Geriatric Day Hospital
Even a cursory check of hospital statistics over the last 20 years reveals the dramatic reduction in the patient hospital length of stay, especially in the over 65 age group. There also has been a concomitant drop in rehabilitation programs, especially for the elderly. The burden of care after stabilizing the patient is now left to outpatient sources.
Many believe that the sole role of the hospital is only to treat acute situations and send the patient elsewhere for rehabilitation services. This has led to a growth of sub-acute care centers as well as increased support for the frail elderly at home. Nursing homes are replacing long-term stay beds with sub-acute care beds. In many cases only the very frail elderly are admitted to nursing homes.
The geriatric day hospital, in which comprehensive care is given at one site, attempts to fill the gap engendered by the shortened length of stay. It is beginning to play an important part in the delivery of service to the elderly. Services at these sites include assessment, rehabilitation and medical treatment.
The question still remains of how to best meet the needs of the growing elderly frail population, especially with the increase in numbers of elderly. Frail patients supported at home usually have a wide range of medical conditions that flair-up and require what the medical field calls revolving admissions, i.e. multiple admissions in and out of hospital.
After a while the hospital may start thinking a nursing home is a better setting for the patient without adequate assessment of rehabilitation potential. (We saw that in the case of our mother in which a cursory in- patient hospital assessment of her rehabilitation potential recommended "no rehabilitation" because of her medical condition i.e. bed ridden, being fed through a tube, and unable to walk or talk. The family did their own "rehabilitation" and she was able to walk out of the hospital and live an enjoyable life for four more years.)
The geriatric day hospital could play an important role in meeting the comprehensive needs of the frail elderly, but must have in place mechanisms to provide the entire spectrum of services required by the elderly. There can be no delay in service delivery and it must be provided 24 hours per day, seven days per week.
This is a tall order. There is some question as to whether the present set-up can meet the needs of the frail elderly in preventing institutional care. They will have to prove this to their funding sources in light of evaluation reports on geriatric day care.
A search of the professional literature turned up two large studies of the effectiveness of the day hospital. The one done by Siu et al in 1994 was unable to demonstrate better outcomes from geriatric assessment in a geriatric day hospital compared with such assessments received in a clinic without a day hospital. One could criticize this study because it was a retrospective cohort comparison study
A more recent study was done by Forster et al. in 1999 which undertook a systematic review of day hospital care for the elderly, looking at a number of significant end points to determine the effectiveness of day hospital as opposed to alternative service deliverers. The review used 12 different studies that had been published by 1997.
Results failed to find a significant difference between day hospitals and the alternative services for the end points of death, disability or use of resources. They did show that patients having comprehensive care, in whatever environment, had lower odds of death or poor outcomes.
Forster et al concluded that day hospital care seemed to be an effective service for elderly people who need rehabilitation but it has no clear advantage over other forms of comprehensive care. Rehabilitation that in the past had been done in hospital settings was being done in day care, at a lower cost, and seemed effective in reducing poor outcomes, a not insubstantial result.
With these studies in mind, it would seem clear that a geriatric day hospital needs to deal with frail patients with unstable medical conditions, and provide a mechanism to avoid hospitalization or institutionalization. Their strength will come in their ability to deal with medical, emotional and social problems that if not addressed in the present (immediately) would lead to a hospital admission.
It calls for a multidisciplinary team with rapid access to various special services as radiology, pathology, skilled geriatric medical personnel as well as an immediate problem solving approach to sick older people. Continuous follow-up, including home visits and social services are necessary components. It is more than an emergency room service. It does have the potential, if used right, to provide a valuable service to a needy population.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
September 10, 2000
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