s e r v i c e s of V a l l e y v i e w H o s p i t a l . oured  The h o s p i t a l has endeav-  t o meet these demands by changing  c u s t o d i a l care of p a t i e n t s t o treatment p a t i e n t s : the "open d o o r  1  philosophy.  i t s r o l e from t h a t of and d i s c h a r g e of T h i s study has attempt-  ed t o assess the e f f e c t i v e n e s s o f t h i s "open door" philosophy which permeates the l i f e o f the h o s p i t a l and t h e h o s p i t a l ' s f u n c t i o n i n r e l a t i o n t o t h e community. We have presented a g e n e r a l view of the problems and pote n t i a l s d i r e c t l y b e a r i n g on aging i n B r i t i s h Columbia and, i n t u r n , on p s y c h i a t r i c g e r i a t r i c p a t i e n t s i n V a l l e y v i e w H o s p i t a l . Secondly, finally,  we have d i s c u s s e d the team approach t o treatment and d i s c h a r g e c r i t e r i a i n r e l a t i o n t o community r e s o u r c e s .  D i s c u s s i o n of such matters  as a team approach,  p l a n s , c r i t e r i a f o r d i s c h a r g e i s , i n the l o n g run, only i n terms o f human b e i n g s .  significant  In order t o b r i n g a l i v e , t o  g i v e added meaning t o the study, we a r e c i t i n g , chapter, some case  treatment  illustrations.  i n this  75  Case H i s t o r y I D i s c h a r g e d t o B o a r d i n g Home.  Admitted  to Valleyview  H o s p i t a l J u l y 2 0 , 1964. Mrs. A., 90 y e a r s o f age,  i s a woman w i t h g r a d u a l m e n t a l  d e t e r i o r a t i o n c a u s i n g p a r a n o i d a l t h i n k i n g f o r t h e p a s t two years.  She has been known t o t h e S o c i a l S e r v i c e Department i n  Vancouver s i n c e 1958*  Mrs. A. i s a widow; she has one m a r r i e d  son, b u t was l i v i n g a l o n e .  R e c e n t l y she became  confused,  s t a t i n g t h a t a "man was p e r s e c u t i n g h e r and c o n t r o l l i n g h e r mind w i t h a machine". for  The son took h e r i n t o h i s home where,  a s h o r t w h i l e , she improved.  B u t e v e n t u a l l y she became  s u s p i c i o u s o f t h e f a m i l y , a c c u s i n g them o f s t e a l i n g h e r b e l o n g i n g s and " p o i s o n i n g " h e r f o o d . daughter-in-law  She f i n a l l y a t t a c k e d h e r  and had t o be t a k e n as an emergency case t o  Vancouver G e n e r a l H o s p i t a l .  N o t h i n g c o u l d be done f o r h e r  t h e r e and she was a d m i t t e d t o V a l l e y v i e w H o s p i t a l . I n h o s p i t a l h e r d i a g n o s i s was " P a r a n o i d a l D e l u s i o n S t a t e , w i t h v e r y l i t t l e C h r o n i c B r a i n Syndrome". Remarkable p r o g r e s s has been n o t e d s i n c e a d m i s s i o n .  By  August 2 , 1964, t h e p a t i e n t improved t o t h e e x t e n t t h a t she was  f r i e n d l y , c o o p e r a t i v e and n o t d e l u s i o n a l .  O c c u p a t i o n a l Therapy and had ground p r i v i l e g e s . 1964,  She a t t e n d e d I n October,  Mrs. A. was r e f e r r e d t o S o c i a l S e r v i c e Department f o r  discharge planning.  The d i s c h a r g e p l a n was d i s c u s s e d w i t h  Mrs. A. and h e r f a m i l y and i t was e v i d e n t t h a t t h e f a m i l y would be unable t o c a r e f o r h e r s u c c e s s f u l l y .  Therefore, the  S o c i a l Worker e n l i s t e d t h e c o o p e r a t i o n o f t h e Vancouver C i t y  76 S o c i a l S e r v i c e Department i n p r o v i d i n g f i n a n c i a l a s s i s t a n c e . Mrs. A. was s u b s e q u e n t l y d i s c h a r g e d t o a b o a r d i n g home a f t e r she had v i s i t e d t h e proposed b o a r d i n g home and agreed t o go there. Mrs. A. i s known t o be d o i n g w e l l i n t h e b o a r d i n g home and i s v e r y happy.  The f a m i l y i s v e r y s a t i s f i e d w i t h t h i s  arrangement.  Case H i s t o r y I I "in-Between" Case. D i s c h a r g e d t o B o a r d i n g Home s t a f f e d w i t h p s y c h i a t r i c  nurses.  Mrs. B. i s a seventy-two y e a r o l d woman who has one son and two d a u g h t e r s , a l l o f whom a r e m a r r i e d .  This patient  l i v e d w i t h one o f h e r daughters and managed f a i r l y w e l l  until  October, 19^2, when she had a c e r e b r a l v a s c u l a r a c c i d e n t and as a r e s u l t e x p e r i e n c e d m i l d memory l o s s and c o n f u s i o n . d e v e l o p e d unreasonable  f e a r and a p p r e h e n s i o n ;  She  she was a f r a i d  t o do a n y t h i n g o r go anywhere, a f r a i d o f f a l l i n g and o f getting lost.  She s t a t e d t h a t she i s " g o i n g c o m p l e t e l y t o  pieces mentally". Mrs. B. was a d m i t t e d t o V a l l e y v i e w H o s p i t a l i n May, 19&3* and diagnosed as " C h r o n i c B r a i n Syndrome a s s o c i a t e d w i t h Cerebral A r t e r i o s c l e r o s i s with Behavioural Reaction". The p r o g n o s i s was good and she was r e f e r r e d t o S o c i a l S e r v i c e Department f o r d i s c h a r g e p l a n n i n g a f t e r t h e a d m i s s i o n conference.  77 In h o s p i t a l her whole mental outlook s t e a d i l y  improved.  She.became i n t e r e s t e d i n O c c u p a t i o n a l Therapy work and i n the various recreational  activities.  The S o c i a l Worker had a s e r i e s of i n t e r v i e w s with Mrs. B. d u r i n g which her d i s c h a r g e was d i s c u s s e d .  Although  Mrs. B.  was w i l l i n g t o t a l k about d i s c h a r g e t o community, she was r e l u c t a n t t o leave the h o s p i t a l as she was v e r y dependent upon her doctor and the nurses on her ward. On September o f the same year, Mrs. B.'s doctor t h a t she was ready f o r d i s c h a r g e .  considered  The S o c i a l Worker spoke  w i t h the f a m i l y about plans f o r d i s c h a r g e and by t h i s Mrs. B. h e r s e l f was w e l l a b l e t o accept d i s c h a r g e .  time  A  s u p e r v i s e d b o a r d i n g home was c o n s i d e r e d most a p p r o p r i a t e f o r her because t h e r e she would r e c e i v e the necessary a t t e n t i o n of the s t a f f .  She i s expected  support and  t o become  apprehensive  and upset p e r i o d i c a l l y and w i l l become v e r y a t t a c h e d t o the b o a r d i n g home s t a f f as she was t o the n u r s i n g s t a f f i n , Valleyview Hospital.  The f a m i l y agreed t o v i s i t  regularly  and O c c u p a t i o n a l Therapy w i l l be p r o v i d e d t o h e l p her t o r e t a i n her i n t e r e s t i n manual work.  In a d d i t i o n , p e r i o d i c  follow-up  from the V a l l e y v i e w H o s p i t a l S o c i a l S e r v i c e Worker w i l l be necessary t o g i v e Mrs. B. a d d i t i o n a l support  so t h a t she may  f u n c t i o n w e l l i n the community.  Case H i s t o r y I I I Discharge  t o a Nursing Home.  Admitted t o V a l l e y v i e w H o s p i t a l June, 1 9 6 2 .  Mr. C , who i s seventy-nine years o l d , was admitted  from  78 S t . P a u l ' s H o s p i t a l where he had been a d m i t t e d because o f  an  a c u t e e p i s o d e o f nausea, v o m i t i n g  been  manifesting  and  distention.  He had  s i g n s of f o r g e t f u l n e s s f o r seven y e a r s p r i o r t o  admission to Valleyview  Hospital.  He p r o g r e s s i v e l y became  s u s p i c i o u s , d i s t u r b i n g , s e l f i s h , and h o s t i l e t o everyone. was  often described  never d i s p l a y e d Mr.  suicidal  C. had  house and  as h a v i n g l o s t i n t e r e s t i n l i f e , but  He he  tendencies.  l i v e d with h i s bed-ridden wife i n a d i l a p i d a t e d  c a r e d f o r h e r u n t i l her d e a t h i n 1961.  her d e a t h h i s mental: c o n d i t i o n . d e t e r i o r a t e d . a l c o h o l i c beverages e x c e s s i v e l y , was many p h y s i c a l problems. P a u l ' s H o s p i t a l , and  Following  He  drank  u n d e r n o u r i s h e d and  E v e n t u a l l y he was  admitted to St.  from t h e r e t o V a l l e y v i e w  D i a g n o s i s on a d m i s s i o n t o V a l l e y v i e w  had  Hospital.  H o s p i t a l was  "Chronic  B r a i n Syndrome a s s o c i a t e d w i t h S e n i l e B r a i n D i s e a s e a g g r a v a t e d with Alcoholism,  M a l n u t r i t i o n and  At V a l l e y v i e w  Anemia".  H o s p i t a l t h i s p a t i e n t was  back t o a b e t t e r p h y s i c a l and mental s t a t e . cooperative, considered ation.  pleasant  and  friendly.  referred to Valleyview  Department f o r d i s c h a r g e p l a n n i n g  Mr.  C.  Hospital Social  i n February,  d i s c h a r g e was plan.  the most a p p r o p r i a t e  H i s f a m i l y , when c o n s u l t e d ,  Several  being considered  and  was  physical deteriorService  l$6k.  Because of h i s p h y s i c a l d e t e r i o r a t i o n , i t was t h a t a n u r s i n g home was  brought  He became  His c o n d i t i o n  s a t i s f a c t o r y d e s p i t e some g e n e r a l  He was  gradually  considered  placement f o r  were s u r p r i s e d  that  were d i s t u r b e d about such a  i n t e r v i e w s w i t h the S o c i a l Worker r e s u l t e d i n  79 b e t t e r understanding agreed  to the p l a n s .  The Mr.  of the d i s c h a r g e p l a n and the f a m i l y  S o c i a l Worker made the necessary arrangements and  C. was  d i s c h a r g e d t o a n u r s i n g home where he i s g e t t i n g the  required p h y s i c a l care.  Although he remains somewhat  confused  and d i s o r i e n t e d , h i s c o n d i t i o n i s not d i s t u r b i n g to p a t i e n t s or staff.  