Being hospitalized can have dramatic impacts on seniors’ wellness, and time spent in hospital contributes to loss of important functions such as strength and mobility – critical to their independence and wellbeing. Camilla Wong, a geriatrician at St. Michael’s Hospital in Toronto says “hospitalization robs us of the things that are really important for older people.”
A tale of two patients
Margaret Young, who is 85 years old, was admitted to a general medicine unit at a downtown Toronto teaching hospital for ‘failure to thrive’. A geriatrician assessed her and diagnosed severe depression and she was transferred to the psychiatric ward after a week in hospital. However, the week of being bedridden in hospital had taken its toll and Margarets’ leg muscles were weak as she had barely gotten out of bed. She fell while going to the bathroom one night and broke her hip. Instead of being discharged home, where she lived with her husband and son, she is now waiting in the hospital’s orthopedics ward for long-term care placement.
Gayle Einarsson saw the dangers hospitalization posed to seniors first hand when her father, Jim Todd, spent 9 weeks in an Eastern Ontario hospital after suffering a stroke at the age of 76. During his inpatient stay, Einarsson and her family rallied around her father to, in her words, “keep his daily routines and his lifestyle as stable and predictable as possible.”
Einarsson believed that her family’s vigilance to maintain Jim’s functional abilities helped his recovery. She says “simple, small interventions are doable in a system that often thinks they are not … but it will require an intentional change of care approaches by the health care system to make the real differences that will improve the experiences for seniors’ and maximize the quality of their lives.”
Wong agrees with Einarsson that interventions to maintain function for hospitalized seniors are “common sense” but often don’t happen, as in Margaret’s case. Wong says “we’ve lost sight of common sense in health care systems and the beauty of processes [to maintain seniors’ function in hospital] is that they are very basic.”
“While the patients have changed, systems have not”
Experts agree that as Canada’s population is graying, the health care system and hospitals have not caught up to meet their needs.
There are efforts underway across Ontario and Alberta to make hospitals more ‘senior friendly’ and to better tailor care to the needs of patients like Margaret and Jim. This article will highlight that there is still considerable variation in the extent of these programs in both provinces. Many of these programs remain pilot or trial interventions, and questions remain about how they will be translated into province-wide efforts to improve hospital care for seniors.
A 2011 report from the Canadian Institute for Health Information highlighted that while seniors aged 65 and above are only 15% of the population, their care accounts for over 40% of hospital costs. The report also highlighted that seniors have longer lengths of stay once admitted to hospital, 9 days compared to 6 days for non-senior adults. It is projected that by 2050 seniors will make up more than one quarter of the population.
Experts like Samir Sinha, geriatrician and lead of the Ontario Senior Care Strategy argue that the way that hospitals deliver care is not optimized to meet seniors’ needs. He writes that “our current acute care model … was developed years ago when most adults tended not to live past 65 … and usually had only one active issue that brought them to hospital.”
Sinha says “while the patients have changed, our systems have not.”
A 2003 study of over 2000 hospitalized seniors found that over one third experienced functional decline in activities of daily living (bathing, dressing, eating, walking and going to the washroom) during the course of their hospitalization. In addition, studies have shown that hospitalized seniors are at increased risk for preventable errors – such as falls, medical and surgical complications and medication errors.
Does Ontario have senior friendly hospitals?
In the past decade there have been a number of programs put in place by geriatric experts to maintain functioning, and increase the likelihood that care is appropriately tailored to the needs of older patients. In Ontario, this was translated into the ‘Senior Friendly Hospital Framework’.
Led by Ontario’s Regional Geriatric Programs – six networks of specialized geriatric professionals and services across Ontario – the framework was designed to be broad in scope, and open to adaptation by individual hospitals.
A 2011 survey of all Ontario hospitals that serve adults found that a formal commitment to senior friendly care “while emergent is not yet firmly established in Ontario’s hospitals.” The survey report notes that just under 40% of Ontario hospitals have goals for senior friendly care within their strategic plans, and around 30% have committees in place to oversee this work.
Pilot projects to improve care for seniors in Ontario
Based on the findings of the survey, it was felt that implementing the ‘Senior Friendly Framework’ was a more long-term undertaking, and “that a staged approach to change is most feasible and practical.”
