SUSTAINABILITY OF HEALTH CARE SYSTEMS

1
SUSTAINABILITY OF HEALTH CARE
SYSTEMS

• Major restructuring
• Acute beds ?
• Length of stay ?
• Ambulatory services ?
• Aging population ?

2
NOT BECAUSE THEY ARE OLD

• Dissatisfaction with care
• Physical environment
• Staff shortages
• Interactions with staff
• Insufficient training
• Poor discharge planning
• Lack of accessibility to community services
• An independent inquiry into the care of older
  people on acute wards in general hospitals,
  Health Advisory Service, UK, 2000

3
TIME FOR ACTIONADVANCING HUMAN RIGHTS FOR
OLDER ONTARIANS

• Ageism
• Health care institutions and services
• a) Insufficient funding
• b) Inadequate community care
• c) Shortage of health care professionals
• d) Physical barriers
• www.ohrc.ca

4
THE PUBLIC HOSPITAL OFTHE FUTURE

• Currently based on needs of providers
• Future framework
• Safe - avoiding injury from care
• Effective - evidence based services
• Patient centred
• Efficient
• Equitable
• Zajac, JD, Med Jour Avs. 2003179250-252

5
GETTING IT RIGHT WHY BOTHER WITH PATIENT
CENTERED CARE

• Managing chronic disease
• Communication with patients
• Partnerships
• Focus beyond specific conditions on health
  promotions and health life styles
• Bauman AE, Fardy J, Harris PG. Med Jour Aus.
• 2003179253-256

6
ACUTE HOSPITAL

• Most costly sector
• 65 highest rate of hospitalization
• Length of stay ?
• Risk of functional decline ?
• Long-term placement ?
• Palmer RM Clinics in Geriatric Medicine.
  Acute Hospital CarePreface. Vol. 14, No. 4
  x1-x11, 1998.

7
HOSTILE ENVIRONMENT

• Cascade of dependency
• Functional loss
• Iatrogenic disease
• Adverse drug reactions
• Nosocomial infections
• Delirium
• Malnutrition

8
ROLE OF SPECIALIZED
GERIATRIC SERVICES

• Premise
• Much of disease, disability, dependence,
• preventable, treatable, manageable
• Inappropriate diagnosis ? inappropriate
• treatment ? length of stay ? ? premature
• placement
• Fact Sheet The Role and Value of Specialized
  Geriatric Services. The Regional Geriatric
  Programs of Ontario, 2000 (www.rgps.on.ca)

9
THE REGIONAL GERIATRIC
PROGRAMS OF ONTARIO

• Coordinated comprehensive range of
  multidisciplinary services
• Acute geriatric units
• Internal consultation teams
• Geriatric rehabilitation
• Geriatric day hospitals
• Specialized clinics
• Community outreach programs
• The Regional Geriatric Programs of Ontario
  (www.rgps.on.ca)

10
MEDICAL NEVER-NEVER LAND

• 1. Age Denial
• 2. Older Patients are marginalized
• 3. Lack of public awareness
• 4. Scarcity of Academic leaders
• 5. Lack of academic infrastructure
• 6. Geriatric medicine not values
• 7. Inadequate reimbursement
• 8. Lack of coordination within medicine
• 9. Clinical trials not including the elderly
• 10. Little research into aging
• JAMA Vol. 287, No. 14 April 10, 2002

11
UNITED KINGDOM

• Needs related 27
• Age related 54
• Integrated 19
• British Geriatric Society (www.bgs.org.uk)

12
ACUTE CARE OF ELDERS UNITS
(ACE)

• Prevention of dysfunctional syndrome
• Patient centered care
• Multidisciplinary assessments
• Interdisciplinary teams
• Palmer RM, Landefeld CS, Kresevic CM, et.al.
  A medical unit for the acute care of the elderly.
  J Am Geriatr 42545-552, 1994.

13
EFFECTIVENESS OF A
GERIATRIC EVALUATION UNIT

• Lower mortality rate
• Discharge to nursing home ?
• Functional status ?
• Less time in institutions
• Rubenstein LZ, Josephson KR Wieland GD, et
  al Effectiveness of a geriatric evaluation unit.
  A randomized clinical trial. N Engl.Med 3111664,
  1984.

14
COMPREHENSIVE GERIATRIC
ASSESSMENT A META ANALYSIS OF
CONTROLLED TRIALS

• Geriatric evaluation programs with strong
• long-term management improve survival
• and function
• Stuck AE, Siu AL, Wieland GD, et al
  Comprehensive
• Geriatric Assessment a meta-analysis of
  controlled
• trials. Lancet, 3421032-1036, 1993.

15
A Controlled Trial of
Inpatient and
Outpatient Geriatric Evaluation and
Management

• Randomized Trial
• 11 Veteran Affairs Medical Centres
• Geriatric care versus usual care
• No significant effects on survival
• Reductions in functional decline
• Improvement in mental health
• No increase in costs
• Cohen HJ. et. al. N Engl J Med 346905-12, 2002.

16
SENIOR SENSITIVE SERVICES

• Elder Friendly Hospitals
• Parke B, Stevenson L. Creating an
  elder-friendly hospital. Healthcare Management
  Forum. 45-48, 1999.
• ACE Unit Philosophy
• Palmer RM, Counsell S, Landefeld CS. Clinical
  intervention trials. The ACE Unit. Clinics in
  Geriatric Medicine, Vol. 14, No. 4 831-849,
  1998.
• Hospital Admission Risk Profile (HARP)
• Sager MA, Rudberg MA, Jalaluddin M, et.al.
  Hospital admission risk profile (HARP)
  Identifying older patients at risk for functional
  decline following acute medical illness and
  hospitalization. J Am Geriatr Soc, 44251-257,
  1996.

17
MEASURES/GUIDELINES

• Adverse drug reactions
• Nosocomial infections
• Falls
• Delirium
• Nutrition/Hydration

18
THE ROMANOW REPORT IMPLICATIONS FOR THE ELDERLY

• General Recommendations
• Health Council of Canada
• Modernization of Canada Health Act
• Information Technology
• Applied Research Policy
• Prevention and Diagnostic Services
• Caregiver Support
• National Drug Agency
• Fisher RH. The Romanow Report Implications for
  the Elderly. Geriatrics Aging, 6(3)46-49,
  2003.

19
THE ROMANOW REPORT IMPLICATIONS FOR THE ELDERLY

• Recognizes aging population and costs but claims
  it is impossible to accurately forecast needs
• Fisher RH. The Romanow Report Implications for
  the Elderly. Geriatrics Aging, 6(3)46-49,
  2003.

20
ADVOCACY

• National Service Framework for Older
• People -Modern Standards and Service
• Models.
• Department of Health, United Kingdom,
• March 2001.
• www.doh.gov.uk/nsf/pdfs/nsfolderpeople.pdf