Case H i s t o r y IV Discharge Mr. He was  uncompleted. D. was  admitted  a s e v e n t y - e i g h t year o l d r e t i r e d l a b o u r e r , who  Canada from S c o t l a n d s i x t y years ago.  He was  came t o  admitted  to  V a l l e y v i e w H o s p i t a l because of severe mental c o n f u s i o n . a d d i t i o n t o mental c o n f u s i o n , he was  Mr.  D. denied  having  s e r i o u s problems i n c o n t r o l l i n g h i s d i a b e t i c c o n d i t i o n ,  although a c c o r d i n g t o h i s f a m i l y , he was coma not long b e f o r e h i s admission Mr. D.'s was  In  a known d i a b e t i c f o r  many y e a r s , and had been t a k i n g i n s u l i n . any  1961.  t o V a l l e y v i e w H o s p i t a l i n March,  i n a s t a t e of d i a b e t i c  to V a l l e y v i e w H o s p i t a l .  d i a g n o s i s a f t e r admission  to V a l l e y v i e w H o s p i t a l  "Chronic B r a i n Syndrome a s s o c i a t e d w i t h S e n i l e B r a i n  Disease w i t h B e h a v i o u r a l R e a c t i o n " . In V a l l e y v i e w H o s p i t a l , the p a t i e n t ' s d i a b e t e s  was  brought under c o n t r o l and h i s mental c o n d i t i o n improved to the extent t h a t he was v i s i t his family.  a b l e to go out on weekend l e a v e s to  80 I n June, 196k,  Mr. D. was  r e f e r r e d to the S o c i a l S e r v i c e  Department f o r d i s c h a r g e p l a n n i n g , by the a t t e n d i n g p h y s i c i a n . The  S o c i a l Worker l e a r n e d t h a t t h e p a t i e n t was  c o o p e r a t i v e o n l y i f he had h i s own When Mr. D. was r e q u i r e d t o pay  way  pleasant  regarding his d i e t .  special attention to his diet  i n o r d e r t o c o n t r o l h i s d i a b e t e s , he became s t u b b o r n hostile.  and  I n view of h i s b e h a v i o u r ,  extra care,  and  understanding  and a t t e n t i o n on t h e p a r t of the n u r s i n g s t a f f was  required.  S e v e r a l b o a r d i n g homes i n the community were  considered  i n p l a n n i n g Mr. D.'s  d i s c h a r g e , but none of them had  the  t r a i n e d s t a f f or t h e f a c i l i t i e s needed f o r t h e c o n t r o l of the p a t i e n t ' s d i a b e t e s and the p r o v i s i o n of c l o s e care supervision.  and  W i t h o u t such s e r v i c e s , the p a t i e n t c o u l d  f u n c t i o n adequately Mr. D.'s  not  i n the community.  d i s c h a r g e p l a n n i n g was,  t h e r e f o r e , postponed  i n d e f i n i t e l y because no s u i t a b l e accommodation i n the community was a v a i l a b l e .  Case H i s t o r y V Discharge  to Family.  Admitted to V a l l e y v i e w H o s p i t a l July,  Mr. E.,  1963.  e i g h t y - t h r e e y e a r s of age,  is a retired  farmer.  U n t i l r e c e n t l y he had no problems w i t h e i t h e r h i s p h y s i c a l or mental h e a l t h .  He was  admitted  to St. Paul's H o s p i t a l f o r  treatment  of d i a b e t e s and head i n j u r y .  admission  t o S t . P a u l ' s H o s p i t a l Mr. E. had  c o n f u s i o n and l a c k of c o o r d i n a t i o n . s t a i r s , l o s t consciousness;  One  subsequently  A few weeks p r i o r t o symptoms of  day he f e l l down he became more  81 confused,  r e s t l e s s and drowsy.  In S t . Paul's H o s p i t a l h i s d i a b e t e s was brought under c o n t r o l i n twenty-four  hours and h i s head i n j u r y i n v e s t i g a t e d .  He r e c o v e r e d from the a c c i d e n t w e l l but continued t o be v e r y d i s o r i e n t e d and confused. of  aggressiveness  P e r i o d i c a l l y he d i s p l a y e d episodes  and h o s t i l i t y .  would take him and he was admitted Mr. was  As a r e s u l t no n u r s i n g home to Valleyview Hospital.  E.'s d i a g n o s i s on admission  to Valleyview Hospital  "Chronic B r a i n Syndrome a s s o c i a t e d w i t h C e r e b r a l A r t e r i o -  s c l e r o s i s w i t h Psychosis and D i a b e t e s " . In V a l l e y v i e w H o s p i t a l the p a t i e n t responded w e l l t o treatment  and soon became p l e a s a n t , q u i e t , and c o o p e r a t i v e i n  a l l respects.  H i s movements were r a t h e r slow but he was q u i t e  t a l k a t i v e and h i s response He  expressed  g e n e r a l l y r e l i a b l e and coherent.  a wish t o go home t o h i s w i f e and was, t h e r e f o r e ,  r e f e r r e d t o the S o c i a l S e r v i c e Department. The V a l l e y v i e w H o s p i t a l S o c i a l Worker i n t e r v i e w e d the p a t i e n t and l a t e r h i s eighty-one year o l d w i f e and i t was l e a r n e d t h a t she was eager t o have h e r husband home a g a i n . Only one problem needed t o be s o l v e d ; c o n t r o l of h i s d i a b e t e s . The  S o c i a l Worker s o l v e d t h i s problem.  Accordingly,  arrange-  ments were made t o have a nurse from the V i c t o r i a n Order of Nurses c a l l r e g u l a r l y t o h e l p Mr. &. Mrs. of  E. with the c o n t r o l  Mr. E.'s d i a b e t e s . Mr.  E. was subsequently  w i f e i n October,  d i s c h a r g e d t o t h e care of h i s  1963.  A r e c e n t f o l l o w - u p v i s i t by a V a l l e y v i e w H o s p i t a l S o c i a l  82 Worker i n d i c a t e s t h a t Mr. E. i s d o i n g w e l l a t home and t h e c o u p l e a r e v e r y happy.  Case H i s t o r y V I Discharged  t o Self-Care.  Mrs. P. i s s e v e n t y - s e v e n y e a r s o f age.  She was b r o u g h t ,  by ambulance, t o V a l l e y v i e w H o s p i t a l on J a n u a r y 10, 19&4, from her home i n Vancouver.  She had been i n f a i r l y good h e a l t h and  had been a b l e t o l o o k a f t e r h e r s e l f u n t i l J a n u a r y ~J> 19°*4. Her f r i e n d , who accompanied h e r t o V a l l e y v i e w H o s p i t a l , s a i d t h a t he and h i s w i f e had c a l l e d t o see h e r on t h a t date and found h e r i n a s t a t e o f m e n t a l c o n f u s i o n .  She had a f l i g h t o f  i d e a s and b e l i e v e d t h a t h e r husband had d i e d t h e n i g h t He had,  i n f a c t , d i e d i n June, 1963.  before.  The f r i e n d s managed t o  calm h e r , b u t e a r l y n e x t morning t h e p o l i c e were c a l l e d because Mrs. P. was wandering i n t h e s t r e e t and s h o u t i n g i n c o h e r e n t l y . Mrs. F. was a d m i t t e d  t o V a l l e y v i e w H o s p i t a l and h e r m e n t a l  d i a g n o s i s as "Minimal Degree o f Chronic B r a i n Syndrome a s s o c i a t e d w i t h C e r e b r a l A r t e r i o s c l e r o s i s " and "a H i s t o r y o f Epolepsy". A f t e r a short p e r i o d o f treatment,  M r s . F. was t r a n s f e r r e d  f r o m t h e main V a l l e y v i e w B u i l d i n g t o a "mixed ward".  She had  improved t o a c o n s i d e r a b l e e x t e n t , was p a r t i c i p a t i n g i n s o c i a l groups on t h e ward and was s u b s e q u e n t l y S e r v i c e Department f o r d i s c h a r g e  r e f e r r e d t o the S o c i a l  planning.  Mrs. F. was i n t e r v i e w e d by t h e S o c i a l Worker s e v e r a l t i m e s and t h e p o s s i b i l i t y o f d i s c h a r g e t o a b o a r d i n g home was  83 discussed with her.  She wished, however, t o r e t u r n t o h e r own  home and be near her f r i e n d s .  T h i s was c o n s i d e r e d a r e a l i s t i c  plan. In March,  Mrs. P. was d i s c h a r g e d t o h e r own home  "on p r o b a t i o n " .  A f r i e n d v o l u n t e e r e d t o v i s i t her p e r i o d i c a l l y  to  ensure t h a t she was managing adequately.  Follow-up  visits  to  h e r home by t h e V a l l e y v i e w H o s p i t a l S o c i a l Worker were made  and up t o t h i s time she i s known t o be managing very w e l l . The  cases c i t e d o u t l i n e some o f t h e s u c c e s s f u l d i s c h a r g e s  from V a l l e y v i e w H o s p i t a l t o community r e s o u r c e s . one  In a d d i t i o n ,  case has been c i t e d which i l l u s t r a t e s t h e problems i n h e r e n t  i n d i s c h a r g e from h o s p i t a l .  CONCLUSIONS By a c c e p t i n g and implementing t h e "open.door" p h i l o s o p h y of  treatment  and d i s c h a r g e , V a l l e y v i e w H o s p i t a l has a t t h i s  time progressed  i n i t s t h i n k i n g f a r i n advance of community  r e s o u r c e s and community a t t i t u d e s toward care of p s y c h i a t r i c ; geriatric patients.  T h i s study has p o i n t e d out some o f t h e  d i f f i c u l t i e s and problems i n h e r e n t i n t h e r e s o u r c e s p r e s e n t l y available.in  community.  1  THE  RESOURCES  1.  Family and S e l f - C a r e .. As presented  1  D e s p i t e the F i s c a l Year of p a t i e n t s treatment a p a t i e n t s on  i n Chapter  TV, the f a m i l y i s not a major  i n h e r e n t problems the h o s p i t a l i n the l a s t (196^-65) d i s c h a r g e d i n numbers t h e e q u i v a l e n t from t h r e e h o s p i t a l wards and admitted f o r number equal t o nine wards. There a r e f i f t y each ward.  &H resource  f o r the discharge  of h o s p i t a l p a t i e n t s .  Self-Care,  because o f t h e n a t u r e and age o f t h e g e r i a t r i c p a t i e n t , i s r a r e l y used. 2.  Licensed  Nursing  Homes  These have been a r e l i a b l e and s a t i s f a c t o r y r e s o u r c e f o r hospital patients. n u r s i n g home.  Only one r e t u r n t o h o s p i t a l came from a  The d i f f i c u l t y  l i e s i n t h e l i m i t e d number o f  s a t i s f a c t o r y homes a v a i l a b l e f o r V a l l e y v i e w s 1  discharged  p a t i e n t s because o f a r e l u c t a n c e , p a r t i c u l a r l y i n Vancouver where a l a r g e number o f t h e s e homes a r e l o c a t e d , t o a c c e p t hospital patients. 