Dr. Warner-Maron has been practicing nursing for 33 years, specializing in the care of geriatric patients. She is an Assistant Professor at St. Joseph’s University in the department of Interdisciplinary Health Services. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.
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I recently had the opportunity to travel to Cuba with the College of Physicians in Philadelphia in order to observe the Cuban health system and determine if there were aspects of care delivery that could be translatable to the US. The only information I had about the Cuban system was learned from watching Sicko, Michael Moore's 2008 film that contrasted the efficiencies of Cuban health against the inefficiencies and waste sound in our health care system. As part of the experience, we went to several health care facilities, including an international medical school, a general hospital, an orthopedic hospital, a clinic for high-risk pregnant women, a rural health clinic, and a "grandparents home." The grandparents home would be the equivalent of an assisted living/intermediate care nursing home in the US.
One of the most striking differences between our countries in the principle role that primary health care plays in the system. The primary care physician is responsible for the preventive care, reproductive health, and health outcomes of a defined number of patients within his community, a community in which both lives and works. He is aware of not only the health needs of his patients but the social, economic, and political issues of the neighborhood. It reminded me of an experience I had of a wound nurse seeing a home care patient who had recurrent exacerbations of asthma. Despite having repeated hospitalizations and medication changes, he—a university-trained, well-respected pulmonologist—was unable to make any headway in improving her care. While in her house, I observed carpets that were full of dander and dust, several old, dying plants, and piles upon piles of clothing, magazines, and other dust-collecting items. What the patient needed was to remove the sources of asthma from her home—not just add medication upon medication to her regimen. Had her pulmonologist taken the time to make a house call, he could have seen why his treatments failed to improve her status, let alone address issues of cost.
The essential issue for Cuba is that 11.5 million people have been promised health care as a right, not a privilege. The problem is that the country has vastly limited resources and the maintenance of anything, whether it is homes, government buildings, roads, hospitals, or health care equipment is virtually non-existent. As a consequence of having limited technology, the physician is expected to exercise his clinical skills in the art of the physical examination in order to identify abnormalities prior to ordering radiological and laboratory testing. For some US practitioners, the art of the physical exam, palpation, auscultation, percussion, and the ability to generate a clinic diagnosis in the absence of laboratory and radiological testing has been lost.
I visited a 360-bed "grandparents home" located in Havana operated by a religious order in which the nursing services are provided by nuns from outside Cuba. In addition to the residents who live in the facility, there are an additional 140 people who come daily for lunch, dinner, and socialization. Essentially, the facility operates at the level of an assisted living, an infirmary and as an adult day care provider. Residents are only admitted to the facility if they choose to be there. There is no ability for the family to place a resident against his/her will in such a facility. The nuns work in shifts of 4 or 7 days per week in a 52-week year.
There were no adult diapers or incontinence products. The cost for these disposable items would be too great, therefore residents' clothing is changed more frequently. Despite this, there was little evidence of odor.
Those who work in the long-term care industry often bemoan the difficulties of securing sufficient numbers of staff and in attracting employees who actually care about the residents in the building. The Cuban nursing home was no different in this regard, as Mother Superior noted that she had insufficient numbers of staff who feel a bond to the residents served. Recruiting and retaining appropriate staff is as universal a problem in Cuba as it is in the US. One feature that is dissimilar, however, is the lack of regulations governing the Cuban facility. Mother Superior was not required to be licensed. There were no cubicle curtains separating the 8-10 residents who shared a dormitory-style room. Full side rails were observed on the rather poorly maintained hospital beds. Locking gerichairs were observed on units in which residents appeared to have significant mobility impairment. An old, rusted weight scale was seen in a corner of a hallway, an antiquated Hoyer lift was seen in another corner.
The cost of care is an overwhelming concern to the staff of the facility and as a consequence, no adult briefs are used. Incontinent residents are changed frequently and the odor in the building was minimal. Although family members in the US often take responsibility for laundering the clothes of their family members, there is no expectation or requirement that families perform this function in Cuba. Instead, families are encouraged to visit and perform basic care. The presence of numerous family members during our Sunday visit was obvious. Men and women are cared for in separate units of the building, with the explanation that "it prevents the men and women from fighting." Perhaps the separation of the genders is performed for additional reasons. Married couples may live in apartments together known as the matrimonial unit, however if one spouse dies, the remaining spouse is expected to move to the section of his/her gender, a loss not only of the spouse but of the special housing they shared together. There was no physician presence during my visit. When asked about the average number of medications used per resident, the exact answer was not known, however Mother Superior believed the number was actually decreasing over the last several years. Perhaps this was more of a consequence of financial pressures rather than a clinical decision. Residents are provided their medications at breakfast; some may also receive medications at lunch. Clearly, I did not observe large numbers of people receiving large numbers of medications, yet I did not observe pacing, aggressive, agitated or obviously sedated residents either.
Payment for nursing home residents is provided by the state, which uses the two-thirds of the person's pension (usually 200 Cuban pesos) for the cost of his/her care. This amounts to approximately $11 per resident per month.
Despite the lack of modern equipment, sufficient staff and incontinence products, the residents appeared content, composed, and secure. There were areas within the structure of the facility to enjoy sun and fresh air for residents, in contrast to many of the long-term care facilities in the US that assist residents outside only if that resident smokes. It was truly amazing how so few people with such limited resources could provide so much for these older adults.
