What might future healthcare of older people who are frail* look like?
The future is in more community-based care with health teams of GPs, geriatric specialists, nursing, physiotherapy, occupational therapy, pharmacy and social services caring for people close to where they live.
There are models of care along these lines being used overseas which have significantly reduced hospitalisation, allowing people to continue to manage in their own homes.
One approach is the hospital-in-the-home where a team of health workers bring the health services to the patient. This type of care is most appropriate for long-term health conditions. A safety net of urgent care teams are in place in case of sudden deterioration.
In the wider scenarios better integration of community services can help make sure older people with complex health needs take full advantage of the services available to them with a personalised care plan.
In rest-homes, early medical intervention strategies can prevent deterioration which could lead on to hospital admission.
Having a rapid response system for older people in the community or in care homes will be important to anticipate and respond to new health and ability problems.
What’s behind the move to increased community-based care?
People want to continue to lead their normal lives in their own homes for as long as possible and overseas evidence points to decreases in ED admissions and hospital stays for older people when programmes are in place to allow them to do this.
Personalised community care also allows earlier treatment to head off more serious problems when health deterioration occurs.
As the population of older people rises in the Southern district it makes sense to implement this change now and the new hospital is an opportunity to transfer more healthcare to the community.
Isn’t this just forcing these patients out of hospital?
Of course when it is appropriate people will be admitted to hospital but for older people who are frail* hospitalisation comes with particular dangers. The unfamiliar surroundings, loss of normal activity and increased medication can have a negative effect.
Patients who enter hospital as independent older people are at real risk of a rapid decline in physical and mental health, and independence, often not directly related to the reason they are in hospital.
Prolonged bedrest, which quickly reduces physical fitness, and some medical interventions are not a good combination and add up to functional decline in up to 50% of hospitalised older people.
What about patients who have to stay in hospital?
There are already programmes to help offset the risk factors by encouraging mobility and mental stimulation in hospital.
Dunedin Hospital runs the Sit Up, Get Dressed and Keep Moving' initiative to get patients out of their pyjamas and up and out of bed.
The new hospital can build on this by streamlining the patient’s movement through the health system - whether they be in ED, waiting in a surgery ward for urgent surgery, waiting for discharge planning and so on. Delays can be eliminated or minimised through good service design and resource planning.
We can also design the new hospital to remove the focus on beds and to encourage walking and to reduce the risk of falls and infections.
There will also be a move from “push” to “pull” – this means that instead of a hospital service looking for the next place for the older person to move to, they actively seek out their next older person.
So in-patient wards would actively seek patients from ED and community services would come into the hospital to seek older people to take home and successfully integrate them back into their normal lives.
Will community services be able to cope with this new model?
The community based programmes for the older people who are frail represent a substantial move away from hospital care so the implications for community services are considerable.
Buy in from community health providers is essential and to achieve this considerable effort will be required to enhance hospital-community collaboration.
It is likely that pilot programmes will be necessary.
Although older people who are frail are the obvious group to support through community programmes they will offer a useful pathway for other groups of patients who will benefit from this approach.
* Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Around 10% of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85 years (British Geriatric Society)
This Q and A is based on a position paper produced by the New Dunedin Hospital project's Clinical Leadership Group