Saturday, 28 March 2015

What is community geriatrics?

What is community geriatrics?

In my last blog, I mentioned how I became frustrated at the experience of practicing geriatrics in hospital; about how frustrating it was to deal with people only when they are sick, and have no role in keeping them well.

I embarked on a job in community geriatrics because I felt that it was an opportunity to at least explore whether the acute model we have is the best model available. In this blog, I will begin to outline what community geriatrics can do, and importantly, what it can’t do.

It is difficult to know what perspective to start this from – from the perspective of the acute sector, or the community sector. The temptation is to project the role of community services from the perspective of the acute hospitals, as these are the part of the healthcare system that garner the most attention for the pressure they are under, and these are the parts of the system that stand to gain the most from a community service that is achieving its full potential. However, neither is the right place to start: the perspective that counts is that of the patients.

In West Dorset, where I am currently working, the nearest acute hospital is 16 miles away. The bus takes over an hour, there is no direct train line, and a taxi costs about £30. This is where the consultants are.

In Bridport, there is a large GP practice, a community hospital, with just under 40 beds, and an x-ray machine. There is a great team of district nurses, and a superb rehab team who assess and support patients at home, as well as offer them rehab after discharge.

When I started in post, the community hospital focused mainly on taking patients from the acute hospital on discharge. On top of this main strand of work, they admitted some patients directly from home, as well as offering end of life care to local elderly patients. Day to day medical cover was provided by a middle grade ward doctor and a nurse practitioner, with 2 sessions a week from a consultant from the acute hospital.

With these facilities in mind, the first question I have been trying to answer, is how can these services provide the best overall utility to the patients that they serve.

To do this, one has to take a look at the needs of the patients involved. This is a key moment. The typical descriptions involve talking about elderly patients, often with cognitive impairment and multiple medical conditions, who are socially isolated. This covers the bulk of patients I deal with, but it doesn’t really describe any of them. Some of them have lived in the area their entire lives, some of them retired to Dorset; some of them have been in good health most their lives, some of them have struggled with illness for many years. Some aren’t even very old at all. I could list the different possible descriptors all day, and it would make for dry reading indeed. The point I want to make is that for all their similarities, they are all different, and with such differences come differences in needs, wants, expectations and goals.

The only way to serve my local patients well, is to be able to adapt easily to their differences, to tailor our approaches and interventions around what is important and necessary to them as individuals.
The worst time to meet someone for the first time is when they are sick. The two main presenting complaints of the elderly are falls and confusion. The worst time to ask someone what they would like you to do on their behalf is when they are scared, in pain, or not their normal selves. Planning for the future should, and could, take place, in good time, by teams of professionals engaged in knowing people when they are well, so that they already know what needs to be done when someone gets sick.
Some elderly people feel that they have lived fulfilled lives. They feel old, they feel tired, and they feel as if they are ready to die. Other elderly people feel that they are still living fulfilling lives, and would very much like to hang on longer should they get sick. With the former, if they became septic, would you admit them to ITU for intensive physiological monitoring, support and treatment, or offer them non-invasive ventilation for type 2 respiratory failure? Would you with the latter? Would you know what to do, if you had never met them before, or knew very little about their lives? Is it fair to base intervention only on what you have learned about them since they got sick? Knowing that someone is sick and old is hardly enough data to go on to determine appropriate treatment levels.

Over the last 18 months, I have therefore come to the realisation that one of the roles of community geriatrics is to fill in the gaps in patients’ biographies, to allow the right actions to be taken on their behalf when they inevitably deteriorate. It is our goal, that a call for an ambulance should not simply mean that that patient is whisked off to hospital, but that other alternatives are available to them: that they might be supported at home, that they could be admitted to the community hospital, and that if they need the kind of care that only an acute hospital can provide, then that is where they go.

My business, therefore, is about getting to know my local patients, and working with them and their GPs to plan in advance what are the possible avenues that could be used to best meet their needs. This means that they do not go to the acute hospital when their needs can be properly met locally, but when they do, that they go quickly and safely, and when they no longer need to be there, we get them home with support, review and monitoring, in their own home.
We have started to make great strides towards this, but there is still a way to go. In the next blogs, I will begin to outline the different parts of the system that help to make this happen, as well as outlining the steps we are making to ensure that as much as possible is done for the patient before they get sick.

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