Article By: Cal Martell, Vice President, Council on Aging of Ottawa, Age Friendly Ottawa Steering Committee
Age-Friendly Cities aspire to promote and develop “A community that supports and enables older people to “age actively” – to live in security, enjoy good health and participate fully in society.”
Health and social services in general, and hospitals in particular, are an important part of our communities and play a critical role in achieving these objectives, increasingly so as we age. We are blessed with the resources of highly skilled physicians and health professionals providing care for those who need it in an increasingly efficient, if at times complex, health care system.
Our hospitals provide excellent care for most of the population, including seniors, and in some communities, seniors are able to benefit from specialised geriatric and rehabilitation programs wholly committed to get older patients back on their feet and back home.
However, for some time we have witnessed a growing disconnect between the way hospital care is organised and developed, and the changing needs of an aging population. Hospitals have been for the most part focussed on the need to diagnose and treat single acute episodes of illness or injury.
They have not always -been equipped to respond to the needs of older patients with acute illnesses and injuries, in addition to the other health problems or chronic conditions which they have acquired in their journey through life. Newspapers occasionally inform us of individual circumstances where the care provided to an older patient has not reflected their needs or preferences, and too frequently we hear of the difficulty hospitals experience in discharging some older patients back home. While the problems with wait lists, cancelled surgeries, overflowing ERs and so-called ‘alternate level of care’ pressures are often blamed on population aging , they also reflect, as a former colleague explained it, the extent to which our health systems and hospitals have failed to respond and adapt to these changing needs.
The experience of hospitalisation can become a pivotal event in the lives of many seniors, drastically changing the course of their lives, independent of the affect of their illness or injury. The loss of strength, which is estimated at 2-5% per day, associated with being bed-ridden, changes in fluid and nutritional intake associated with diagnostic and treatment procedures, and the overall noise and disorientation of hospital life can have a dramatic effect on the health and function of older patients and affect the possibility of returning to their own home.
Combined with the increased level of risk seniors face for adverse events affecting patients of all ages, such as infections, wait time and so-called efficiency pressures to discharge patients as soon as possible, and a health care work force not fully trained and prepared to respond to the needs a of an aging population, these situations can quickly conspire against the very objective of both the health system and Age-Friendly Cities… to optimise the health and independence of seniors.
Although governments cannot be faulted for not investing in our hospital and health care system (health care spending already reflects almost half of government expenditures and much of these resources are used by seniors) it is evident these investments are not achieving the outcomes seniors and the community at large require and expect. The time to transform or adapt hospital care to the needs of its primary patient population is overdue. Given the admitted complexities of health and hospital care for seniors, a common pathway or road map is needed.
Elder or Senior Friendly Hospital Frameworks must become a focus for those of us concerned about creating truly Age-Friendly Communities. We know from research the potential to improve both health outcomes for seniors and reduce unnecessary utilisation of hospital services that can be realised from hospital care oriented towards acute care of the elderly. We should be encouraged that some health care leaders are beginning to consider a common framework or pathway for hospitals to use in re-orienting their approach to respond to the changing needs of their patients.
Elder or Senior Friendly Hospital Frameworks have been proposed to answer five fundamental questions of the hospitals in our communities. A few examples of what older patients and their families might look for in assessing the readiness of a hospital to deliver on senior friendly care are included below.
Processes of Care
Does the care and treatment of seniors take into account research and evidence regarding the physiology and pathology of aging, as well as social science research? Issue:
Older patients discharged home from the Emergency Department are at greater risk functional decline, hospitalisation and death.
• Geriatric assessment is available in the ED to identify potential risk factors for my return home.
• If I have certain chronic conditions, I am provided information and education to better manage my own health before going home.
Issue:
Early mobilisation is critical to offset the loss of function associated with being bed-ridden in hospital.
• If I am having problems with walking, strength or endurance, an exercise program is offered.
Issue:
Delirium is relatively common for older patients and is associated with loss of physical and cognitive function, even death.
• There is initial screening to determine the risks I may face as part of the hospital stay.
• My functional status, the presence of chronic pain and nutritional status are all evaluated as part of an initial assessment in the hospital.
• I am able to reach the things I need in my hospital room.
• Volunteers will visit if my family and friends are unable to do so.
Issue:
Coordinated discharge planning is critical to support a safe and sustainable discharge home.
• The people involved in my care seem to understand my health care needs.
• I have been asked what supports I need once at home and I can be confident
they have established plans to ensure they will be there when needed.
• I know who to contact if I have questions about my care at home.
Emotional & Behavioural Environment
Do staff interact with older patients in a respectful, supportive and caring way? Issue: The unique needs of older patients can conflict with the way in which hospital services are currently organised and delivered.
• I feel informed and involved in decisions about my care
• I feel staff understand and interact with me as the mature adult that I am.
Ethics in Clinical Care & Research
Do care providers, researchers and others ensure that ethical issues are fully addressed with elderly patients or research subjects?
Issue: Decisions about the care and treatment of older patients respond at times to broader health system pressures.
• My needs for health care and treatment are seen as important as everyone else’s and I am not being forced to consider a discharge option that is not in my best interests.
• I feel I have been given the information I need to understand the risks and benefits involved in decisions about my care.
Organizational Support
Does the organization show its support for being a Senior Friendly Hospital in its’ organizational structures and processes
Issue: Older patients reflect the primary users of hospital services
• The Board of Directors has declared its intent to become a Senior Friendly Hospital;
• There is a designated senior administrator and committee to plan and coordinate programs and services for older patients.
• A geriatric nursing model of care has been adopted within the hospital, such as a geriatric resource nurse, or an Acute Care of the Elderly Unit.
• The hospital measures its success by whether I am safely discharged home not just how quickly I am discharged.
Physical Environment
Is the physical environment sensitive to the capacities of elderly patients and visitors?
Issue: The physical design of hospitals does not always consider the needs of older patients and can contribute to stress, fear, anxiety and worry. It can also limit independence, way finding, promote deconditioning, and make visiting difficult ( Parke, 2007).
• Wheelchair accessible parking is available near the hospital entrance.
• There is easily visible signage with colour coding at all major intersections that allows me to be able to find my way from one area of the hospital to another.
• There are automatic doors at hospital entrances and lever-style handles on other doors.
• There are handrails on both sides of hallways and stairs.
• Lighting is consistent across the hospital and glare is limited.
• Environmental noise is reduced and hearing amplifiers are provided in all patient areas.
• Washroom doors open outwards, allow for walkers and wheelchair access, and are equipped with grab bars and night lights.
• There are clocks and calendars in patient rooms .
Irrespective of a particular strategy or approach, these are questions we need to ask of all our hospitals as key resources in our Age-Friendly Communities.
More information about how these changes can be achieved will be provided in the future.