3.  Licensed  B o a r d i n g Homes  As i n d i c a t e d by t h e s t a t i s t i c s mands f o r f o l l o w - u p t o discharge  o f r e t u r n s and by t h e de-  s e r v i c e s , t h e g r e a t e s t problems r e l a t e d  l i e i n t h i s area.  The causes a r e l a c k o f t r a i n i n g  of t h e s t a f f s and t h e l a c k o f a r e q u i r e m e n t t h a t s t a f f be t r a i n e d , by l i c e n s i n g r e g u l a t i o n s .  The problems o f t h e p a t i e n t s  a r e n o t u n d e r s t o o d and t h e p s y c h o l o g i c a l and s o c i a l needs o f t h e p a t i e n t s a r e n o t met. k.  " B o a r d i n g Homes S p e c i a l " These homes a r e v e r y s u i t a b l e f o r d i s c h a r g e d  patients,  p a r t i c u l a r l y f o r t h o s e p a t i e n t s who r e q u i r e t w e n t y - f o u r hour s u p e r v i s i o n by t r a i n e d s t a f f .  These homes a r e , however,  l i m i t e d by t h e i r s h o r t a g e i n numbers and by t h e f i n a n c i a l difficulties  which d e p r i v e w e l f a r e r e c i p i e n t s o f t h i s type o f  care o u t s i d e o f . t h e h o s p i t a l . A l l t h e l i c e n s e d f a c i l i t i e s i n t h e community a r e l a c k i n g  8  5  i n programs o f O c c u p a t i o n a l and R e c r e a t i o n a l Therapy.  There  i s a l s o a tremendous gap i n the type o f care and s u p e r v i s i o n o f f e r e d between the present boarding and n u r s i n g homes. gap  can be f i l l e d  This  only by an i n c r e a s e i n the number o f  "boarding homes s p e c i a l " and t r a i n i n g f o r b o a r d i n g home operators.  VALLEYVIEW HOSPITAL DISCHARGE CRITERIA An examination  of admission  and treatment  facilities  i n d i c a t e t h a t these aspects of the s e r v i c e a r e v e r y factory.  satis-  However, the method of s e l e c t i o n and r e f e r r a l of  p a t i e n t s f o r d i s c h a r g e p l a n n i n g Is l e s s w e l l s t r u c t u r e d . The problem l i e s i n the l a c k of s u i t a b l e r e s o u r c e s i n community t o accept p a t i e n t s once they have responded t o treatment.  The  c r i t e r i a f o r d i s c h a r g e from h o s p i t a l a r e r e s t r i c t e d because of the n e c e s s i t y o f c o n s i d e r i n g what types of r e s o u r c e s a r e a c t u a l l y a v a i l a b l e w i t h i n t h e community.  DISCHARGE There a r e d i f f i c u l t i e s i n h e r e n t i n t h e communities' a t t i t u d e s toward d i s c h a r g i n g p a t i e n t s .  Moreover, t h e r e remains  i n the community agencies, p a r t i c u l a r l y i n some l o c a l ments o f Welfare,  Depart-  t h e r e a c t i o n a r y view t h a t V a l l e y v i e w H o s p i t a l  should serve i n the r o l e of "home f o r c u s t o d i a l c a r e " . The O f f i c e o f the P u b l i c T r u s t e e r e p r e s e n t s  frustrating  d e l a y s i n the area of d i s c h a r g e because of t h e i n a b i l i t y t o cope with the i n c r e a s i n g l o a d which more and more d i s c h a r g e s represent.  86  RECOMMENDATIONS Based on our c o n c l u s i o n s concerning community r e s o u r c e s , h o s p i t a l c r i t e r i a f o r d i s c h a r g e and community a t t i t u d e s toward d i s c h a r g e , the f o l l o w i n g recommendations a r e made: I.  Implementation of an o r g a n i z e d p u b l i c r e l a t i o n s program i s  needed w i t h i n the h o s p i t a l .  With such a program c l o s e r  liaison  w i t h the community i n g e n e r a l and w i t h v a r i o u s government departments, p a r t i c u l a r l y the l o c a l Department of Welfare, be maintained.  could  Such a program c o u l d i n t e r p r e t the needs of the  aged person, g e n e r a l l y , but more p a r t i c u l a r l y ,  could i n t e r p r e t  the p h i l o s o p h y , purpose and program o f V a l l e y v i e w H o s p i t a l t o a p p r o p r i a t e community h e a l t h , w e l f a r e , and other agencies, as w e l l as t o the g e n e r a l p u b l i c . II.  C r e a t i o n o f s m a l l e r p s y c h i a t r i c g e r i a t r i c treatment  throughout  the p r o v i n c e .  units  Some of the advantages of such u n i t s  would be: 1)  To permit the p a t i e n t t o r e c e i v e treatment familiar  2)  To enable  within  surroundings. community p a r t i c i p a t i o n and involvement i n  p r o v i d i n g r e s o u r c e s such as the l i c e n s e d homes and O c c u p a t i o n a l and R e c r e a t i o n a l f a c i l i t i e s community 3)  itself.  To p r o v i d e s m a l l e r u n i t s w i t h more i n d i v i d u a l as opposed t o the l a r g e impersonal  k)  w i t h i n the  type  treatment  hospitals.  To p r o v i d e an a v a i l a b l e r e s o u r c e f o r day or n i g h t care when a d v i s a b l e and d e s i r a b l e thus e n a b l i n g the p a t i e n t  87 to remain with h i s f a m i l y while r e c e i v i n g III.  treatment.  The establishment of government s u b s i d i z a t i o n f o r " i n -  between" care homes.  T h i s i n c l u d e s "boarding homes s p e c i a l "  and those homes p r o v i d i n g "in-between" care on a p h y s i c a l needs basis. the need f o r t h i s type of treatment has a l r e a d y been demonstrated i n Chapter  IV of t h i s study.  The present w e l f a r e  r a t e f o r " l i c e n s e d boarding homes" i s i n s u f f i c i e n t t o cover c o s t of care p r o v i d e d i n the homes a l r e a d y i n e x i s t a n c e .  the  It i s  our b e l i e f t h a t an i n c r e a s e i n the present w e l f a r e r a t e of $5°«~ 60.  per month per p a t i e n t would enable b e t t e r use of the present  homes and encourage the establishment of s t i l l more homes of this  calibre.  IV.  Government s u b s i d i z a t i o n f o r an a f t e r - c a r e program of  1  R e c r e a t i o n a l Therapy and O c c u p a t i o n a l Therapy w i t h i n the l i c e n s e d homes i n community.'  U n t i l such time as t h i s program  can be implemented an i n c r e a s e i n the number of o c c u p a t i o n a l and r e c r e a t i o n a l s t a f f i n h o s p i t a l i s recommended i n order to c a r r y out a weekly program with p a t i e n t s a l r e a d y i n community. V. 1  Compulsory courses f o r o p e r a t o r s of boarding homes c a t e r i n g The present c o s t of care i n V a l l e y v i e w H o s p i t a l i s $ 7 . 5 P day ( t h i s f i g u r e does not i n c l u d e b u i l d i n g and equipment c o s t s ) . The p a t i e n t pays $1.50 per day of t h i s amount. 2  e r  2 The need f o r such a program has been demonstrated by a study of the Community Chest and C o u n c i l "A Study of Unmet Needs i n the R e h a b i l i t a t i o n of the A d u l t C h r o n i c a l l y 111." A. r e p o r t of the Sub-Committee on Chronic I l l n e s s , S o c i a l . P l a n n i n g S e c t i o n , Committee on the Welfare of the Aged, Community Chest and C o u n c i l s of the Greater Vancouver area, September, 196k.  88 to  the g e r i a t r i c p a t i e n t .  The l e a d e r s h i p f o r such a program  s h o u l d be p r o v i d e d by V a l l e y v i e w H o s p i t a l .  This could c o n s i s t  o f an i n t r o d u c t i o n t o V a l l e y v i e w H o s p i t a l , i t s s e r v i c e s and d i s c h a r g e program; i t s changed p h i l o s o p h y toward t h e aged; and i t s f u n c t i o n w i t h i n t h e community. i n c l u d e a s e r i e s o f evening  Such an i n t r o d u c t i o n c o u l d  l e c t u r e s on s e l e c t e d s u b j e c t s  concerned w i t h t h e a g i n g p r o c e s s .  Valleyview Hospital i s  p r e s e n t l y b e i n g used as a t e a c h i n g f a c i l i t y f o r s t u d e n t i a t r i c n u r s e s from t h e P r o v i n c i a l M e n t a l H o s p i t a l .  psych-  The  a s s i s t a n c e of the teaching s t a f f o f the Mental H o s p i t a l could be o f a i d i n p r e p a r i n g such a course f o r b o a r d i n g home o p e r a t o r s . VI.  I t i s s t r o n g l y recommended t h a t a s e p a r a t e department be  c r e a t e d w i t h i n t h e O f f i c e o f t h e P u b l i c T r u s t e e w i t h headq u a r t e r s a t V a l l e y v i e w H o s p i t a l t o d e a l w i t h t h e l e g a l and f i n a n c i a l problems o f V a l l e y v i e w p a t i e n t s .  It i sfelt  that  such a s t e p , by s i m p l i f y i n g t h e channels o f communication between t h e h o s p i t a l and t h e O f f i c e o f t h e P u b l i c T r u s t e e , c o u l d p r o v i d e an e f f i c i e n t s e r v i c e and r e d u c e t h e problems p r e s e n t l y c r e a t e d by d e l a y s i n t h e a d m i n i s t r a t i o n o f p a t i e n t accounts.  FUTURE RESEARCH Because o f t h e s u b j e c t m a t t e r , p r i m a r i l y d e s c r i p t i v e i n nature. examination  of a philosophy  a c c e p t a n c e and u n d e r s t a n d i n g  t h i s s t u d y has been  I n essence i t has been an  concerning,  i n a b r o a d sense, t h e  of the e l d e r l y person i n s o c i e t y ;  i n t h e narrow sense, i t has been an e x a m i n a t i o n  o f some o f t h e  89 problems posed f o r a p r o g r e s s i v e G e r i a t r i c H o s p i t a l , i n which the e f f o r t s of a l l s t a f f members are d i r e c t e d towards appropr i a t e treatment  o f the m e n t a l l y i l l e l d e r l y person and h i s  r e t u r n t o the community when treatment  has been concluded.  In  the course of such a pioneer study many q u e s t i o n s have been raised.  Such q u e s t i o n s can only be posed here.  