How to make hospitals right for seniors
Much has been written about the Ontario government’s decision to release older adults into nursing homes against their will, but much of it misses the complex underlying issues that caused this crisis and the real solutions needed to address it.
The healthcare system, especially acute care, as we know it today, is not geared to the needs of today’s population – but it could be.
People over the age of 65 are major users of acute care, often for serious cardiovascular and respiratory conditions and hip fractures. Many of these patients are medically complex, frail, and often affected by chronic illness and cognitive impairment. They are particularly vulnerable to hospital-acquired complications such as delirium and functional decline, which in turn lead to Alternate Level of Care (ALC) designation.
It is important to understand that ALC is an administrative designation: it is not a diagnosis or a clinical condition. The ALC designation is applied to patients when the health issue that brought them to the hospital is considered resolved. However, these patients still have chronic health problems, now compounded by hospital-acquired delirium and functional decline, that have not yet been fully addressed.
ALC reflects a system that leaves patients’ needs unmet. ALC is not inevitable and will not be addressed by discharging patients without considering their post-hospital needs.
The solution is to make hospitals suitable for the elderly. Senior-friendly hospital policies have been shown to prevent delirium, hospital falls, functional decline, long-term admissions, and reduce healthcare costs; however, only a handful of hospitals across Canada have implemented these.
Early consideration of rehabilitation, either in the hospital, in specialized programs in nursing homes, or in immediate settings, is essential, especially for older people who often need more time to recover. Therefore, senior-friendly hospital practices must be mandated and a robust federal quality assurance system linked to accreditation and public reporting implemented.
Basically, a person cannot become an ALC if they are not hospitalized at all. As noted above, fractures and exacerbations of chronic heart and lung disease, much of which is preventable, are the most common diagnoses for admission to acute care in the elderly. Patients with chronic conditions are less likely to be hospitalized when cared for in primary care interprofessional settings.
A recent evaluation funded by the Ontario Department of Health showed that memory clinics in primary care can reduce hospital admissions, delay admissions and save $26,000 per patient per year; However, 80 percent of Ontarians do not have access to these. Additionally, improving home care and community services, including elder-friendly rehabilitation, and ensuring these are better integrated with primary care will further ease the pressure on acute care and LTC homes.
Alternative levels of care are not an inevitable consequence of aging but the product of a healthcare system that does not adequately address the complex care needs of the population. Any government seriously addressing the health crisis must invest in integrated community and primary care services supported by specialized geriatric services to reduce the likelihood of hospitalization.
This needs to be complemented by senior-friendly acute care to prevent hospital-acquired complications and the necessary reintegration services to support recovery and reintegration into the community. This all depends, of course, on the availability of adequately trained and remunerated health care workers.
Hospitals as we know them today are not right for the elderly and this has consequences for all those in need of care. This can be fixed.