Out of the responses, priorities were established around what could most improve care for seniors in hospitals. Based on survey results, the two identified priorities were preventing functional decline and managing delirium for seniors. For the prevention of functional decline, the program involves ensuring that patients are up and out of bed at least three times a day to minimize loss of strength and mobility. For the management of delirium, staff are trained to screen, prevent and monitor delirium so that patients’ cognitive function is maintained.
Hospitals are intended to monitor their progress on these two priority programs for seniors by measuring patients’ functioning and delirium rates at admission, and discharge. Hospitals are encouraged to collect indicators on the priority programs internally, and about 42 Ontario hospitals have done so.
Barbara Liu, is a geriatrician at Sunnybrook Health Sciences and executive director of Toronto’s Regional Geriatric Program. She notes that while these indicators are being collected voluntarily, they are not yet being used for accountability agreements with Local Health Integration Networks, nor are there province-wide data on indicators measuring these programs. “We don’t have a full provincial picture yet” says Liu.
Liu also emphasizes that embedding these programs into a commitment and strategy for elderly patients takes time. She says “its not a good use of [hospitals’] time to do it superficially, it needs to be embedded in processes and be second nature.” She highlights that the goal of the strategy is a long-term commitment by hospitals to being senior friendly. “We are looking for stickiness, we want this to be the standard of care going forward – this shouldn’t be considered add on and should just be core practice” she says.
However, the Seniors Friendly Framework, associated projects and measurements remain pilot programs in the Ontario hospitals that have put them in place.
Wong believes that “these pilot projects are all pieces of the puzzle – change takes time and the strategy has put seniors on the map.”
Thomas Parker, cardiologist and Physician in Chief at St. Michael’s Hospital wonders, however, if the time for pushing ahead with change is now. Parker suggests that “there should be a standardization across Ontario in a small number of outcome measures related to seniors care.” He notes that in Ontario publicly reporting on emergency department wait times was an important motivator for all hospitals to improve processes of care in that area, and invest in making changes. “In the absence of externally imposed standards I’m not sure sure we’ll see a response [from hospitals] to implement senior friendly programs in an accountable way that actually improves care for older adults” Parker says.
Elder friendly initiatives in Alberta
Alberta has taken a similar incremental approach to Ontario as it introduces senior friendly programs in hospitals. The province has a Seniors Health Strategic Clinical Network (SCN), but it has a much broader focus than hospitals, and promotes well-being for seniors and improving their care throughout the entire health system and in the community.
Jayna Holroyd-Leduc, a geriatrician and Scientific Director for the Seniors Health SCN says that “while the SCN is focused on looking at seniors as a whole and optimizing their health at home and keeping seniors out of hospital” there are efforts underway to “address all the potential complications for seniors that happen in hospital.”
She highlights programs in Calgary zone hospitals known as the ‘Elder Friendly Initiative’ which include three specific process changes to caring for seniors. The first is a nursing intervention, known as ‘comfort rounds’ where nurses see patients at intervals of two hours, and encourage them to change positions or get out of bed, use the washroom and ensure that they are well hydrated. Research suggests that comfort rounds have the potential to improve patient outcomes. The second is delirium detection and early screening – aimed at reducing and managing delirium for elderly patients. And the third is training staff in using alternatives to using restraints for seniors who are assessed as being at risk to themselves or others.
Holroyd-Leduc says that the initiative is starting work on an evaluation plan, but that there are no publicly available data measuring the initiative yet. She says “some units are further along than others, but there have been some early adopters and good successes.”
James Silvius, a geriatrician and provincial medical director of the Seniors Health SCN notes that “these are still early days – and there is no publicly reported data on the Elder Friendly Initiative yet.”
Similar to Ontario, these individual initiatives to change processes of care are seen as fitting into broader goals of shifting the hospital system towards meeting the needs of elderly patients. However, there remains an absence of province wide approaches in both Alberta and Ontario to have all hospitals adopt these promising processes of care for seniors.
“There is an overarching desire to have elder friendly facilities … and while its one thing to say that you want to be elderly friendly it’s another to change the culture” says Holroyd-Leduc.