Answers can  o n l y be found by f u r t h e r r e s e a r c h . T r a n s l a t i n g our q u e s t i o n s i n t o concrete r e s e a r c h p o s s i b i l ities, 1.  t h e f o l l o w i n g areas of study seem t o be important: An assessment of d i s c h a r g e d p a t i e n t s - t h e i r and  2.  adjustment  s o c i a l w e l l being w i t h i n the community.  A study of reasons f o r , and p a t t e r n s o f behaviour i n , returns to hospital.  3.  A q u a l i t a t i v e and q u a n t i t a t i v e assessment of the present c r i t e r i a f o r d i s c h a r g e from V a l l e y v i e w H o s p i t a l with the use o f c o n t r o l l e d and experimental groups o f p a t i e n t s w i t h i n h o s p i t a l over a s p e c i f i c p e r i o d o f time.  k.  A study o f community a t t i t u d e s and agency a t t i t u d e s toward V a l l e y v i e w H o s p i t a l ; i t s p h i l o s o p h y , i t s f u n c t i o n , its facilities.  Such a study might r e f l e c t  changing  community a t t i t u d e s toward the aging person,  particularly  the p s y c h i a t r i c g e r i a t r i c p a t i e n t . 5.  An assessment of the e f f e c t i v e n e s s of the "mixed, open wards" p r e s e n t l y o p e r a t i n g a t V a l l e y v i e w H o s p i t a l . i s a new experiment yet  i n t r o d u c e d i n 1963•  ^ e ^^ e  e c  ^  This n  a  s  t o be s c i e n t i f i c a l l y e v a l u a t e d i n terms of h e l p i n g  p a t i e n t s toward r e h a b i l i t a t i o n and d i s c h a r g e .  1  90 6.  A study of the p o s s i b i l i t y of implementing a d i s c h a r g e program a t Skeenaview and D e l l v i e w H o s p i t a l s .  These  u n i t s could become extensions of the model of V a l l e y view s e r v i n g some o f the needs w i t h i n the  Province.  In c o n c l u s i o n , the  the I n t e r i o r of  we look o p t i m i s t i c a l l y t o the f u t u r e and  e f f e c t s o f the changing p h i l o s o p h y toward the aged i n our  affluent society.  We have t r i e d t o i n d i c a t e some o f the  l i m i t a t i o n s apparent i n the present community r e s o u r c e s and i n the government l e g i s l a t i o n r e g u l a t i n g them.  Many p s y c h i a t r i c  g e r i a t r i c p a t i e n t s have been s u c c e s s f u l l y d i s c h a r g e d from Valleyview Hospital obstacles future  t o r e s o u r c e s i n the community.  Many  remain but the ground-work has been l a i d and the  of V a l l e y v i e w H o s p i t a l as a treatment f a c i l i t y  t o be a b r i g h t one.  appears  91  APPENDIX  A  Bibliography  92 (1)  Articles  Alderman, T. "The Gold Watch." Imperial Gold Review. February, 1964. I m p e r i a l O i l Review, Toronto. A l l e n , Ruth. 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B a s i c E m o t i o n a l Needs o f t h e O l d P e r s o n . A paper p r e s e n t e d a t t h e American P u b l i c Welfare A s s o c i a t i o n ' s Southwest R e g i o n a l C o n f e r e n c e , i960.  (6)  Theses  and S t u d i e s  D e i l d a l , Robert Michaux. F o s t e r Home C a r e f o r t h e D e p e n d e n t Aged. S o c i a l Work T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a .  1955. G u e s t , Denis. T r e v o r . T a y l o r Manor. A Survey o f t h e F a c i l i t i e s f o r t h e Aged. M a s t e r o f S o c i a l Work T h e s i s , U n i v e r s i t y o f B r i t i s h Columbia. 1952. Keyes, E f f i e K a t h l e e n . An E x p e r i m e n t a l Program f o r I n s t i t u t i o n a l i z e d Older People. M a s t e r o f S o c i a l Work T h e s i s , U n i v e r s i t y of B r i t i s h Columbia. 1963. L e y d i e r , B e r n i c e R a e . B o a r d i n g Home C a r e f o r t h e A g e d . Master o f S o c i a l Work T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a . 1948.  103 McCubbin, P r a n c e s . A Study o f t h e P o s s i b l e R o l e o f t h e Department o f U n i v e r s i t y E x t e n s i o n I n t h e F i e l d o f Gerontology. S c h o o l o f S o c i a l Work, U n i v e r s i t y o f B r i t i s h Columbia. September, 1961. N i c h o l l s , Wm. M. A S t u d y o f C u r r e n t R e s e a r c h on t h e A g i n g . Seminar Notebook. U n i v e r s i t y o f B r i t i s h Columbia. 1964. A S t u d y o f C u r r e n t R e s e a r c h on t h e A g i n g - S e m i n a r , A p r i l 2 3 June 4, 1 9 6 4 . E x t e n s i o n Department, U n i v e r s i t y o f B r i t i s h Columbia. A. S t u d y o f Unmet Needs i n t h e R e h a b i l i t a t i o n o f A d u l t C h r o n i c a l l y 111. S o c i a l P l a n n i n g S e c t i o n Committee on t h e W e l f a r e o f t h e Aged. Community C h e s t and C o u n c i l s o f G r e a t e r Vancouver. September, 1964.  10k  APPENDIX  Letters  B  December D r . M. M a r t i n , C h i e f , Mental Health D i v i s i o n , D e p t . o f N a t i o n a l H e a l t h and Ottawa, Ontario Dear D r .  23rd,  1964.  Welfare,  Martin:  I w r i t e from V a l l e y v i e w H o s p i t a l , Essondale, the l a r g e s t of t h r e e u n i t s c o m p r i s i n g the G e r i a t r i c D i v i s i o n of t h e M e n t a l H e a l t h S e r v i c e s o f B r i t i s h C o l u m b i a . .The p u r p o s e o f t h i s l e t t e r i s t o d e t e r m i n e whether c o m p a r a b l e . I n s t i t u t i o n s e x i s t i n o t h e r P r o v i n c e s and i f s o , t o d e t e r m i n e t h e i r w h e r e a b o u t s so t h a t we m i g h t communicate w i t h them t o s h a r e i d e a s and e x p e r i e n c e s w i t h r e g a r d t o p r o g r a m s . I w o u l d l i k e t o s t a t e t h a t t h i s h o s p i t a l has 7 9 beds and i t s p u r p o s e i s t o p r o v i d e t r e a t m e n t and r e h a b i l i t a t i o n f o r e l d e r l y men and women s u f f e r i n g f r o m p s y c h i a t r i c i l l n e s s consequent t o the aging p r o c e s s . P a t i e n t s are a d m i t t e d d i r e c t l y f r o m t h e Community. Patients with p s y c h i a t r i c d i s o r d e r s o f l o n g s t a n d i n g , e.g. C h r o n i c S c h i z o p h r e n i c s , a r e n o t i n c l u d e d . We have a n a c t i v e Rehabi l i t a t i o n and D i s c h a r g e p r o g r a m . 1  I t w o u l d be a p p r e c i a t e d , t h e r e f o r e , i f y o u w o u l d l e t h a v e t h e names o f o t h e r h o s p i t a l s w i t h s i m i l a r p r o g r a m s . Yours  me  truly,  J . Walsh, M.B., Medical Superintendent.  JW:p«r  DEPARTMENT NATIONAL.  H E A L T H  OF  A N D W E L F A R E  SANTE  CANADA  NATIONALE  File:  E T D U BIEN-ETRE  SOCIAL  435-2-9  Ottawa 3, Ontario, January 6, 1965.  Dr. J . Walsh, Medical Superintendent, Valleyview Hospital, Essondale, B.C. Dear Doctor Walsh: Re:  Institutions f o r the Aged  I was interested i n your enquiry as to whether there are comparable i n s t i t u t i o n s to yours i n other provinces. I have not been to Valleyview since 1961 but I r e c a l l the impressive program and f a c i l i t i e s at that time. The Dominion Bureau of S t a t i s t i c s recognizes nine types of mental i n s t i t u t i o n s , one of which i s the "Aged and Senile Home". V a l l e y view and Dellview are i n that category as you w i l l see from the attached Directory. Some i n s t i t u t i o n s with excellent programs f o r the aged may be c l a s s i f i e d i n other categories. I do not f i n d Rosehaven which i s at Camrose, A l b e r t a , i n the 1962 directory. I t has a f i n e program f o r the aged and you could get d e t a i l s from Dr. Randall Maclean or from Mrs. Olive Noonan, i f she i s s t i l l Superintendent You w i l l note that there are f i v e county hospitals l i s t e d f o r Nova Scotia. These hospitals are developing rapidly and there are many aged patients. Dr. Clyde Marshall could provide i n f o r mation. Your question i s an interesting one and I would l i k e very much to hear from you i f you make additional discoveries"of i f you have additional questions. Yours sincerely,  Morgan Martin, M.D., M.Sc., Chief, Mental Health D i v i s i o n . Encl.  DIRECTORY  152  Directory of Psychiatric In-patient F a c i l i t i e s ,  1960  Repertoire des hopitaux de so ins psychiatriques,  Location  Name  Category  Situation  Norn  Catggorie  1960  Type of institution  Ownership  Affectation  Appartenance  Psychiatric bed capacity Capacity en llts psychiatriques  Newfoundland Terre-Neuve St. John's  Hospital for Mental and Nervous Diseases  Pub.  Ment.  Prov.  835  Provincial Infirmary (Welfare Institution since April 1, 1960) Riverside Hospital and Hillsborough General Hospital  Pub.  Ment.  Prov.  377  Pub. Pub. Pub. Fed. Pub. Pub.  Ment. Ment. Ment. Gen. Ment. Gen.  Mun. Mun. Prov. D.V.A. Mun. Prov.  60 500 650 22 330 24  Ment. Ment. Ment. Ment. H.M. Def. Ment. •  Mun. Mun. Mun. Mun. Prov. Mun. '"  200 160 500 168 105  Pub. Fed. Pub. Pub. Pub.  Ment. Gen. Ment. Gen. Gen.  Prov. D.V.A. Prov. Mun. Mun.  600 . 25 1,350 11 27  Pte. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Fed. Pub. Pub. Pub. Fed. Pub. Pub. Pub. Fed. Pub.  Ment. Ment. Dist. Chid. Gen. Ment. Ment. Ment. Ment. Gen. Ps. H . Ment. Ment. San. Gen. DisL Chid. Ment. Gen. Gen. Gen. Gen. Gen. Ps. H . Gen. Gen. Gen. Gen. Ment. Gen. Gen. Gen. Ep. H . H.M. Def. Ment. Gen. Ment.  