Dr François de la Fournière,
Geriatric Internist, Pau
Email: [email protected]
Professor Pierre Peyré,
Université de Pau et des Pays de l’Adour
Health manager, Pau Hospital
Can hospitals deal with an ageing popula tion and a rising prevalence of Alz heimer’s disease? The new governance structure, Hospital 2007, strives to meet this pressing challenge. It will undoubtebly produce other care sections, more gerontology networks, provide better support for the local hospital and regulations for general and regional hospitals.
However, beyond the structural level, these governance processes are complex and are torn between unity and diversity. Talk of transdisciplinary care must no longer be empty rhetoric between those who are responsible for service provision clusters and representatives for ca re givers and administrators. This ap plies particularly to those on hospital executive boards, who are a new decision-ma king force.
A Demographic Overview
People over 75 years of age represent nearly half of all general hospital admittances and the majority of unscheduled early re-hospitalisations.
The PAQUID-Bordeaux study projects that this age segment will increase from 7.7% of the population in 2003 to 9.6% in 2010 and 18.1% in 2050. In conjunction, the prevalence of dementia (be it Alzheimer’s or similar conditions) will increase from 6.5% between 75 and 79 years old, to 15.1% between 80 and 84, and to 27.9% between 85 and 89. For its part, life expectancy is still on average 3 years for 90 year-olds.
These figures are higher for rural areas, which is a particular cause for concern because in these outlying areas, health services are already offered at a lower level, with fewer general practitioners, fewer nurses, etc.
The main epidemiological conclusion made from both the PAQUID study co-ordinator and a parliamentary report is that the state is failing to institute measures aimed at prevention, early diag nosis and subsequent care of demen tia.
There are cases of loss of op portu nity for the patient and his or her family, disorganised recourse to the healthcare system and a lack of adequate study regarding those not seeking treatment. There are also increasingly high numbers of hou sehold accidents and maltreatment cases.
With the current numbers of vulnerable groups set to increase, the number of automobile accidents is also expected to rise, despite national campaigns set on prevention.
Hospital Care and Geriatrics
The level of geriatric care in hospitals is insufficient: few hospitals offer a complete range of short-term stay care (including Alzheimer’s and daytime admittance beds), follow-up and rehabilitation care, long-term care, mobile units attached to the emergency ward, out-ofhospital gerontology networks with the hospitals’ participation, among other neces sary services.
Hospital missions are increasingly technical in nature, with a gradual divestment from their social role. Senior citizens take up a great deal of resources but count for few points under the new rating system. This situation has al ready been studied for two regions and as a test of new measures for re source distribution for the follow-up and rehabilitation care sectors.
How ever, our aim is to partner with the administrative, medical and care-giving stakeholders of the hospital sector to envision a new governance structure centred on gerontology.
Transdisciplinarity, Intercultural Approaches
Within hospitals, there are three subgroups: doctors, caregivers and administrators. Older patients who are hospitalised are cared for in a general hospital setting half the time, and much more often in a local hospital setting. It is not standard practice for executive boards to include a geriatric specialist among their 6 or 8 members, however the board must periodically define the institution’s policy on geriatrics.
There fore, hospital specialists in geriatrics wield little influence over decisions, even if they lead their departments. Whether they strive to create geriatric day beds (or increase their numbers); encourage investment of more resources into another typical aspect of geriatric hospital care or create specialised assessment consultations in liaison with networks within or beyond the hospital setting, often geriatric specialists are facing an uphill battle.
The commonality between all the hospital- based gerontology public health necessities is their real financial impact. This impact is minimal in comparison with that of an emergency room re structuring or a capacity increase for an intensive care unit or an operating theatre, but as the medical and administrative community sees the field of geriatrics as being subordinate and a secondary priority, its value is often underrated and misunderstood.
What is then to be done in the case of those over 75, and even more urgently the “very old” in Anglo-Saxon parlance, those over 80, when they are no longer “capable” of lea ving hospital for sociomedical reasons?
The Pau Experiment
Let’s study the real world case of the Pau Hospital, where despite having 40 short-term stay geriatric beds (over
2000 admittances a year) and 4 geriatric day hospitalisation beds, current needs for emergency and specialised services continue to outstrip geriatric care offerings. The coefficients of occupancy and length of stay are both incompressible. After 2 years of planning (2002-2004), an official working plan was signed at the Regional Hospitalisation Agency (ARH) in 2005. The objective was to replace 10 beds in a closing department with a short stay geriatric hospitalisation unit as of 2006.
Length of stay would be considerably shorter (4 days); services offered would be coordinated with other hospital depart ments (i.e. geriatric day beds, emergencies) and coordination with structures outside of the hospital (i.e. social and sociomedical services, developing local level geron tology networks) would be optimised.
Over 800 admittances were received over the first full year of operation (2007). All of these admittances were processed from emergency cases, thus alleviating the pressure on the latter service.
The unit has also implemented collaborative mea sures with other hospital departments and organisations out side the hos pital setting (follow-up services, home care).
In fact, in cases in which a stay in this unit was initially meant to be brief but turned out to have been underestimated, a transfer to another branch of geriatric care can ensue.
In most cases, this short hospital stay allows for the main clinical diagnosis to take place without affecting the functional autonomy or worsening the level of dependency of these patients.
Nonetheless, the Achilles heel of the structure established in Pau and in all other institutions of this type is a signifi cant readmittance rate (33% at ap proximately 6 months).
This leads one to ques tion why there is a quasi-absence of home-based healthcare specific to geria trics in France, and gene rally why the need for care before and after hospitalisation is not ad dressed.
This accomplishment shows that when doctors, even those in less common fields such as geriatrics, strive to communicate with administrators and caregivers, they can convey their messages and trigger change that benefits all.
Additionally, a Béarn-based gerontology network centred on palliative care has exis ted in one county since 1996, and in six counties since 2004.
Its survival de pends on financing allocated by authorities according to decisions made by State service providers. In 2005, the region’s social services promoted a network that complemented their programmes, though they did not finance it.
While it gathers together many health institutions, currently this network only exists at the insti tutional level. To be truly effective, it should enable real colla bora tion between general practitioners, independent nurses and hos pitals as well create an easily ac ces sible structure for all geriatric care providers.
Such networks act before and after hospitalisation:
• Assessment of the senior citizen;
• Coordination of caregivers in order to avoid certain hospitalisations (for example, admittance to retirement homes);
• Anticipation of problems (admittance without being processed by emergency services), and
• prevention of unnecessary rehospitalisation.
Gerontology networks are a highly de sirable complement to short stay geria tric hospitalisation and are an important part of a good public health governance plan.
This example of the pairing of short stay geriatric units with gerontology networks illustrates:
• an alternative to standard hospitalisation;
• an attempt at finding answers to issues related to demographic aging for hospitals;
• a decompartmentalisation of hospital caregivers in relation to each other and to outside agencies, and finally,
• a genuine attempt to adopt interdisciplinarity.
This melding of expertise is indubitably at the core of Hospital 2007 and cannot be ignored in the fields of gerontology and geriatrics in particular.
Following the new hospital governance is clearly also a question of learning how to think and act with complexity in mind. It all flows from keeping track of the fundamental regulations which oversee its vital equilibriums.