What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Wednesday, May 10, 2006

Nursing Homes, Part Two

I now continue with my suggestions, wishes, and deliberations on things that I feel would constitute the ideal (and perhaps doable) nursing home facility,
1)Medications and Pharmaceuticals: Small variances in medications can have significant effects in those who are least stable, from a medical perspective. At present, most nursing homes will stock one or two drugs from a class of drugs, and the patient gets the particular drugs that are stocked. In many cases there is no harm in this, however, broad allowances must be made for individual variations, and if a family wishes to supplement the “pharmaceutical” requirements of a patient on the advice of the attending physician, there should not be negative attitudes on the part of the nursing home. More medications could be used for dementias, osteoporosis, and other chronic diseases but there is a lack of consistency in application of many proven modalities and medications, and the cost of some medications is prohibitive. On the other hand, I truly believe that there are many medications that are continued inappropriately in circumstances where a patient’s status has changed. Our nursing homes have moved significantly to improving this area of care by having multidisciplinary patient care conferences on a regular basis. Unfortunately, they occur too infrequently and not soon enough after the initial admission of the patient.
So our ideal nursing home will have a multidisciplinary meeting within a week of the patient’s admission to a long term care facility (this would include the family of the patient, the patient, the patient’s family doctor, the physician that will be assuming care, and other professionals that will be involved in the care of the patient). Further, such meetings would occur every three months or at other times as requested by the family.
2) The facility: (a) As already mentioned, many newer facilities have been significantly improved by having more private rooms. This would seem to have been a “good thing, but in some ways, for some patients, this was not a benefit. Having an appropriate room mate can be ideal for an elderly person who was married for fifty years and is accustomed to a “room mate”. The private room can be a place for regression and isolation, and as previously mentioned, requires more “travel time” on the part of the care givers to attend their patients. Having a blend of larger “double occupancy rooms” with some private rooms would likely be ideal. In addition, the facility should be able to accommodate married couples, even though they may be at different “care levels”. All too often couples who have been married for sixty years are separated during placement. To me, this represents abandonment akin to death, since the partner not institutionalized may not be able to travel or visit. On occasion both may be institutionalized, but to different facilities.(b) The facility must include the necessary medical tools to look after a group of patients that are ever increasing in medical complexity and acuity. Various areas of our long term care facilities are designated “transitional care”, or “palliative care”, and in general there is an ever greater need to be able to medically assess, on short notice, this group of patients. Having the ability to monitor oxygen saturation, do blood work, and basic X-ray imaging, should be on site. Why are diagnostic facilities located in shopping centers? Community patients could access these modalities if they were part of a geriatric facility, and the in-patients would have access and availability. As it is now, if I wish my nursing home patient to have an X-ray, someone has to cart them off to a shopping center or wait for hours in an emergency department. The integration of community patients in the form of a “day hospital” at such a long term care facility would also be a plus. (c) The location of the facility is extremely important. In the last ten years, elder foster homes have been sponsored and promoted by the government in the large cities, while large nursing home facilities were being built in the country. The reverse should happen. In the city, a large nursing home should be located ideally in an older community. Fewer people would be dislocated, especially if they were given preference of placement. This would enable visitation from friends and a draw of healthy “similar aged” volunteers. Out patient programs in such a location would be advantageous to the community at large. In the rural setting, elder foster placement or small scale institutions are ideal. Abuse would be rare since in small towns everyone seems to know what everyone else is doing, and friends and relatives would have easy access. Building large nursing homes in the country often means that the patient’s elderly friends have to travel 40 or 50 miles to visit, and many in this age bracket don’t drive. The result has been isolationism to the extreme.
So, to clarify this issue, our ideal facility in the city would be large, located in an older part of town, have an out patient treatment aspect, have a mix of private and semi-private rooms, and have basic laboratory and X-ray facilities that could be used by the community as a whole. In the smaller rural communities, a more ideal setting would be elder foster care or smaller group homes, where there can be more involvement of friends and family, with the consequent capability of transporting the patients for services that may be required.
Before closing, I would like to pay tribute to the many wonderful hard working and caring care-givers that work in our long term health care settings. In my experience, this group is among the finest in our health care system. They are, however, stretched far too thin. During one of the regular November flu outbreaks, one of my nursing home patients phoned me from the nursing home and said she thought she had pneumonia, and that the nurses wouldn’t phone me. After the office I dropped by the nursing home and confirmed the patient had pneumonia and was admitted to hospital. Asking the charge nurse about this incident she said: “Doctor, we haven’t time to properly assess each patient during flu periods, much less phone the physician for each patient that has the flu. One third of our residents are sick on top of their usual problems, one third of our staff our sick and we don’t have the relief staff to replace them. With each flu season we are in a care crisis here”.
This has been a basic sketch of our institutional “elder care”, and of some aspects of what I would call an ideal “elder care facility. In some ways, it would resemble the old community hospital with the care being less “high tech” and less acute than our present day city hospitals, with a stronger emphasis on comfort, caring, and support, but with strong medical backing. There is no need for large palatial, hotel-like accommodation. Keeping simple and effective is the key. But don’t hold your breath waiting for things to go in these directions. As one gerontologist said: “But our old people will live longer, and how is that going to be cost effective”?

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