L. Rel. Prov. Rel. L. Rel. L. L. Rel. Rel. Rel. Rel. . L. L. Rel. Prov. Rel. L. L. L. Rel. L. L. L. L. D.V.A. Rel. Rel. Rel. D.V.A. Rel. Rel. Rel. D.V.A. Rel.  225 1,150 14 50 164 5,695 1,333 220 10 160 5.000 33 240 128 21 700 39 26 24 12 41 145 16 14 30 50 140 20 20 25 275 1,100 750 498 1,463  Prince Edward Island Ile-du-Prlnce-Edouard Charlottetown Charlottetown Nova Scotia Nouvelle-Ecosse Bridgetown Cole Harbour Dartmouth Halifax Halifax Halifax Mulgrave Pugwash Stellarton Sydney River Truro Waterville  Annapolis County Hospital Halifax County Hospital Nova Scotia Hospital (T.B. Unit) Camp Hill Hospital Halifax Mental Hospital Victoria General Hospital' Inverness County Hospital' (closed 1960) (fermee 1960) Cumberland County Home Pictou County Hospital? Cape Breton Hospital Nova Scotia Training School Kings County Hospital : •. 1  1  1  '....i  1  1  1  Pub. ,Pub.Pub. Pub. Pub. Pub.  New Brunswick Nouveau-Brunswick Campbellton Lancaster Lancaster Moncton Saint John  Provincial Hospital Lancaster Hospital Provincial Hospital Moncton Hospital' Saint John General Hospital'  Quebec Austin Baie-Saint-Paul Beaconsfield Chicoutimi Disraeli Gamelin Joliette Lac Etchemin LSvis Masta'i Masta'i Masta'i Mont-Joli Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Montreal Quebec Quebec Quebec Quebec Riviere-des-Prairies Roberval Ste-Anne-de-Bellevue St-Ferdlnand  Cecil Memorial Home' HOpital Sainte-Anne Allancroft" Hotel-Dieu St-Vallier Foyer Ste-Luce' HOpital Saint-Jean-de-Dieu Hopital St-Charles de Joliette .-. Sanatorium Begin Hotel-Dieu de Livls Clinique Roy-Rousseau Hopital Saint-Michel-Archange Sanatorium Masta'i Sanatorium St-Georges Allan Memorial Institute* Centre D'Orientation Hopital de Bordeaux Hopital Maisonneuve et Institut de Cardiologie Hftpital Notre-Dame Hopital Ste-Jeanne-d'Arc Hopital Ste-Justine Hotel-Dieu de Montreal" Institut Albert PrSvost Jewish General Hospital' Montreal Children's Hospital' Montreal General Hospital' Queen Mary Veterans' Hospital' Hopital Saint-Benott Hopital de l'Enfants-Je'sus Hopital du St-Sacrement' HOpital Ste-Foy' H6tel-Dleu-du-Sacrg-Coeur-de-J£sus HOpital Mont-Providence HOpital Salnte-Elizabeth Ste-Anne's Hospital HOpital SalnUJullen 1  1  1  1  1  1  1  .•  See footnotes and abbreviations at end of directory. - Voir renvois et abrgviatlons a la fin du repertoire.  REPERTOIRE  153  Directory of Psychiatric In-Patient F a c i l i t i e s , 1960 -  Continued  Repertoire des h6pitaux de soins psychiatriques, 1960 — s u i t e  Location  Name  Category  Type of institution  Situation  Nora  Categorte  Affectation  Quebec-Con. — fin St-Hilaire Sherbrooke Trois-Rlvieres Verdun  Foyer Diepne' Hopital General St-Vincent-de-Paul' Hopital Ste-Marte' Verdun Protestant Hospital  Ownership Appartenance  Psychiatric bed capacity Capacity en lits psychiatriques  Pub. Pub. Pub. Pub.  Ep. H . Gen. Gen. Ment.  L. Rel. Rel. L.  120 10 12 1,574  Pub. Pub. Pub. Pub. Pte. Pub. Pte."  H.M. Def. Gen. Ment. Ment. Ps. H . Ment.'' Ps. H .  Prov. L. Prov. Prov. L. Prov. L.  250 24 1.544 320 225 1,465 14  Pub. Pub. Pub. Pub.Pub. Pub. Fed. Pte. Pub. Pub. Pub.  Gen. Ment. Dist. Chid. Gen. Ment. Gen. Gen. Dist. Chid. Ment. Ment. H.M. Def.  L. Prov. Prov. Rel. Prov. Mun. D.V.A. L. Prov. Prov. Prov.  40 1,445 14 30 1,100 52 873 18 1, 100 764 2,400 40 30 13 20 600 43 764 24 1,822 2,038 ' 33 75 30 55 9  Ontario The Ontario Hospital Brantford General Hospital The Ontario Hospital The Ontario Hospital Homewood Sanitarium The Ontario Hospital i Institute of Psychotherapy Kingston General Hospital (opened Sept. 12. 1960) - (ouvert le 12 sept. 1980) The Ontario Hospital Sunnyside Children's Village* St. Joseph's Hospital The Ontario Hospital Victoria Hospital Westminster Hospital Warren Dale School For Girls' The Ontario Hospital The Ontario Hospital The Ontario Hospital School Ottawa Civic Hospital (opened Nov. 8, 1960) (ouvert le 8 novembre 1960) Ottawa General Hospital Protestant Children's Village' General and Marine Hospital' The Ontario Hospital Ontario Home For Mentally Retarded Patients' The Ontario Hospital St. Catharines General Hospital The Ontario Hospital The Ontario Hospital School Sudbury General Hospital The Ontario Hospital St. Michael's Hospital Sunnybrook Hospital Sunnyside Private Hospital Alcoholism and Drug Addiction Research Foundation The Ontario Hospital Wellesley Hospital Toronto Psychiatric Hospital . Toronto Western Hospital Women's College Hospital Bethesda Home The Ontario Hospital Wlllowdale Private Hospital ... Metropolitan General Hospital The Ontario Hospital  Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Fed. Pte.  Gen. Gen. Dist. Chid. Gen. Ment. H.M. Def. Ment. Gen. Ment. H.M. Def. Gen. Ment. Gen. Gen. Ment.  Mun. Rel. L. L. Prov. • L. Prov. L. Prov. Prov. Rel. Prov. Rel. D.V.A. L.  Pub. Pub. Pub. Pub. Pub. Pub. Pte. Pub. Pte. Pub. Pub.  Ale. Ment.. Gen. Ps. H . Gen. Gen. Ment. Ment. Ps. H . Gen. Ment.  Prov. L. Prov. L. L. Rel. Prov. L. Mun. Prov.  85 1,574 9 30 1,518  Manitoba Brandon Portage la Prairie St. Boniface St. Vital Selkirk Winnipeg Winnipeg Winnipeg Winnipeg Winnipeg  Hospital for Mental Diseases Manitoba School for Mentally Defective Persons St. Boniface Hospital St. Boniface Sanatorium' !".!!!!'.!!!!!!!'.!! Hospital for Mental Diseases Children's Home of Winnipeg' ; Deer Lodge Hospital Winnipeg Psychopathic Hospital Misericordia Hospital Winnipeg General Hospital  Pub. Pub. Pub. Pub. Pub. Pub. Fed. Pub. Pub. Pub.  Ment. H.M. Def. Gen. T.B. Ment. Dist. Chid. Gen. Ps. H . Gen. Gen.  Prov. Prov. Rel. Rel. Prov. L. D.V.A. Prov. Rel. L.  1,350 1,014 24 58 1,005 10 60 56 17 86  Saskatchewan Moose Jaw Moose Jaw North Battleford Regina Regina Saskatoon Weybum  Moose Jaw Union Hospital Saskatchewan Training School Saskatchewan Hospital Regina General Hospital, Munroe Wing Regina Grey Nuns' Hospital' University Hospital Saskatchewan Hospital  Pub. Pub. Pub. Pub. Pub. Pub. Pub.  Gen. H.M. Def. Ment. Gen. Gen. Gen. Ment.  Mun. Prov. Prov, Mun. Rel. Prov. Prov.  21 1,109 1,120 34 11 39 950  Aurora Brantford Brockville Cobourg Guelph Hamilton Kingston Kingston  -.  Kingston Kingston London London London London Newmarket New Toronto North Bay Orillia Ottawa Ottawa Ottawa Owen Sound Penetanguishene Plainfield Port Arthur St. Catharines St. Thomas Smiths Falls Sudbury Thistletown Toronto Toronto Toronto Toronto Toronto Toronto Toronto Toronto Toronto Vineland Whitby Wlllowdale Windsor Woodstock  1  i  See footnotes and abbreviations at end of directory. - Voir renvois et abreviations a la fin du repertoire.  15 850 40 64 35 20  DIRECTORY  154  Directory of Psychiatric In-Patient F a c i l i t i e s , 1960  -  Concluded  Repertoire des hdpitaux de soins psychiatriques, 1960  -  fin  Location  Name  Category  Type of institution  Situation  Norn  Categorie  Affectation  Calgary General Hospital Colonel Belcher Hospital Rosehaven Home for the Aged' Provincial Auxiliary Mental Hospital Provincial Mental Institute University of Alberta Hospital* Provincial Mental Hospital Provincial Auxiliary Mental Hospital Deerhome Provincial Training School Linden House  Pub. Fed. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub. Pub.  Gen. / Gen. / A.S.H. v Ment. Ment. Gen. Ment. Ment. H.M. Def. H.M. Def. Dist. Chid.  Provincial Mental Hospital Crease Clinic of Psychological Medicine Provincial Mental Hospital (T.B. Unit) ... Valleyview Hospital Hollywood Hospital Woodlands School Skeenavlew Hospital Tranqullle School Shaughnessy Hospital Vancouver General Hospital Dellview Hospital Royal Jubilee Hospital  Pub. Pub. Pub. Pub. Pte. Pub. Pub. Pub. Fed. Pub. Pub. Pub.  Ment. Ps. H. Ment. A.S.H, . Ps. H. H.M. Def. A.S.H. H.M. Def. Gen. Gen. A.S.H. Gen.  Alberta Calgary Calgary Camrose Claresholm Edmonton Edmonton Ponoka Raymond Red Deer Red Deer Red Deer  .-.  Psychiatric Ownership  /  bed capacity  Appartenance  Capacity en lits psychiatriques  Mun. D.V.A. Prov. Prov. Prov. Prov. Prov. Prov. Prov. Prov. Prov.  22 15 510 112 1,600 68 1.077 134 1,050 792 28  Prov. Prov. Prov. Prov. L. Prov. Prov. Prov. D.V.A. L. Prov. L.  222 228 2,602 780 73 1,473 300 150 42 40 239 24  British Columbia Colombie-Britannique Colquitz Essondale Essondale Essondale New Westminster New Westminster Terrace Tranqullle Vancouver Vancouver Vernon Victoria  Based on period of operation. — D'apres la perlode d'actlvlW. ' Did not report morbidity data for 1960. — N'ont pas envoye de flches de morbidity pour 1960. ' Did not report In any form for 1960. — N'ont fait aucun rapport pour I960. Includes temporary transfers from the Provincial Mental Hospital, Ponoka. - Y compris les transferts temporaires de l'hopltal psychiatrlque provincial de Ponoka. 1  4  Category — Catjgorle Pub. Pte. Fed.  Public - Publlque Private — Prlve Federal - Federal  Type of Institution — Affectation Ale. Hospital for alcoholics — Hdpital pour alcooliques AJ5.H. Aged and senile home — Hospice pour vleillards Dist. Chid. Hospital for emotionally disturbed children - Hopital pour enfants souffrant de troubles emotifs Ep. H . Epilepsy hospital — Hopital pour epileptlques Gen. General hospital — Hopital general H.M. Def. Hospital for mentally defectives — Hopital pour deficients mentaux Ment. Mental hospital — Hopital pour maladies mentales Ps. H . Psychiatric hospital — Hopital psychiatrlque San. Sanatorium  Ownership — Appartenance D.V.A. L. Mun. Prov. Rel.  