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.
The comments section is closed.
Great review of the issues and what can be accomplished.
Sadly, the lack of senor friendly health care environments reflects the general attitude and undervaluing of seniors. As long as seniors continue to be viewed as a burden to society and problem for healthcare (how many times have we heard grey tsunami?) little will change.
One has only to look at the daily funding rates for long term care to appreciate the extent of the challenge. Even hospitals with ACE units often end up staffing them with little support, few registered nurses and minimal medical coverage, always intending to provide ACE training for staff but somehow never quite getting to it amidst the other competing priorities for scarce resources.
The described pilot programs and new initiatives are great, but the existing funding levels require choices and sacrifices – and senior care is an easy target. Family members also have to take accountability – I see seniors in hospital for days and weeks without visitors. Younger patients seem to get visitors, support and demands for accountability – but seniors, often, easily forgotten.
As with many things in healthcare, lots of blame to go around on this one.
There is some great thinking around elder care in hospital described in this article and the comments are very pertinent, but feel very urban-centric.%featured% It’s important to also look at this issue from the perspective of small/rural hospitals, where all staff are generalists and there aren’t teams of experts.%featured%
Perhaps provincial-level teams could provide training and support. For many seniors experiencing a stroke, transferring to a facility hundreds of kilometres away is probably not in their best interest, even if they could receive more specialized care. Let’s find ways to support in place, including seniors’ continuing care or assisted living facilities.
I am in full support of making hospitals as ‘senior friendly’ as possible – who isn’t? The question is where to focus one’s efforts. The examples provided at the beginning of this(quite excellent article illustrate 2 challenges facing ‘acute care’.
Margaret Young should never have been admitted to an acute care medical bed for ‘failure to thrive’ in the first place. ‘Failure to thrive’ is a non-diagnosis to begin with, and a catch-all phrase that the Geriatricians who are quoted in this article detest as much as I do. Margaret’s depression and frailty could have – and should have – been diagnosed by her primary care provider(s), with the help of out-patient Elder’s Clinic and Geriatric Psychiatry physicians and inter-professional team members +/- home outreach services.
Jim Todd should have been transferred to a stroke rehabilitation program within 3-5 days of admission – all things being equal. His 8.5 weeks of additional time in an acute care environment was a recipe for disaster; as it would be for any patient; regardless of age.
We have to get past this idea that ‘hospitals’ are this great fantasy island that can address all physical, emotional, and spiritual ills – AND the effects of frailty and aging. Make hospitals as ‘elder friendly’ as possible, for sure; but for goodness sake keep the elderly out of them when they aren’t acutely ill!
Bravo on the article and the work underway in various settings.
I also say yes to public reports on indicators for seniors’ friendly hospital care. The negative impact of not pursuing these initiatives is not ethical and ends up burdening the system in many ways.
But seniors’ friendly hospital care also relates to other issues (see Brian Goldman’s comments on the secret language of hospitals here http://www.calgaryherald.com/health/Toronto+doctor+reveals+secrets+hospital+slang/9772059/story.html) and more effective communication between the inevitable series of shifts of caregivers involved. No single nurse or orderly should ever be surprised to hear that their surgical patient is actually suffering vascular dementia that has badly affected his/her retention or judgement. But this happens routinely in the various hospital components through which they will travel. This dramatically affects care and outcomes and family support can only cover this part of the time.
Excellent article! The outcome measures should be created by the experts in the field – that way we can be sure we are measuring the most meaningful outcomes for hospitalized seniors. So often we hear that hospitalized older adults cannot meet basic human needs because there is no time. What is taking up time that is more of a priority than basic human needs (eating, walking, and getting to the bathroom)? We need to shift the traditional ways of measuring and collecting data so as to make it meaningful for nursing work. We have a responsibility also to create new norms of care that meet human needs while meeting gerontological best practice (which tend to be one in the same).
As a member of a geriatric outreach team, I see first-hand the effects of hospitalization on older adults when they return home at a lower functional level and often get stuck in a revolving door of emergency department visits/multiple admissions. Their daily care needs become greater, caregiver burnout is prevalent, and individuals come closer and closer to needing long term care with each successive hospital admission.
We may be need to treat acute illness in hospital, but if we don’t prevent chronic deconditioning and functional decline at the same time, our patients are not coming out ahead. If we are truly committed to aging in place, then any acute events that necessitate hospitalization need to be treated in an atmosphere that encourages as much continuity in daily activity and routine that the individual’s medical condition allows.
If a person is placed in a passive, medicalized environment that does not promote activity, independence, and rehabilitation, we cannot reasonably expect them to be internally motivated to do anything, especially when they are not feeling well. However, if, despite their illness, they are surrounded by an attitude and atmosphere of health and activity promotion, and they see that the hospital staff and administration fully embraces this, we can expect to see a shift in patient and caregiver attitudes and behaviours as well.
Please keep up the great work on these initiatives, everyone!
If there is no accountability, the issue will be lost amongst other competing priorities.
Great Article. Nice to see a growing recognition of the importance of elder friendly care across our hospitals.
This is also a great opportunity to focus on the successes of those organization that have really taken this philosophy to heart and are now seeing amazing results. See the summary here about what Mount Sinai Hospital has achieved with its Acute Care for the Elderly (ACE) Strategy:
Also congrats to Queensway Carelton hospital in Ottawa that is also advancing elder care in a big way with recently announced plans to open its own ACE Unit and implement a hospital-wide ACE Strategy!
Dear Dr Sinha:
It is indeed encouraging to hear that the needs of older adults in hospital are being considered, and while much has been published about senior friendly hospital philosophy, strategies and best clinical practices sometimes I think administrative decisions override these laudable goals.
I was visiting recently in Mount Sinai Hospital and was confronted with the dilemma of an elderly patient who was unable to contact any one because the bedside phones had been removed. (Apparently it’s the same situation at Sunnybrook; I have not checked UHN yet). Phones are available for a charge, with a credit card deposit, but of course there is a lag-time until they are installed. The thinking behind this, apparently, is that everyone has a cellphone. Not true! And many elderly have neither a cellphone nor a credit card.
Cutting older patients off from being able, from the time of admission, from communicating with loved ones is appalling. Please replace bedside phones.
Our office, the Regional Geriatric Program of Toronto, has been coordinating and providing coaching for the Ontario hospital collaborative implementing the Senior Friendly Hospital indicators for delirium and functional decline. We have seen incredible collaboration between the hospital sites and uptake of complex clinical knowledge, whereby front-line providers who were just beginning to learn about the clinical features of delirium are now integrating this knowledge into their work and asking more complex questions such as how to differentiate delirium from signs of dementia. Throughout this work, our team has encouraged a shared learning and bottom up approach, engaging the front line to ensure the feasibility and clinical value of this quality improvement effort. We do appreciate the message within this article – it may very well be the ideal time for the leadership and guidance our policy makers can provide to ensure ongoing sustainability and building up of these important care processes for our vulnerable older patients.
This issue is of utmost importance to us all. This article is one of the best and well presented arguments for mandating changes needed in our HCS. Forget all the alliances and links to the likes of any of the initiatives by the current politicians of the day to set up something likes LHIN’s, because they are just one more level of bureaucracy that doesn’t act/work to get the results we know we need.
If you want results: get patents mobilized: they know much more than many of the officials whether they work in hospitals or have other types of government jobs, they’ll get the job done! We lose sight when we don’t “pay” the people who understand what to do and how to do it. Hire Patients as “Patient Advisory Consultants.”
Want one? I’m available!
Elizabeth Rankin BScN