Mrs Williams enters the emergency room with a broken hip, caused by a fall. After the operation she is admitted to a nursing home for a temporary stay. After a few weeks she returns home, but then she develops a delirium and is admitted to hospital again. The hospital stay lasts longer than expected, because Mrs Williams must wait for a referral to the nursing home. Once she is admitted, the old lady dies within a month.
‘Sufficient expertise available, but …’
This example underlines the importance of integrated and person-oriented collaborations in health care for older people who end up in emergency departments or at out-of-hours services. Mrs Williams had been moved unnecessarily and received the care she needed too late. To prevent this, better cooperation and coordination is needed between organisations and professionals who are involved in geriatric health care. This includes for example GPs, paramedics, hospitals, geriatricians, nursing homes, geriatric rehabilitation care facilities, psychologists, psychiatrists and neighbourhood teams. Added together, there is sufficient expertise available – but what is the value of this expertise if health care professionals do not know the right moment to collaborate with or refer to another professional or organisation?
Better use of expertise
Furthermore, it is also important that older people and their families are well informed about care and support options. Only then can they make well-informed decisions. And finally, better use must be made of expertise regarding older people at home and in emergency departments, for example by using a specialist in geriatric medicine and a nursing specialist in home situations. Deploying a geriatrician or a ‘cure and care nurse’ in emergency departments could improve the triage.
Examples from practice
Fortunately, I see many good examples of integrated and person-oriented care in practice that ensure that vulnerable older people do not need to be hospitalised unnecessarily, such as the APOP programme. APOP is a screening method and stands for Acutely Presenting Older Patient. It gives caregivers a greater insight into the individual situation and vulnerability of the patient. Leiden University Medical Center (LUMC) has conducted research into this over the past five years. It recently published a handbook with practical tips on www.apop.eu.
The model ‘Urgency in geriatric health care’
For Vilans, I am engaged in developing the model ‘Urgency in geriatric health care networks’. This model aims to enhance cooperation between professionals who are involved in emergency situations that concern older people. The model challenges professionals to make a shift towards preventive and proactive care and support. If more attention is being paid to support in the preliminary phase, health care professionals can see a crisis coming and possibly prevent it. It is therefore important to adopt a more inclusive approach by mapping not only medical, but also social and psychological aspects and to ask what the older person wants.
Working principles
The starting point is to move older people as little as possible and to meet their wishes and needs for a better quality of life. The model ‘Urgency in geriatric health care networks’ distinguishes nine steps in the ‘patient journey’ to enhance integrated care and person-centred geriatric health care. We have identified the working principles for each step. These are based on examples from literature and interviews with professionals and experts in emergency and geriatric care. We will soon publish this interactive model on this website, I hope it will stimulate you and your partners to move towards more preventive and proactive care and support for vulnerable older people in emergency situations.