Department of Veterans Affairs — Affaires des anclens combattants Lay — Lalque Municipal — Municlpale Provincial — Provlnciale Religious - Rellgleuse  REPERTOIRE  155  Directory of Mental Health C l i n i c s and Out-patient Departments, Repertoire des dispensaires d'hygiene mentale,  1960  1960 Sessions per week  Location  Name  Parent hospital  Auspices  Situation  Norn  Institution mere  Responsabllite'  1  Nombre de stances par semaine 1  Newfoundland  Type of patient  1  Genre de patient 1  •  Terre-Neuve St. John's St. John's St. John's St. John's  Psychiatric Clinic — Outpatient Department. Mental Health Clinic  St. John's General Hospital Hospital for Mental and Nervous Diseases. St. John's General Hospital  1  Nfld. Dept. of Health' Nfld. Dept. of Health  8  A, C A, C  Nfld. Dept. of Health  2  A, C  P . E . I . Dept. of Health  10  A, C  N.S. Dept. of Health and Board of Directors (Local)  10  A, C  Western Nova Scotia Mental Health Group Incorporated N.S. Government; City of Halifax; Dalhousie University Dept. of Veterans Affairs N.S. Government; Victoria General Hospital; University Cape Breton Board of Directors  18  A, C  11  C  3 11  A A  10  A, C  N.S. Government; Canadian Mental Health Association N.S. Government; Acadia University Institute, Kings Co.; Mental Hygiene Society  10  A, C  10  A, C  N.B. N.B. N.B. N.B.  10 10 10 10  A, A, A, A,  St. Clare's Mercy Hospital  Prince Edward Island Ile-du-Prince-Edouard Charlottetown  Mental Health Clinic  Nova Scotia Nouvelle-Ecosse Antigonish  Digby  Eastern Counties Mental Health Clinic. Mental Health Clinic Western Nova Scotia C l i n i c . Halifax Mental Health Clinic for Children. Out-patient Department  Halifax Halifax Halifax  Wolfville  Cape Breton Mental Health Centre. Colequid Mental Health Centre. Pundy Mental Health Centre  Yarmouth  Mental Health Clinic  Truro  St. Martha's Hospital Digby General Hospital  -  Camp Hill Hospital Victoria General Hospital  -  -  -  Yarmouth General Hospital  New Brunswick Nouveau-Brunswick Edmundston Predericton Moncton Saint John  Mental Mental Mental Mental  Health Health Health Health  Clinic Clinic Clinic Clinic  Dept. Dept. Dept. Dept.  of of of of  Health Health Health Health  and and and and  Qui bee Service de neuropsychiatry Service social psychiatrique Levis  HOtel-Dieu St-Vallier Sanatorium Ross HOtel-Dieu de Levis •  Centre d'orientation Montreal  Montreal  HOpital Maisonneuve HOpital Notre-Dame HOpital Ste-Jeanne d'Arc HOpital St-Joseph de Rosemont HOpital Ste-Justine HOpital St-Luc HOtel-Dieu Institut Albert Prevost Jewish General Hospital Mental Hygiene Institute  See footnotes and abbreviations at end of directory. — Voir renvois et abre'viatlons a l a fin du repertoire.  ••  ••  Social Social Social Social  Services Services Services Services  C C C C  1 5  6  DIRECTORY  Directory of Mental Health C l i n i c s and Out-patient Departments, 1960 — Continued Repertoire des dispensaires d'hygiene mentale, 1960 — suite Location  Name  Parent hospital  Auspices  Situation  Nom  Institution mere  Responsabilite  Sessions per week  1  Type of patient  1  Nombre de Genre de seances par patient semaine 1  1  s  Quebec-Con. - fin Montreal Children's Hospital Montreal General Hospital • Royal Edward Laurentian Hospital. Royal Victoria Hospital St. Mary's Hospital Montreal Quebec Hopital de 1'Enfant-Jesus Hopital St-Francois d'Assise Hopital St-Sacrement H6tel-Dieu de Quebec H6tel-Dieu du Sacre-Coeur Jeffery Hale's Hospital  Quebec  Quebec Service de ^adaptation sociale. Service d'hygiene mentale ....  Hopital St-Vincent-de-Paul ilfltel-Dieu de Sherbrooke Sherbrooke Trois-Rivleres  . •• Hopital General de Verdun '  Ontario Mental Health Clinic Oobourg Dunnville Hamilton  Mental Health Clinic Mental Health Clinic Psychiatric Clinic Mental Health Clinic Mental Health Clinic Kitchener - Waterloo Health Service. Mental Health Clinic Child Guidance Clinic  t  New Toronto Ottawa  St Catharines St Thomas  • -  Victoria Hospital Ontario Hospital Ottawa General Hospital Ontario Hospital  Ottawa Civic Hospital Out-patient Department of Ottawa General Hospital Psychiatry. General Hospital Mental Health Clinic Pembroke Cottage Hospital Peterborough Civic Hospital Mental Health Service Ontario Hospital Victoria Hospital Mental Health Clinic St. Catharines General Hospital Mental Health Service Ontario Hospital Ontario Hospital  10 13 8 .10 1 . 13  A, C A, C A, A, A. A,  C C C C  10  A, C  11 10 10  C A, C A. C  Ont. Dept. of Health; City of London Ont. Dept. of Health Ottawa General Hospital Ont. Dept. of Health  11 10 10 10  A. C A, C C A, C  Ont. Dept. of Health Ottawa General Hospital  10 10  A, C A  Ont. Government Ont. Dept. of Health  10  u  A, C A. C  St. Catharines General Hospital Ont. Dept. of Health Ont. Dept. of Health Ont. Dept. of Health  10  A. C  10 10  A. C A. C  St. Mary's Hospital War Memorial Children's Hospital Ont. Dept. of Health Ont. Dept. of Health Ontario Hospital Ont. Dept. of Health Chil-  Institute for Retarded dren. Mental Health Service Mental Health Clinic Division of Child Psychiatry Mental Health Clinics Day Patient.  North Bay  Pembroke Pembroke Peterborough Port Arthur  Ont. Dept. of Health Ontario Hospital Ont. Hospital Cobourg Ontario Hospital Haldimand War Memorial Hospital Ont. Dept. of Health Ontario Hospital Ont. Dept. of Health City of Hamilton Hamilton General Hospital Ont. Dept. of Health Ontario Hospital Kingston General Hospital Ont. Dept. of Health Mental Kitchene'r General Hospital  See footnotes and abbreviations at end of directory. — Vols renvois e't abrevlatlons a la fin du repertoire.  RFPERTOIRF.  157  Directory of Mental Health C l i n i c s and Out-patient Departments, 1960 — C o n t i n u e d Repertoire des dispensaires d'hygiene mentale, 1960 - s u i t e Location  Name  Parent hospital  Auspices  Situation  Nom  Institution mere  Responsabilite  Sessions per week'  Type of patient  Nombre de seances par semaine  Genre de patient  1  1  1  Ontario —Con. - fin Sault Ste-.tarie Toronto Toronto Toronto Toronto  »  Toronto Toronto Toronto Toronto  .".  Toronto Toronto Toronto Toronto Toronto Toronto Toronto Toronto Toronto Toronto  ...  General Hospital Mental Health Clinic Alcoholism and Drug Addiction Research Foundation. Baycrest Hospital Mental Health Clinic Child Adjustment Services .... Clinic for Psychological Me- Hospital for Sick Children dicine. Toronto General Hospital Toronto General Hospital Day Care Centre Toronto Psychiatric Hospital Division of Mental Health East York Leaside Child Guidance Clinic. Forensic Clinic Toronto Psychiatric Hospital Mental Health Clinic Northwestern General Hospital St. Joseph's Hospital Out-patient Department Ontario Hospital Out-patient Clinic Toronto Psychiatric Hospital Out-patient Department New Mount Sinai Hospital Psychiatric Clinic, O.P.D St. Michael's Hospital Mental Health Clinic Toronto Mental Health Clinic Mental Health Clinic York Township Child and Adolescent Guidance Clinic Mental Health Clinic Child Guidance Clinic Mental Health Clinic Mental Health Clinic Mental Health Clinic  Windsor Windsor Windsor Whitby Woodstock  Ont. Dept. of Health  13  Toronto Board of Education Hospital for Sick Children  10 10  Toronto General Hospital Toronto Psychiatric Hospital City of Toronto Dept. of Public Health Ont. Government  12 10 10 10  Ont. Dept. of Health .  10  Sisters of St. Joseph Ontario Hospital Ont. Dept. of Health New Mount Sinai Hospital  .  C • C A A A, C C  1 11 11 7  A, C A, C A, C A  10  A, C  City of Toronto Board of Health  10  A, C  Ont. Dept. of Health City of Windsor  10 10 10 10 10  A, C C A, C A, C A, C  10  A, C  United Community Fund  .  Toronto Western Hospital  Hotel-Dieu Ontario Hospital Ontario Hospital  Ont. Dept. of Health "  '  '  Ont. Dept. of Health  Manitoba Child Guidance patient Clinic.  Gilbert Plains  Gilbert Plains Medical Nursing Unit. Manitoba School for Mentally Out-patient Department Defective Persons. Selkirk Mental Hospital Mental Health Clinic Hospital for Mental Diseases : Out-patient Department Psychiatric Clinic, Out-Pa- St. Boniface Hospital tient Department. Child Guidance Clinic of Greater Winnipeg. Children's Hospital of Winnipeg Mental Health Clinic Deer Lodge Hospital Neuropsychiatric Service Winnipeg General Hospital Out-patient Department Psychopathic Hospital Out-patient Department  '. •  St- Boniface Winnipeg  Man. Government  Mental Health Clinic  Portage-la-Prairie Selkirk Selkirk  and  Out- Hospital for Mental Diseases  Brandon  ;  Winnipeg Winnipeg Winnipeg Winnipeg  Man. Dept. of Health and Public Welfare  A, C  Man. Government Man. Government St. Boniface Hospital  1 8 3  Man. Dept. of Health and Winnipeg School Division Man. Hospital Service Plan Dept. of Veterans Affairs Winnipeg General Hospital Man. Dept. of Health and Public Welfare  A. C A. C A .  10 10 10 5 10  C A A A, C  month mois month mois month mois  A, C  Saskatchewan Assiniboia  Mental Health Clinic  Biggar  Mental Health Clinic  Davidson  Mental Health Clinic  Estevan  Mental Health Clinic  Fort Qu'appelle Grenfell  Sask. Dept. of Public Health  .... ... St. Margaret Hospital  Sask. Hospital North Battleford Sask. Dept. of Public Health  Weybum Hospital  Mental Health Clinic (Part- Indian Hospital and Sanatorium time) Grenfell Mental Health Clinic (Part-time)  , per par . per par 2 per par  Sask. Dept. of Public Health Sask. Dept. of Public Health Sask. Dept. of Public Health  See footnotes and abbreviations at end of directory. - Voir renvois et abreviatlons a la fin du repertoire.  A. C A, C A, C  per month par mois  A, C A. C  15fi  DIRECTORY  Directory o r Mental Health C l i n i c s and Out-patient Departments, 1960 — Concluded Repertoire des dispensaires d'hygiene mentale, 1960 — fin  Location  Name  Parent hospital  Auspices  Situation  Nom  Institution mere  Responsabilite  Sessions per week  1  Nombre de seances par semaine'  Saskatchewan—Con. — fin K am sack Kindersley ... Leader Maple Creek . Melfort  Mental Health Clinic (Part- Union Hospital time) Kindersley Mental Health Union Hospital Clinic Swift Current Mental Health Mental Health Clinic Clinic Maple Creek Hospital Mental Health Clinic  Sask. Dept. of Public Health  . per month par mois , per month par mois „ per month par mol s 2 per month par mois 2 per month par mois 10  , per month par mois  Sask. Dept. of Public Health Sask. Hospital North Battleford Sask. Dept of Public Health Sask. Dept. of Public Health Sask. Dept. of Public Health  Moose Jaw  Mental Health Clinic Moose Jaw Mental Health Clinic  Moose Jaw Union Hospital Moosomin Union Hospital  Moosomin  Moosomin Union Hospital ....  