As in all industrialised countries, the population of France is ageing rapidly. Today, 15% (1 in 6) of people are over 65 years old and 4% (>2 million) are older than 85. These figures are set to increase over the next decade. With an older population comes increased morbidity from age-related diseases. However, the hospital environment remains hostile to the older patient, because it is not adapted to an ageing population.
Most general practitioners (GPs) try to avoid the hospitalisation of older patients unless absolutely necessary and alternatives do exist. Specialised day hospitals for the older patient provide capacity for treatment adjustments, diagnostic or exploratory examinations and other short-term care under hospital conditions.
Another important initiative is the creation of a domiciliary care structure (HAD: hospitalisation à domicile). HAD is supported by the public hospital system and reimbursed by the social security. It enables aged patients to receive the equivalent of hospital care in their own homes. It provides an ideal option for the elderly, especially those with chronic illness, medical and paramedical services are obtained without the trauma of hospitalisation. Unfortunately, the network is not fully developed and many departments, especially in semi- or completely rural areas, are not equipped to provide such a service, which requires flexible staffing and time. Figures for Brittany in 2008 show that the nine existing HAD centres treated a total 251 patients, average age: 70 years. Each patient received an average of 0.8 doctor, 1.31 nurse and 1.79 physiotherapist visits a day. The average length of a nursing visit was 34 minutes per patient.
Therefore, for many elderly patients, hospital is the only option. Although many GPs and hospitals try and programme a short period of stay, this often becomes protracted. With elderly patients rapidly losing autonomy, returning to their homes requires planning and coordination. Understanding of this difficulty has led to the creation of support networks for the elderly, the so called ‘réseaux gérontologiques’. The idea is that with the GP acting as a coordinator between healthcare in the local hospital and the community, each patient has a personalised project for their return home.
In theory this care starts before hospitalisation, when the reasons for and the possible outcomes of the hospital stay are fully explained. This discussion should also include the patient’s family so that they can be aware of future changes in the daily life of their relative. Then the community nursing team and other necessary paramedical staff should be contacted to ensure the correct continuum of care. For a successful return home, which is possible if all works well in almost two-thirds of cases, a fully integrated multidisciplinary team is essential.
Unfortunately, it is at this point that theory is often not translated into reality. One barrier is financial, while some of the cost of medical care comes from the global hospital budgets much of extra care needed has to be financed either from the patient’s own health insurance or from family resources. State aid is available from different departments but this requires time and quite lengthy form filling. The burden on the patient’s family is high, needing coordination, determination and knowledge of the possible options.
Legally, a patient cannot be discharged unless they have family at home waiting for them, but the quality of attention and family willingness to assist in the return and medical follow-up is not necessarily verified. According to one district nurse in the Parisian region, communication between the hospital and her office is virtually non-existent. Often no one informs them of a patient’s potential hospitalisation or return home. On visiting, they find that conditions at home are not suitable for follow-up treatment, with no sufficient provision in place for basic necessities such as cleaning, shopping and cooking. This is due entirely to a lack of communication and coordination between the different players responsible for the patient’s care. This nurse fully appreciates the work of individuals in trying to improve the lot of the older patient returning home, but feels that they are working to no avail, in splendid isolation. Her belief is that until French society values the elderly rather than considering them as an inconvenience, the continued care of the chronically, or acutely ill, old will remain piecemeal and erratic. With the majority of the population rapidly becoming ‘old’ let us hope that their ‘value’ is realised sooner, rather than later.
Despite the legal discharge requirement, 50% of hospitals have not implemented it, writes Martin Steinberg
The reduction in hospital length of stays to the necessary minimum is desirable from an individual as well as an economic viewpoint. Patients are allowed to reintegrate into their jobs and social life faster and hospitals are given some financial relief in these days of case-based remuneration systems. However, the individual, medical and psychological needs of patients are at risk of being pushed aside for the sake of economic arguments. Therefore, a well-functioning discharge management system, at the interface between out- and in-patient care, is increasingly important. The German Network for Quality Development in Care (DNQP) published an Expert Guide to Discharge Management for the German healthcare system in 2004 as ‘disruption of care after discharge (…) bears health risks, exposes patients and their relatives to unnecessary strain and can lead to high consequential costs’. This view was shared by the legislator who, in 2007, passed the GKV-WSG law (statutory health insurance competition reinforcement law), ensuring patients’ rights to professional discharge management: ‘Insured patients are entitled to adequate care management, particularly for the solution of problems inherent in the transition between different areas of care (§ 11 AGBV V). However, the law leaves room for interpretation regarding which occupational group should carry out which tasks: ‘The affected service providers ensure appropriate follow-up care of insured patients … They are to be supported in these efforts by the medical insurers. The care facilities are to be involved in this care management process …’
The Cochrane review supports efforts partly to redistribute the tasks involved in discharge management. On the basis of ten randomised, controlled studies, it examined a concept involving the transfer of responsibility for a unit dealing with discharge preparation within an acute hospital to nursing staff, with doctors only required on an advisory basis. Result: No significant statistical effects regarding mortality in hospital and the three- and six-month mortality rates respectively. Moreover, the functional status of patients looked after by the NLU (nurse-lead unit) was better than that of patients in a normal ward (Anderl-Doliwa, 2008). The Charité Clinic in Berlin considered these findings and was among the first to redistribute tasks among hospital staff in 2006. Last year, the Pfalzklinikum for Psychiatry and Neurology, in Rockenhausen, began its Ward Manager project, which plans the use of staff on the ward cross-professionally, coordinates appointments and takes over service controlling. According to Brigitte Anderl-Doliwa, of the clinic’s nursing directorate, this redistribution of tasks and responsibilities can only succeed if the discharge processes are actually perceived as management tasks.
