Dr Ashraf Nasim Specialist Registrar Geriatrics, Department of Senior Health, St George’s Hospital, Tooting

The concept of community geriatric care is not new. John Sheldon2 in 1948 reported problems faced by community, dwelling older people and emphasised their day to day strive. Sheldon et al also spoke about the importance and benefit of good self-care, focusing on continence and personal hygiene, hearing, vision and appropriate footwear.  He also gave special emphasis to old age mobility problems faced by community old aged dwellers and suggested falls prevention strategies, stressing the importance of good lightening and rails to hold  on to.3  This was the birth of “community geriatrics”. Most UK trainees in geriatrics currently have little formal training in community geriatrics; a recent survey of 268 specialist registrars in the UK showed less than half had visited a community hospital during their training.4

 

 

 

 

 

 

 

I worked at a geriatric day hospital during the last three months of my year rotation at the Geriatrics Department of St George’s Hospital. It was a refreshing experience right from the start. Being away from the busy and bustling acute geriatric ward; I first felt jobless but quickly realised I had the time to extract and concentrate on minute history and social details about patient affairs, that I craved for earlier.

The service offered at St John’s day hospital is physician based and is a team structured approach. It offers care on a day basis for assessment and treatment of community-dwelling elders in the local borough. The inter-professional team at the geriatric day hospital is a vital group of healthcare professionals that bring expertise to help the patient achieve their goals.

 

Who is it for? 

Typically, our patients are mainly older persons who have lost, or are losing, their ability to function independently. The reasons for their decline or failure are usually multiple and often complex, with an interaction of physical and mental illness, overt or impending, plus any number of psychological, social, economic, environmental or familial factors contributing to the decline.

Some of the attendances are due to more specific medical, rehabilitation or social reasons. These include the need for rehabilitation after medical or surgical illness; support and treatment during the transition from hospital to home or facility; provision of an area for consultation or investigation that requires a hospital, but not a “bed”; consultation for general deconditioning; medication and drugs overhaul; evaluation of competence; and other purposes. It is in these situations that the unique position of the day hospital, standing between the traditional hospital and the community, has a striking utility and an important role to play.

The selection process was very basic; the unit received referrals from all over the borough from GP’s, community physiotherapies, the STAR team at St George’s hospital, community matrons, and social services. Sometimes patients from hospital outpatient clinics will be referred if it is felt that they would benefit from a comprehensive geriatric assessment and brief rehabilitation intervention.

All the referrals are discussed during the early morning meeting to assess appropriateness and if accepted, a specific day slot was allocated for that patient for an initial physician evaluation and later detailed therapy assessment. If the referral is considered inappropriate, the patient is re-directed to acute hospital, psychiatry, inpatient rehabilitation hospital, palliative care, or another source of care such as out-patient clinic, primary care therapy etc.

 

Pre-assessment

Sometimes a pre-assessment was done by means of a pre-planned home visit, usually conducted by one of the senior team professionals: nurse, occupational therapist or senior physiotherapist. Whenever possible, one of the doctors may also accompany, providing a medical component. This initial step in the assessment process usually provides highly significant and relevant information.

The pre-assessment home visits allow healthcare professionals to meet caregivers; observe patients in their own environment, review safety, hygiene, comfort, access and also the patient’s interaction with family. During the visit, compliance with medications and the performance of activities of daily living (ADLS) are also assessed. By the end of the visit, the assessor is able to decide if the patient is suitable for attendance to one of the day programmes and submits a detailed report to the physician, but if there is any doubt, she or he will discuss the case with other team members during the meeting.

The day hospital

Our day hospital has 14 daily rehabilitation slots along with two slots for new patients. Patients attending the day hospital must be fit enough to be brought in and returned home by transport, which serves many patients in wheelchairs, and to tolerate being away from home for at least four to six hours at a stretch. These patients attend two sessions weekly for up to six to eight weeks.

Their progress was regularly assessed during the weekly multidisciplinary team meetings (MDT). During their attendance, special emphasis was given to their drug history and all medication history was properly assessed with frequent input from patients’ GPs and local pharmacies. Medication profiles and compliance were evaluated, often with gratifying results such as being able to stop one or more unnecessary drug.

Patients attending the day hospital usually receive a comprehensive geriatric assessment at the beginning with basic investigations such as blood and some radiology tests. During the assessment, the patient gets a complete general system check up including cognition and psychological evaluation.

During their subsequent visits the patient is seen by the therapy team for physical assessment following which objectives and goals are agreed and discussed in the MDT meetings. The team regularly liaises with the primary physician, family, social services, care homes and carers, and if needed with other specialists involved with the patient’s recent care. As stated by Williamson et al “the most important point to emphasise is that a day hospital can only flourish if it has forged strong links both with general practice and other relevant medical disciplines in the same district.”1

The whole atmosphere in the day hospital was serene and congenial. I believe quite a few of us have forgotten how to enjoy our work over past years. Some of us sometimes even give a grumpy physician look of someone with little or no sense of humour.

