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Fall 2025
Fall 2025 Issue Long Term Care: Relocation Stress in Older Adults Relocation to a new setting can present severe problems for older adults. Increased mortality rates, morbidity, and negative psychological changes observed following relocation provide strong evidence of the consequences of such movement. The experience of moving for older adults is often made more difficult when it is involuntary, especially if they have cognitive impairment, limited mobility, or serious medical conditions. While the research on relocation stress has examined relocation outcomes, efforts to minimize the stress experienced by older adults have not been emphasized in most care settings. Defining Relocation Stress Effects of Relocation Stress Relocation of residents within or between long term care facilities occurs frequently and for a variety of reasons, including changing health care needs and the closure of care facilities. In reviewing relocation initiatives used in long term care facilities, Broekharst and colleagues found that scientific literature on relocation initiatives was scarce. They concluded that the scope of the relocation initiatives was limited, focusing on specific types, aspects, and residents, and didn’t address the multifaceted nature of the relocation process. In the case of involuntary relocation, such as a change in medical status, the loss of Medicare eligibility, or the closure of a health care facility, anticipatory grief, stress, and anxiety may occur when residents are informed of the move. Residents facing discharge when their facility is closing have even less choice or control and are more vulnerable to relocation stress. This was the situation in San Francisco when Laguna Honda Hospital, which had the tradition of caring for the city’s most vulnerable citizens, announced the closure of its long term care unit in 2018. The closure plan followed the withdrawal of federal Medicare and Medicaid funding when the CMS determined the unit’s standards of care to be inadequate. Options to place residents, many without families or financial resources, in other facilities in the community were few, and the plan was to move them out of the area. Fifty-seven residents were in the first group to be discharged. Within weeks, 12 had died, and mandated discharges were halted. Symptoms indicating that an older adult may be experiencing relocation stress include: • depression; Risk Factors • individuals being moved involuntarily from home to a care facility; Strategies for Prevention and Intervention A demonstration program that was conducted by the Erie County, New York Office for the Aging in 1974 included all three strategies. It was initiated after the agency found a large number of older adults were in inappropriate settings throughout the county. It was estimated that approximately 104 of the Medicaid recipients residing in skilled nursing homes could be relocated to a lower level of care if relocation services were available. In addition, a survey of the major hospitals in the area found 64 elderly patients who were medically dischargeable, but they remained in the hospitals awaiting placement. The results of the study, as well as the necessity for relocating residents of several large skilled nursing facilities that were closing, prompted the start of a relocation counseling program. Funded through the Erie County Office for the Aging and the Lakes Area Regional Medical Program,3,4 it was designed to demonstrate the feasibility of providing centralized relocation services to older adults who were identified as being at high risk of trauma from relocation. High risk indicators included the absence of family or social support, a history of depression or psychiatric problems, and a negative attitude toward relocation. Referrals were accepted from agencies and facilities serving older adults, as well as older persons or their families. A screening team, consisting of a physician, two public health nurses, and a social worker, evaluated the patients, assessed their medical condition, activities of daily living, adjustment to their present setting, and psychological status. Recommendations regarding the level of care were then formulated, and a social worker was assigned to work with each participant throughout the relocation process. Participants were given the opportunity to be involved in decision-making in the relocation process, and counseling was provided to address any anxiety or fears associated with the move. It was deemed essential that the social worker would be available prior to, during, and after the relocation, providing a bridge from the current to the new environment and helping participants establish relationships and become comfortable in their new environment. It can be challenging for health care providers to support their geriatric patients through the complex process of relocation. For those patients who are moving into residential care, the sustainability of the patient-physician relationship is made more difficult as contact becomes episodic and reactive, with patient care under the direction of the facility’s medical director. When a patient is considered at risk for relocation stress, the following strategies demonstrate ways to mitigate its impact: Engage the individual in the decision-making process. Discuss their needs and preferences, exploring options and giving them a sense of control. For those who have difficulty participating in the decision-making process because of medical conditions or impaired cognition, keep them informed of the plan, giving them the opportunity to express their concerns. When possible, discuss the possibilities of a future move prior to a crisis. Many older adults face sudden relocation because of a fall, accident, or medical incident. The opportunity to explore alternative care settings is best made before a crisis, while there are more options available. Strive to involve family members or friends in the relocation process. This helps the person being moved feel less lonely and more supported. If the older adult is moving to a supportive or health care setting, consult staff in the new environment about strategies they may use to reduce the stress of relocation. Increasing Awareness — Mary Kaplan, MSW, is a clinical social worker who has worked in the field of geriatric health care for over 45 years as a clinician, administrator, educator, and community activist. She is the author of six books, including her most recent, The Practice of Social Work With Older Adults.
References 2. Miller D, Lieberman MA. The relationship of affect state and adaptive capacity to reactions to stress. J Gerontology. 1965;20(4):492-497. 3. Kaplan M, Cabral RM. Relocation trauma counseling for the elderly: a demonstration project. J Gerontological Social Work. 1981;2(4):321-329. 4. Erie County Office for the Aging. Report on evaluation of Medicaid clients judged to be inappropriately residing in nursing homes. Published 1973.
Resources 2. Broekharst DSE, Brouwers MP, Stoop A, Achterberg WP, Caljouw MAA. Types, aspects, and impact of relocation initiatives deployed within and between long-term care facilities: a scoping review. Int J Environ Res Public Health. 2022;19(8):4739. 3. Broekharst DSE, Stoop A et al. An exploration of relocation initiatives deployed within and between nursing homes: a qualitative study. BMC Health Serv Res. 2024;24(1):22. 4. Halifax E. Nursing home residents, transfer trauma or relocation stress syndrome. University of California website. https://emancipatorysciences.ucsf.edu/eslabblog/nursing-home-residents-transfer-trauma-or-relocation-stress-syndrome. Published March 20, 2023. |
