This section was adapted from the “United Way Metro Vancouver Family & Friends Caregivers Information and Resource Handbook 2016/17” with permission from the author.
The hospital journey can be alarming for both care recipients and family caregivers. The older a person is, the higher the use of hospital services, and seniors are likely to have longer hospital stays. As explained in the FH publication, Code Plus: Physical Design Components for an Elder Friendly Hospital (by Belinda Parke and Kathleen Friesen), “Not only must the care provided respond to an acute health care crisis, it also must recognize the developmental phenomena associated with aging, and the likelihood that chronic illnesses are present, and compounding, both diagnosis and treatment. In the face of a rapidly growing aging population, a new approach to hospital care is imperative — one that takes into account the special considerations of being old in a system of care focused on acute illness episodes.”
When admitted to a hospital, ask for the hospital pamphlet; not all hospitals have one but if they do, it can help you understand how some things work and where things such as the cafeteria, internet service, quiet chapel room, etc. are located. There are also a number of hospital-based elderly friendly programs for frail seniors, but not every hospital has all programs.
Dorothy’s Story – Seniors, Families and Professional Partners in Care is an eight minute video resource to support older patients and their loved ones during a hospital stay. It emphasizes the need to proactively participate in hospital care. Created by Vancouver Coastal Health’s Community Engagement Advisory Network (CEAN), it reminds us that frail elderly in the hospital need to ask questions, express themselves, be vocal about changes, be aware of medications, get adequate liquid and food, and to move and be as active as possible. Dorothy’s Story can be found on YouTube – enter the video title.
1) Geriatric Emergency Nurse Clinicians (GENC). In the emergency room these nurses have specialized knowledge and skills in managing the care of older adults. Generally, the GENC, when available, assesses patients who are 75 years of age or older who present with: an acute illness, a number of medical problems, a sudden or recent change in function or a loss in ability to maintain their usual daily activities. The GENC can assist patients with the following concerns: functional decline, changes in mobility, falls, pain management, continence issues, nutritional and medication concerns, caregiver stress, behavior and memory changes. The GENC works with the patient and care partners to develop an individualized plan of care for patients who present with complex needs. This role includes: assessing and identifying care needs, providing patient and family education, providing information regarding health services and community resources.
2) 48/6 Model of Care addresses 6 care areas of functioning through patient screening and assessment within the first 48 hours of hospital admission. By addressing these essential needs early in a patient’s admission, 48/6, which is mandated in all BC hospitals by the BC Ministry of Health, can reduce the risk of functional decline in hospital and proactively support independence:
- i) Bowel and Bladder Management
- ii) Cognitive Functioning which refers to the mental processes including memory, thinking, judgement, calculation, and visuospatial skills. Attention will also be paid to the possibility of delirium, depression, dementia, and mild cognitive impairment
iii) Functional Mobility, i.e. a person’s ability to stand, walk, and transfer from bed to a chair. N.B. Bed rest inhibits a person’s capability to perform these functions as it contributes to muscle atrophy and reduced endurance
- iv) Medication Management which involves reviewing each person’s medication list, dosages (dose and dose interval), potential medication interactions and balancing the benefits versus the risks of medications
- v) Nutrition and Hydration to assess for adequate amount and type(s) of food and liquid consumed, assessing for any swallowing difficulties and/or food allergies
- vi) Pain Management i.e. the use of medications and other interventions (such as massage, exercise, or physiotherapy) to prevent, reduce, or stop acute or chronic pain.
This screening and/or assessments are then supported by the development of an individualized care plan to address key areas of health for the senior. Care Plans must be developed within 48 hours of decision to admit and further supported by a discharge (see 26f for more on discharge) and/or transition plan to ensure the senior can return to home safely, with established access to the health resources in the community they require.
Adapted from www.48-6.ca
3) Acute Care of the Elderly (ACE) units. ACE is a unit in some hospitals that provides specialty care to admitted seniors who have a number of serious medical problems, and are at risk of losing their ability to function independently. The medical unit provides comprehensive care for frail geriatric patients who typically are 75 years or older, have complex medical issues, and are experiencing recent changes in their physical, cognitive or functional abilities. The care provided in an ACE unit is uniquely designed to help seniors get well quickly so they can return home, and to prevent or delay their admission to RC.
The interdisciplinary ACE team, which includes dedicated health providers directed by a geriatrician, is specially educated in the care of seniors. They treat problems common in the older population such as dehydration, falls, pain, confusion, drug-related illnesses, delirium and dementia. The ACE team involves families, community providers and other local health services, such as Home and Community Care, to help patients maintain or improve their physical, social and functional abilities, and to plan for a successful return home. Elderly patients admitted to hospitals with ACE units are assessed for their physical, cognitive, psychosocial and functional status to determine whether or not they are a candidate for ACE care.
4) Keeping Patient Rooms Safe from Germs. Reducing the incidence of hospital-acquired infections is a hospital priority. Keeping hospital rooms clutter free and ensuring staff and visitors keep their hands clean are two important goals. Hospital rooms can harbor germs (bacteria, fungi, and viruses) that can cause serious infections, especially for elderly patients, those with weakened immune systems and those who have undergone surgery or who have catheters or tubes inserted in the body.
Patients play an important role in reducing the risk of infection transmission by keeping their hospital bed space clutter free. Please limit personal items and keep them inside the bedside table as much as possible, off the floor and away from waste containers to reduce the harboring and spreading of germs and reduce clutter in order to simplify the critical job of the cleaning staff.