The best part of the day hospital was that I had all the time on earth to talk to my patient. The day hospital reminded me of the human side of medicine. It showed me how much difference some words of reassurance can have on a patient’s morale and confidence, especially for someone who was attending the unit after a series of unfortunate falls and was so petrified of falling again. My days at the day hospital showed me how to work in harmony; being part of a team, listening to people, appreciating everyone, encouraging each other, enjoying and celebrating every moment of sharing, thanking one another for making it happen for our patients. During my days at the day hospital, I was thanked so many times by my patients that if I collect all the thanks I received during my entire career, I am sure it will be less than what I received there just in three months.

I believe geriatric day hospitals can still be the golden section of any geriatrics department but sadly over the past few years, they have been left in tatters, and completely neglected—mostly for not being a productive business unit for any Trust. I also believe it desperately needs a new vision, a new leadership; a new advert and a stronger partnership bond between primary care and community geriatrics.5

The challenge is not to treat patients in an acute environment but to manage them at home and prevent an acute admission journey. It seems adept to use and improve our core expertise in areas that are basic to geriatric medicine, such as cognitive neurosciences, palliative care, continence issues, alcohol and drug counselling, geriatric pharmacology and polypharmacy, frailty and a team based medicine approach. The benefits of these programmes including health education, addressing quality of life etc are now highly apparent to the local public, and our continuing contribution to them will be of political value. This will add to a greater satisfaction and diversity to our professional life also. For those trainees who wish to take up a community consultant post, changes will have to be considered to the geriatric medicine training curriculum to incorporate community training. Some might believe community geriatrics may de-skill geriatricians in acute care if too much time is spent outside the hospital.6 With the right balance and commitment the necessary acute skills can be retained while focusing on the community work. 

Kane et al suggested that geriatrics is at a crossroad with many successful past endeavours to “gerontologise” other medical sub-specialties.7 This pronounced palpable change prescribes that geriatrics as a specialty has now reached the point where during the next phase in its journey, it requires a newer strategy to focus more on community based chronic disease management as its defining niche.

 

As with any other medical services, the day hospital has its own share of problems. Getting patients into the regular rhythm of a day hospital routine was difficult at the beginning; sometimes we came across deliberate excuses from the patient to avoid coming to the unit. Also, for some patients the journey was exhausting and a few did complain about it. I thought that the biggest setback was when patients get acutely admitted while still attending the day hospital due to various other acute medical problems, causing a major setback in achieving their rehabilitation goals. Perhaps due to these unexpected outcomes, Foster and colleagues questioned the overall effectiveness of a geriatric day hospital.8 Foster mentioned in her conclusion “Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care”. However she acknowledged the methodological limits of her conclusions and suggested further randomised trials.

I think the geriatric day hospital does fulfil the purpose it was first designed for. These are:

     Supporting early and safe discharge of elderly inpatients to the community, speed up their return to pre-morbid function and reduce the number of hospital beds

    More successful discharge to the community, reducing the number of readmissions 

    Maintaining frail elderly people in the community who need ongoing rehabilitation boost and other medical or social support on more than the usual outpatient basis.

From what I have experienced so far, I believe the geriatric day hospital offers a unique opportunity for interested young aspiring geriatricians to expand this forgotten legacy further into a productive, virtuous running unit using their ingenuity and inspiring leadership. The widely believed false perception of a geriatric day hospital as a financially burdened ineffective unit was proven wrong by Tousignant et al9 who demonstrated the benefit of attending a geriatric day hospital that outweighed cost by more than 100%.

From my recent experience I conclude that the geriatric day hospital is not a setting sun but remains a beacon of hope for many of our elderly patients.

 

Conflict of interest: none declared. I wish to thank Dr Judith Coles; Consultant Geriatrician at the Department of Senior Health, St George’s Hospital for giving me the opportunity to attend a day hospital unit.

 

References

  1. Morales FM, Carpenter J, Williamson J. Dynamics of a geriatric day hospital. Age Ageing 1984; 13:34-41.
  2. Sheldon JH. The social medicine of old age. Oxford: Oxford University Press, 1948
  3. George J, Young JB. Joseph Sheldon and the social medicine of old age: 40 years on. Care of the Elderly 1989; 1:272–4.
  4. Bansal A, Young J. A survey of community training and experience for specialist registrars in elderly-care medicine. Age Ageing 2001;30:533
  5. A Barton and G Mulley; History of the development of geriatric medicine in the UK Postgrad Med J 2003 79: 229-234
  6. Michael Wolochow, Richard J. Ham; The Geriatric Day Hospital: A Canadian Experience; Can Family Physician. 1986 December; 32: 2625–2629. 
  7. Kane RL, 2002. The future history of geriatrics: geriatrics at the crossroads. J Gerontology Med Sci.57A:M803-M805
  8. Anne Foster, John Young, Peter Langhorne; Systematic review of day hospital care for elderly people BMJ 1999; 318c doi: 10.1136/bmj.318.7187.837
  9. M Tousignant, R Herbert, J Desrosiers, M J. Hollander; Economic evaluation of a geriatric day hospital: cost-benefit analysis based on functional autonomy changes; Age and Ageing 2003; 32: 53–59