Nipawin  Mental Health Clinic  Sask. Dept. of Public Health  North Battleford ...  North Battleford Mental Health Clinic  Sask. Dept. of Public Health  Prince Albert.  Prince Albert Mental Health Clinic  Sask. Dept. of Public Health  Regina  Mental.Health Clinic  Rosetown  Mental Health Clinic  Saskatoon  Department of Psychiatry.  Saskatoon  MacNeill Clinic  Shaunavon ....  Mental Health Clinic  Swift Current  Swift Current Mental Health Clinic  Sask. Dept. of Public Health  Tisdale.  Mental Health Clinic  Sask. Dept. of Public Health  Regina General Hospital  Sask. Dept. of Public Health Sask. Dept. of Public Health  University Hospital  Sask. Government Sask. Dept. of Public Health  Shaunavon Union Hospital  10 , per month par mois  Sask. Dept. of Public Health  Weybum  Weybum Mental Health Clinic  Bask. Dept. of Public Health  Yorkton ..  Yorkton Mental Health Clinic  Monroe Wing, Regina General Hospital  Yorkton .  Mental Health Clinic (Parttime)  Sask. Dept. of Public Health  Provincial Guidance C l i n i c , Calgary General Hospital Mental Health Clinic Provincial Guidance Clinic .. Provincial Guidance Clinic .. Provincial Guidance Clinic .. Provincial Mental Hospital Provincial Guidance Clinic  Alta Dept. of Public Health  9 10 2 per month par mois  per month par mois o per par . per par  month mois month mois  Alberta Calgary Calgary Edmonton Lethbrldge .— Ponoka Red Deer  Alta Alta Alta Alta  Dept. of Public Health Dept. of Public Health Dept. of Public Health Government  10 10 1 2  British Columbia Colombie-Britannique Bumaby Powell River Vancouver...Vancouver. Victoria 1 1  Mental Health Centre Powell River General Hospital Mental Health Clinic Out-patient Department: Vancouver General Hospital Health Centre for Children Mental Hygiene Division Child Guidance Clinic ....  Unless otherwise specified. — A moins d'avls contralre. A - A d u l t s ; C - C h i l d r e n . - A—Adultes: C - E n f a n t a .  B . C . Government  10  Lay Corporation  10  Metropolitan Health Committee B . C . Government  20 10  Type of patient 1  Genre de patient 1  December 1, Department o f H e a l t h , W e l f a r e , Education, U n i t e d S t a t e s Government, WASHINGTON 2 5 , D. C., U. S. A. Dear  1964.  &  Sirs:  T h i s l e t t e r comes t o y o u f r o m V a l l e y v i e w H o s p i t a l , t h e l a r g e s t o f three units comprising the G e r i a t r i c D i v i s i o n of Mental H e a l t h S e r v i c e s f o r t h e P r o v i n c e o f B r i t i s h Columbia, Canada.. T h e p u r p o s e o f t h i s l e t t e r i s t o d e t e r m i n e w h e t h e r i d e n t i c a l . i n s t i t u t i o n s e x i s t i n t h e U n i t e d S t a t e s and, i f so, t o d e t e r m i n e t h e i r w h e r e a b o u t s s o t h a t we m i g h t communicate w i t h them t o s h a r e i d e a s , c o n c e r n s a n d e x p e r i e n c e s , etc., with r e g a r d t o r e s p e c t i v e programs. F i r s t o f a l l , I would l i k e t o s t a t e t h a t t h e purpose o f V a l l e y v i e w H o s p i t a l ( b e d c a p a c i t y o f a p p r o x i m a t e l y 800) i s t o p r o v i d e c a r e a n d t r e a t m e n t f o r e l d e r l y men a n d women who are s u f f e r i n g from p s y c h i a t r i c i l l n e s s e s "consequent t o t h e aging process". Most p a t i e n t s a r e a d m i t t e d a s c e r t i f i e d p a t i e n t s b u t i t i s a l s o p o s s i b l e t o g a i n a d m i s s i o n on a voluntary basis. V a l l e y v i e w H o s p i t a l i s an i n s t i t u t i o n separated from t h e l a r g e M e n t a l H o s p i t a l complex f o r t h e P r o v i n c e , a t E s s o n d a l e , B.C. I n t h e performance o f our f u n c t i o n s and d u t i e s , t h e administration of this hospital i s responsible d i r e c t l y to the Deputy M i n i s t e r o f Mental H e a l t h S e r v i c e s Branch o f t h e Province o f B r i t i s h Columbia. We f e e l t h a t we a r e d i f f e r e n t f r o m most o f t h e known p s y c h i a t r i c h o s p i t a l s f o r t h e ' a g e d i n t h a t we a r e s t r i c t l y a p s y c h i a t r i c g e r i a t r i c h o s p i t a l . An a p p l i c a n t f o r a d m i s s i o n i s n o t a c t u a l l y r e q u i r e d t o be a c e r t a i n a g e s u c h a s s i x t y f i v e o r s e v e n t y , b u t c o u l d come i n t o h o s p i t a l a t a n y e a r l i e r age i f h i s m e n t a l , e m o t i o n a l , o r b e h a v i o u r a l d i s o r d e r were p r i m a r i l y associated with the aging process. On t h e o t h e r hand, s u c h p a t i e n t s f o r example a s t h e c h r o n i c s c h i z o p h r e n i c o r t h e p a r a n o i d a l p a t i e n t - even o f s e v e n t y - f i v e y e a r s o f age - w o u l d n o t b e a d m i t t e d t o t h i s h o s p i t a l i f he were b a s i c a l l y w e l l o r i e n t e d b u t w i t h p s y c h i a t r i c disorders of long standing.  - 2 D e p t . o f H. ¥ . Washington 25,  & Educ, D. C.  December 1,  196k.  I t has b e e n r a t h e r e n c o u r a g i n g t o n o t e t h e number o f o u r p a t i e n t s whose r e s p o n s e t o c a r e and t r e a t m e n t p e r m i t s them t o r e t u r n t o community. Such p a t i e n t s r e t u r n t o f a m i l y or r e l a t i v e s , t o B o a r d i n g and R e s t Homes, and t o P r i v a t e H o s p i t a l s i n community -. d e p e n d i n g on t h e i r r e s p e c t i v e c i r c u m s t a n c e s and care needs. The number who r e t u r n t o h o s p i t a l f o r f u r t h e r c a r e has b e e n a l m o s t n e g l i g i b l e . F o r example - d u r i n g t h e f i r s t e i g h t months o f t h i s f i s c a l y e a r , 1964-65, © have d i s c h a r g e d f r o m h o s p i t a l one h u n d r e d and f o u r p a t i e n t s . D u r i n g t h i s same p e r i o d o f t i m e o n l y e i g h t p a t i e n t s have r e t u r n e d t o h o s p i t a l and some o f t h e s e had b e e n out o f h o s p i t a l f o r as l o n g as two and a h a l f y e a r s . w  B e c a u s e o f t h e f o r e g o i n g and b e c a u s e t h e f i e l d o f g e r i a t r i c s i s r e l a t i v e l y new, we w o u l d l i k e t o know a b o u t s i m i l a r i n s t i t u t i o n s so t h a t we m i g h t communicate w i t h them. able  We w o u l d be g r a t e f u l f o r any i n f o r m a t i o n to supply i n regard to t h i s matter. Yours  you  might  truly,  Dr. J . Walsh, Medical Superintendent, Valleyview Hospital, Essondale, B r i t i s h Columbia, Canada.  JW:jda  be  DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE WELFARE  ADMINISTRATION  W A S H I N G T O N . D.C. 20201 OFFICE O F AGING  March 4, 1965  .Dear D r . Walsh: We wish t o a p o l o g i z e f o r the l o n g d e l a y i n r e p l y i n g t o your forwarded t o t h e O f f i c e o f A g i n g .  letter,  We have c o n t a c t e d t h e P u b l i c H e a l t h S e r v i c e and i t s N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h t o o b t a i n i n f o r m a t i o n about i n s t i t u t i o n s i n the U n i t e d S t a t e s t h a t p r o v i d e p s y c h i a t r i c g e r i a t r i c t r e a t m e n t . The N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h has made a number o f grants t o s u p p o r t s t u d i e s i n s e v e r a l i n s t i t u t i o n s . A few persons t o whom y o u may address i n q u i r i e s a r e : (1)  Mrs. M a r j o r i e F i s k e Lowenthal, L a n g l e y P o r t e r Neurop s y c h i a t r y I n s t i t u t e , 401 Parnassus Avenue, San Francisco, C a l i f o r n i a . This i n s t i t u t e , f o r the past s i x y e a r s , has engaged i n a r e s e a r c h s t u d y c e n t e r i n g about mental h e a l t h problems o f aged p a t i e n t s adm i t t e d t o and d i s c h a r g e d from a c i t y g e n e r a l h o s p i t a l .  (2)  The D i r e c t o r , Y p s i l a n t i S t a t e H o s p i t a l Y p s i l a n t i , Michigan,* a l s o D r . Wilma Donahue, Chairman, D i v i s i o n o f G e r o n t o l o g y , The U n i v e r s i t y o f M i c h i g a n , 1510 Rackhara B u i l d i n g , Ann A r b o r , M i c h i g a n . D r . Donahue has conducted a number o f comprehensive s t u d i e s on„the g e r i a t r i c mentally i l l at Y p s i l a n t i .  (3) .  S u p e r i n t e n d e n t o f Boston S t a t e H o s p i t a l , 591 Morton S t r e e t , B o s t o n 24,. M a s s a c h u s e t t s . They d i d a s t u d y o f g e r i a t r i c p a t i e n t s a d m i t t e d t o a s t a t e mental h o s p i t a l ; a m u l t i d i s c i p l i n a r y team i n v e s t i g a t e d p h y s i c a l , s o c i a l , e c o n o m i c a l , and e m o t i o n a l problems o f such h o s p i t a l i z e d patients.  - 2 (4)  Superintendent of DeWitt State Hospital, Auburn, C a l i f o r n i a . They conducted a study to evaluate the potentials f o r s o c i a l r e h a b i l i t a t i o n of state mental h o s p i t a l patients,.65 and over, including patients i n a wide v a r i e t y of diagnostic categories, and varying periods of h o s p i t a l i z a t i o n . The study centered about pre-placement services, follow up, and community services.  (5)  Mr. Jack London, Administrator, V i l l a S e l i c i n i a G e r i a t r i c Hospital, Jackson, Louisiana. The V i l l a i s reported to have g e r i a t r i c wards of good repute. Their main objective i s to r e l i e v e the pressure upon p s y c h i a t r i c i n s t i t u t i o n s throughout Louisiana, and improve the care of the g e r i a t r i c patient who does not require extensive p s y c h i a t r i c h o s p i t a l ization.  