Watch staff to ensure they wash or sanitize their hands with waterless sanitizer before providing care – and remind them if they forget. Don’t be shy to ask: “Doctor, have you just washed your hands?”
To keep your environment as clean as possible, visitors should not sit on your bed or handle your equipment. Ask visitors to sanitize their hands when entering and leaving your room to avoid bringing in and carrying out germs. And remember, patient bathrooms are just for patients. Visitors should use common bathrooms in the lobby or hallways. Visitors should stay home if they feel sick or have a fever. This will help protect everyone in the hospital. Remember, what may seem like just a little cold to others can be a big problem for someone in the hospital. Adapted from: Keeping Your Hospital Room Clean – Association for Professionals in Infection Control.
5) Patient and Family Education Centres. Many hospitals have centres where patients and family caregivers can get information about health-related topics and HA services. They can also have time-limited access to onsite computers offering internet and email access to access online government forms, and research needs. Be sure to ask the information staff or volunteers to assist with health-related inquiries.
6) Discharge (also referred to as released from hospital care) plans. When an acute (urgent) episodic illness occurs in addition to normal aging changes and chronic (ongoing) medical conditions an elder might have, then a potential crisis exists. The episodic illness or event can diminish whatever independent function exists.
Evidence shows leaving the hospital as soon as possible and recuperating at home with home supports and community services is better than waiting to fully recover in hospital. Hospital environments can be very disruptive: new routines can cause confusion (as can some pain medications) making it difficult to think as clearly as one does at home in a familiar environment; mobility is severely restricted causing rapid loss of general muscle tone (known as de-conditioning – one day in bed leads to loss of 1-5% muscle strength, or 7-20% per week); loss of joint articulation flexibility (one day in bed requires one week to regain); medication errors can occur; noise makes sleeping difficult; falls (which can be devastating) occur more often in unfamiliar settings; food is ‘strange’; and immune systems weakened by age make seniors more vulnerable to bacterial and viral infections. (Adapted from a 2012 public presentation Top Ten Reasons Home is Best delivered by Dr. Cheryl Nagle, Richmond, BC). These and other possible unfavorable responses from the activity of a health care provider (e.g. diagnostic and or treatment procedures) or institution are referred to ‘iatrogenic disorders’ and they can cause deterioration in health status of a senior.
BC hospitals have discharge processes intended to set frail elderly patients up with the support they need to be independent back at home for as long as possible, when hospital care is no longer needed. Some patients need further health care such as home care nursing, or rehabilitation services. Your health care team will work with you to help plan your discharge and any additional care that is required. This is based on the BC Ministry of Health philosophy that Home is Best as the place to recover from illness and injury, and manage chronic conditions as long as one is safely able to do so with appropriate supports in place; and, home is the best place to recover from illness once hospital care is no longer needed. A discharge goal is to support high-needs clients to live in their homes while waiting for RCif that is required, to avoid RC if possible, to avoid emergency room visits and hospitalization if not appropriate, and for end of life clients to allow for a supported home death if possible. This supports the wish to remain in their homes for the rest of their lives expressed by many seniors.
The case manager should be monitoring to ensure the patient is managing safely at home. If care needs can no longer be safely met in one’s home, patients are assessed for alternate living arrangements, such as AL or RC.
If you are concerned about how a loved one who is recuperating will manage at home when leaving the hospital, speak to a member of the health care team on your ward and they will relay your concerns to a hospital coordinator called a Home Health Liaison or Quick Response Case Manager who understands how to match patient needs to resources in the community.
Before leaving the hospital, care teams should give patients a Discharge Plan document which summarizes their hospital stay, any follow-up tests or appointments, medication information, and contact information for community health providers. Make sure the person you care for does not leave the hospital without a written discharge plan.
Let’s Get You Home is a pamphlet that addresses the needs of hospital patients and their loved ones who are exploring home care support options.
Getting Home Safely: A Hospital Discharge Guide for Older Adults & their Families addresses the importance leaving the hospital as soon as medical problems have been treated due to the risks of being in the hospital longer than necessary. It also provides a long list of questions you might ask to start the discussion of the transition home such as:
- Why was I in hospital?
- What are my main health concerns?
- What do I need to do to manage my health at home?
- Is there anything I need to learn to do to follow the recommendations made by the team?
- What supports or service will I need?
- What information should I get before going home?
Google the title of the 9-page guide to download a copy.
A Checklist: Preparing to Go Home poses some questions to ask before going home: Have you arranged transportation to get home? Do you have your keys? Do you have clothing and shoes to get home in? Is there food in the house? Do you need someone to help you get groceries or provide meals? Have meal services been ordered? Will you need someone you know or a community health worker to help when you return home? Will you need some help to get new medications? Do you require a follow-up visit with your doctor, a physiotherapist, or other health care professionals?
Checklist adapted from Discharge Planning Resource Guide, Lions Gate Hospital.
Depending on the reason for hospitalization, you may receive some health specific information. For example for those treated for a hip fracture, the health authorities along with some hip health organizations have produced FReSH START Toolkit Fracture Recovery for Seniors at Home: A hip fracture recovery guide for patients & families available by emailing firstname.lastname@example.org.Watch The FReSH START video So the journey begins: Recovery after Hip Fracture.
7) Language Services. This service provides interpretation or written translation in over 60 different languages and dialects. Sign language interpreters are also available for deaf, deaf-blind, and hard-of-hearing persons. There is a free interpretation or written translation service provided through a provincial program to ensure patients understand their health issues, how the hospital can help, and what patients need to do to maintain their health after they leave the hospital. If you will require the use of language services, please inform the hospital; it will do its best to provide a trained interpreter.