However, the reality is currently rather different. According to Anderl-Doliwa, roughly five years after the introduction of the expert DNQP standards, and despite legal requirement, less than 50% of hospitals actually have written standards on discharge management. It is the responsibility of hospital management to create the organisational, legal and structural prerequisites for the redistribution of tasks, he points out.
The claim of a third group, after doctors and nurses, to the right of involvement in discharge management demonstrates the danger of a struggle over competencies in the hospitals. In 2004, the German Association for Social Work in Healthcare (DVSG) also published a policy document on discharge management, defining the objective of the joint efforts. ‘The objective is to enable each patient to receive the type of care that best takes his wishes and his requirement for help into consideration, whilst ensuring his right of self-determination, voluntariness and freedom of choice.’ Because of the emphasis on the ‘freedom of choice care’, the DVSG underlines its claim to be a firm point of contact in interface management and not only – as often perceived by the public – a helper in the fight against bureaucratic hurdles. And it is hard to contradict the social workers in their policy document, which points towards their ‘broad training spectrum and multidimensional approach’. Social work is classic interface management.
In view of the existing interdisciplinary competence it is surprising that not more hospitals have professionalised and standardised discharge management. This increases the danger of the aspired, comprehensive reduction in the length of individual hospital stays, actually leading to a revolving-door effect with high follow-up costs. German hospitals should quickly define and implement these quality standards in their own interest, but particularly in the interests of patients. The DVSG is right to emphasise that ‘discharge management is a multiprofessional task where each occupational group has to abide by quality standards’.
We can only hope that the ‘German Patient’ has been cured of the symptoms of a sophisticated struggle over competencies linked with a chronic belief in hierarchies.
The Czech Republic
Policies are needed to provide medical education in geriatrics, a restructuring of institutional care, and to change the current critical care/follow-up care beds concept, Rostislav Kuklik reports
Gerontology/geriatrics care is not well organised – best proven by the fact that Tomas Julinek, the last Health Minister, proposed that geriatrics as a specialised medical field should be repealed. If this was to happen (no progress has been noted since the government fell and the minister changed), geriatrics would undoubtedly gradually diminish and die out in the end. Another evidence of poor organisation comes from data published by the Czech Research Institute for Labour and Social Affairs, which states that the present care of elderly citizens is unsatisfactory on both sides. Relatively, there are enough beds in nursing homes; however, admission for many applicants (regardless of social and/or financial status) is simply refused and there is no alternative. For those wanting home care there is a critical lack of professional carers, so the situation is the same - desperate.
In the Republic, the history of the long-term geriatric care settings (LTC) began in the 1980s, when LTC beds emerged as ‘a geriatrics bed base’ and the position of geriatric nurse was introduced into practitioners’ work in town areas. A concept of follow-up care began in 1998. Since then, not much has changed, and LTCs are usually perceived as the ‘last resort’ for those without relatives, or old, polymorbid, and/or unable to care for themselves. Beds for elderly are very frequently operated by personnel with no proper geriatrics medical training and, unfortunately, these medical professionals do not have an adequate training opportunity to obtain further knowledge to deal with these patients. Postgraduate education in this very medical field is quite tricky and lacks resources on all fronts.
Being retired and over 65 means a lot to anyone, anywhere; in the Republic, it also means (with slight regional differences) that such a person has about 80% probability to be fully independent, 10% probability to need home assistance, 7% probability to need home care, and 3% probability to be fully dependent and needing institutional care. Unfortunately, for some reason we seem unable to meet up with the home care offerings of other European states, despite many efforts made, and even a law on social services applicable since 2007. This country lacks urgent geriatrics beds, and their numbers decrease annually: 611 in 2002, 439 in 2006, and only 393 in 2007. Conversely, as we do not lack follow-up geriatric care beds, there are sufficient opportunities to place an elderly patient in a nursing home, but with the risk of improper care, as discussed.
The future - All over the developed world, the coming of age is an issue seen hand in hand with two general problems: changes need to be implemented in retirement income insurance policy and elderly care. It seems quite advantageous to take the necessary steps as soon as possible, because even politicians in the government feel a strong urge to make unavoidable changes and they have agreed on implementing a national aging programme for the period 2008 to 2012.
Postgraduate medical education for physicians working in geriatrics, restructuring of institutional care and changes to the critical/follow-up care beds concept should be cornerstones of new policies.