I hope the foregoing information w i l l s t i l l be timely and u s e f u l . Please l e t us know i f we can be of further assistance. Sincerely,  t  Donald P. Kent Director  Dr. J . TJalsh Medical Superintendent Valleyview Hospital Essondale, B r i t i s h Columbia Canada  January 2 7 t h ,  19&5•  M i n i s t r y of H e a l t h , Alexander Fleming House, Elophant and C a s t l e , London S. E. 1, ENGLAND Dear S i r s : T h i s l e t t e r comes t o you from v a l l e y v i e w H o s p i t a l , the l a r g e s t of t h r e e u n i t s comprising the G e r i a t r i c D i v i s i o n of the Mental H e a l t h S e r v i c e s f o r the P r o v i n c e of B r i t i s h Columbia, Canada. The purpose of t h i s l e t t e r i s t o determine whether i d e n t i c a l i n s t i t u t i o n s e x i s t i n the U n i t e d Kingdom, and i f so t o determine t h e i r whereabouts so t h a t we might communicate with them t o share i d e a s , concerns and e x p e r i e n c e s , e t c . , with r e g a r d t o r e s p e c t i v e programs. V a l l e y v i e w H o s p i t a l (bed c a p a c i t y approx. 800) i s designed t o p r o v i d e care, treatment and r e h a b i l i t a t i o n f o r e l d e r l y men and women who are s u f f e r i n g from p s y c h i a t r i c . i l l n e s s e s (consequent t o the aging p r o c e s s ) . Most p a t i e n t s are admitted as c e r t i f i e d p a t i e n t s but i t i s a l s o p o s s i b l e t o g a i n admission on a v o l u n t a r y or i n f o r m a l b a s i s . Acceptance f o r admission i s based on c l i n i c a l f a c t o r s i n accordance w i t h i l l n e s s e s r e s t r i c t e d t o aging r a t h e r than on a s p e c i f i c age. T h i s would exclude c h r o n i c psychoses e.g. S c h i z o p h r e n i a or dementias due t o other causes. My experience i n Mental H o s p i t a l s i n England up t o 1 9 5 suggests t h a t G e r i a t r i c P s y c h i a t r y may s t i l l be p a r t of each Mental H o s p i t a l program. Under these circumstances our s t a t i s t i c s would not be comparable. 2  I have r e a s o n t o b e l i e v e , however, t h a t much progress i n g e r i a t r i c s has been made i n r e c e n t years and would be g r a t e f u l f o r any i n f o r m a t i o n you may be a b l e t o supply on t h i s matter. Yours t r u l y , J . Walsh, M.B., M e d i c a l Superintendent, Valleyview Hospital, Essondale, B. C , Canada JW:pw  MINISTRY OP HEALTH Alexander Fleming House Elephant and Castle LONDON S.E.I  BY AIR MAIL  M/Health r e f : P/M121/2/TF1  ' ^te£rvtaxy 19^5  Dear S i r , I am r e p l y i n g to your l e t t e r of 27th January. The r e s p o n s i b i l i t y f o r the p r o v i s i o n of services f o r the e l d e r l y mentally, infirm i n Great B r i t a i n i s j o i n t l y held by the Local Authorities and Hospital Services. Local Authorities care f o r the majority of such patients i n welfare homes, but i t i s recognised that there i s a need to separate the more d i f f i c u l t management problems into Homes f o r the E l d e r l y Mentally Infirm. I f the Local Authority are unable to manage e l d e r l y i n f i r m patients because they are i n need of considerable nursing care, or other f a c i l i t i e s of a h o s p i t a l , the patients may be admitted to a g e r i a t r i c u n i t . Here assessment of medical,psychiatric and s o c i a l factors take place, and the disposal of the patient i s decided. The majority of such patients are sent to, and are looked a f t e r , i n chronic annexes to g e r i a t r i c u n i t s . The patients with more d i f f i c u l t behaviour problems (because of dementia or personality disorder) are looked a f t e r i n p s y c h i a t r i c hospitals. Another f a c i l i t y , of which increasing use i s being made, i s the Day H o s p i t a l . This may cater f o r the aged with physical handioaps, the e l d e r l y mentally i n f i r m or both. There seems l i t t l e doubt that t h i s typo of f a o i l i t y i s useful i n ( l ) f a c i l i t a t i n g e a r l y discharge of patients, (2; l i g h t e n i n g the burden on r e l a t i v e s , and thus enabling patients to stay i n the community, who would otherwise have been admitted to a long-stay bed. You may care to write to Dr. L. Z. Cozin, C l i n i c a l Director Cowley Road Day Hospital Oxford, f o r further information i n t h i s f i e l d . You may also be interested i n the study done by Dr. C. B. Kidd at Purdysburn Hospital B e l f a s t , published i n the B r i t i s h Medical Journal, Volume I I page 149"-> 1st December 1962; or i n Professor Martin Roth's study c a r r i e d out i n the Newcastle-upon-Tyne area and published i n the B r i t i s h Journal of Psychiatary, Volume 110, pages 146-15B and 668-682 i n February and September 1964. I should stress that I have used the term " e l d e r l y mentally i n f i r m " to indicate aged i n d i v i d u a l s who have a mild degree of dementia, often accompanied by physical handicap. There are of course a group of patients whose main problem i s a p o t e n t i a l l y recoverable p s y c h i a t r i c oondition, (e.g. depression, paraphrenic); these are dealt with by p s y c h i a t r i c u n i t s and are frequently able to return to the community. Yours f a i t h f u l l y ,  /\0  J . Walsh Esq. M.B. Medical Superintendent Valleyview Hospital ESSONDALE B.C. CANADA  1 1 —  \  i'.i  109  APPENDIX  Nursing  C  Form  ASSESSMENT FOR PROSPECTIVE DISCHARGE PATIENTS -NURSING Ward:  P a t i e n t s ' s Name:  P h y s i c a l care needs:  Please note i f p a t i e n t r e q u i r e s help or s u p e r v i s i o n with any of the following a c t i v i t i e s :  1.  D r e s s i n g n e a t l y and a p p r o p r i a t e l y  2.  Washing hands, f a c e and t e e t h , c a r i n g f o r h a i r and shaving  3.  Bathing  4.  Using the t o i l e t  5«  G e t t i n g up or going t o bed  6.  Walking  (stairs  or l e v e l )  Does p a t i e n t eat w e l l ? Any s p e c i a l problems? Is  s p e c i a l diet required?  Are t a b l e manners d i s t u r b i n g t o others? Sleep w e l l ? Does p a t i e n t snore, scream or wander a t n i g h t ? Incontinent? Constipation? Could p a t i e n t care f o r own room? Help around house? A t t i t u d e t o medication:•  cooperative? Requires Resists?  Sight: Hearing:  supervision?  N u r s i n g Form cont'd. Social patterns:  I n t e r a c t i o n with other p a t i e n t s friendly,; shy  or withdrawn;  controlling; critical; s a r c a s t i c or quarrelsome? I n t e r a c t i o n with s t a f f does p a t i e n t r e q u i r e  from s t a f f  (other  What a t t e n t i o n  than p h y s i c a l  care  needs)?  Does he/she make e x c e s s i v e demands on s t a f f ? What means o f c o n t r o l seem necessary or e f f e c t i v e ? Interested  and v i s i t i n g r e l a t i v e s and f r i e n d s : Has  Has  leave been permitted?  he/she ground p r i v i l e g e s ?  Nurse's e v a l u a t i o n  of patient's  a b i l i t y to function i n  boarding; home/nursing home placement*: P l e a s e add any comments t h a t person c a r i n g f o r p a t i e n t note.  Date:  Charge Nurse:  should  112  APPENDIX  D  Boarding and Nursing Home Questionnaire  QUESTIONNAIRE FOR BOARDING HOME OPERATORS AND NURSING HOME MATRONS 1.  (a) I d e n t i f y i n g I n f o r m a t i o n Name of Home Address Type of L i c e n s e  - nursing  home/boarding home  Owner (b) Finances Number of p r i v a t e p a t i e n t s Number of w e l f a r e p a t i e n t s -  Sex: M F -  Total Is cost determined by: a- p h y s i c a l  facilities?  ( i . e . p r i v a t e room, -ward) b- the i n d i v i d u a l care needs? c- by p a t i e n t ' s a b i l i t y to pay? Range of Costs . Measurement of the home " t o l e r a n c e l e v e l " and a b i l i t y t o cope with the p s y c h i a t r i c g e r i a t r i c p a t i e n t . (a)  Are there p a t i e n t s who a r e : - incontinent?  ( i f yes, i s cause p h y s i c a l or mental)  - not ambulatory? ( i n c l u d e bed p a t i e n t s , deck c h a i r , wheelchair and those who can walk only with a s s i s t a n c e ) - delusional? - hallucinating?  (details) (visual? auditory?  details)  Questionnaire  cont'd.  - confused? (degree-memory? d i s o r i e n t a t e d t o time? place? • person? a l l spheres? Details) - wandering? ( i f yes, means of c o n t r o l ) - r e s t l e s s at night? - i r r i t a b l e , agitated: (b)  Any p a t i e n t on d i s c h a r g e from V a l l e y v i e w ? Any  p a t i e n t on w a i t i n g l i s t  Admitted  to Valleyview?  at Valleyview?  Why?  Why?  Are there p a t i e n t s p r e s e n t l y i n home from P.M.H.? Crease? other boarding home? n u r s i n g home where • patient evicted? 3•  S t a f f and P a t i e n t R e s p o n s i b i l i t i e s What i s the r a t i o of s t a f f t o p a t i e n t s ? What i s the time extent of care and s u p e r v i s i o n o f f e r e d by s t a f f on a d a i l y b a s i s ? (maximum-24 h r s . ) What r e s p o n s i b i l i t i e s a r e expected of p a t i e n t s ? ( i . e . c a r i n g f o r own room, own laundry, e t c . ) .  4.  Medical Is t h e r e a house doctor or i n d i v i d u a l f a m i l y d o c t o r s ? Are t r a n q u a l i z i n g medications  5.  used?  t o what extent?  Staff Training a.  psychiatric.nurses  b.  r e g i s t e r e d nurses  c.  t r a i n e d p r a c t i c a l nurses, a i d e s and/or o r d e r l i e s , where t r a i n e d ?  d.  u n t r a i n e d but with previous experience  e.  none of the above  Worker's comments:  i n homes  

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