Can the Geriatric Day Hospital act as a hub for services for older people across the spectrum of ageing from active ageing to advanced frailty?
- 1NUI Galway, Ireland
- 2Connolly Memorial Hospital, Ireland
- 3St Vincent’s University Hospital, Ireland
This article examines the potential of the Geriatric Day Hospital to address the challenge of an ageing society, which has begun to place an emphasis on the promotion of active and healthy ageing, yet faces rising numbers of pre-frail and frail, older adults with complex care needs. Can the Day Hospital model become a hub for the care of older adults across the spectrum of ageing? This paper explores its origins and traditional role in delivering Comprehensive Geriatric Assessment (CGA), assesses how it is currently being used to identify, triage and manage frailty, providing reablement, chronic disease management and anticipatory care planning and discusses future models focused on the prevention, surveillance and monitoring of frailty. It will examine how such approaches could increasingly deploy information communication technologies (ICT) using the Geriatric Day Hospital as a hub to maintain older adults in their home environment, to promote active ageing, while both preventing and managing frailty.
A consequence of population ageing worldwide but particularly in the European Union (Rechel et al.,2013) is high rates of frailty (Collard et al.,2012) and multi-morbidity (Prince et al.,2015) amongst older people. This has directed health polices towards prevention and the pursuit of active and healthy ageing (O’Caoimh et al.,2015a), (Michel et al.,2016) but has nevertheless resulted in increasing numbers of older patients who could benefit from specialist geriatric services, meaning that limited resources must be stretched further. A fundamental challenge now faced in the management of older adults with multiple interacting medical and social problems is how to move from a single system, uni-dimensional construct to a more holistic and multi-dimensional model of care (Lacas and Rockwood,2012) that promotes preventative approaches and reablement as well as providing long-term management and rehabilitation. In this evolving environment established ambulatory models of care for older people with complex needs that traditionally focused on the latter such as the Geriatric Day Hospital could be leveraged to find a additional purpose, to promote active and healthy ageing and manage pre-frailty, while continuing to support the care of frail older adults.
The Geriatric Day Hospital, which originated in the United Kingdom in the 1950’s, is a dedicated outpatient service providing specialised, interdisciplinary, ambulatory and usually rapid access geriatric medical, nursing and rehabilitation care to community-dwelling older patients, whose primary strength is arguably the flexibility it offers (Black,2005). Day Hospitals represented an evolution in primary and secondary level ambulatory care models for older people with complex needs. Those attending Day Hospitals receive and benefit from CGA, individualised multi-domain assessment by a multidisciplinary team using validated scales and interventions that reduce adverse outcomes, hospital admission and length of hospitalisation (Ellis et al.,2011). CGA is however, labour-intensive and economically costly; the Day Hospital rationalises and targets this limited resource ‘under one roof’ (Brown et al.,2015) in an effective (Forster et al.,1999) and cost-effective manner (Tousignant et al.,2003). A recent systematic review summarising evidence from 16 studies comparing Geriatric Day Hospitals to non-integrated, non-comprehensive services suggests that it is superior, reducing the risk of functional impairment, institutionalisation and death, albeit the evidence remains limited and no cost benefit has been established (Brown et al.,2015). Further, there is much heterogeneity in terms of what is offered and to whom with studies varying in their sampling strategies; the strongest evidence being for models focusing on geriatric rehabilitation and subspecialty diseases such as stroke, dementia and heart failure (Petermans et al.,2011). There is limited evidence for its use in prevention and health promotion.
The most recent change in Day Hospitals is a shift towards specialty services, clinics and ambulatory investigations. Paralleling this change, the relatively new construct of frailty has begun to replace historical models of geriatric care and is increasingly being used in Day Hospitals to select and risk-stratify attendees. Frailty is a multi-factorial state correlating with vulnerability, disability, co-morbidity and self-reported health status with a recognised prodrome, pre-frailty (Rodríguez-Mañas et al.,2013). This construct recognises that the stereotypical characteristics of community-dwelling older patients such as age are insufficient to identify older adults deemed most at risk of adverse healthcare outcomes and hence most in need of CGA (O’Caoimh et al.,2015b). Given the growing number of older adults (Rechel et al.,2013), the construct of frailty can help identify those most likely to benefit from the Day Hospital (Pereira et al.,2010). However, few studies have been conducted to examine the role of the Day Hospital in identifying frail older adults. A study using the SHARE Frailty Index to examine the prevalence of frailty among community-dwelling attendees at a university hospital affiliated Day Hospital in Ireland found that the prevalence of frailty in this transitional care sample was high at 32% (Ntlholang et al.,2013). In France another observational cross sectional study applying consecutive sampling, using Fried’s criteria, to a similar sample referred to a single geriatric unit, found a higher prevalence of 51% (Soler et al.,2016). Levels of pre-frailty were also high in both samples at 26% and 41% respectively. These data represent values between those in community and in-patient settings (Andela et al.,2010),(Collard et al.,2012),(Clegg et al.,2013), suggesting that most attendees at Day Hospitals have high care requirements but also represent an ideal population to target for measures designed to tackle, prevent and reverse frailty, including those that promote active and health ageing at population-level.
The Geriatric Day Hospital is also increasingly being used as a coordination centre to deliver integrated care (Moorehouse et al.,2017) between acute services (emergency departments, acute medicine assessment units and inpatient wards) (Jones and Maxwell,2016), rehabilitation services (formal inpatient and early supported discharge teams), community services (primary care teams and general practitioners) and public health services designed to promote active and healthy ageing in place, the person’s own community, (implementation of local, national and transnational population-level preventative healthcare strategies). A consistent approach to identify frailty across primary, secondary and social care e.g. coordinated by case managers, community public health nurses or primary care physicians can promote equity of access to CGA services (Liotta et al.,2017). Identifying pre-frailty and frailty in people attending for Day Hospital assessment services may be looked on as a form of case-finding and an opportunity for health promotion (Roberts et al.,1995). This in turn allows for comprehensive proactive management of conditions that result in high levels of acute care episodes. Models that reflect mutual goal-setting in determining outcomes (Goal Attainment Scores) will be increasingly identified as providing a key element of person-centred support in the Day Hospital (Moorehouse et al.,2017). Screening for complexity and pre-frailty in this way may have the additional benefit of taking on a much more proactive approach to the planning of care needs and potentially impact on transitions of care given that most of the CGA has taken place beforehand (Baker et al.,2012). In essence, the Day Hospital is becoming the ‘hub’ or ‘command centre’ to integrate the delivery of CGA services, subspecialty clinics and preventative healthcare to those most in need.
The Day Hospital may be the ideal location to encourage anticipatory care planning including end-of-life care and cancer survivorship care planning, which help people think about their future health and social care needs. When aligned with CGA, the development of a person-centred care plan to promote this way of thinking about the future in a non-acute care setting enables the older person, their family members and the multidisciplinary team to address changing needs, complexity and requirement for support, surveillance and monitoring from health and social care systems (Baker et al., 2012). Advanced and personalised care planning is most sustainable when incorporated into routine care in a specialised, dedicated environment where patient trajectories can be predicted and followed (Coulter et al.,2013),(Lund et al.,2015). Similarly, cancer survivorship care is ill-coordinated in general practice, with little evidence for its integration into routine care (Rubinstein et al.,2017). Older patients with chronic conditions such as dementia (Moorehouse et al.,2017) and older cancer survivors (O’Caoimh et al.,2017a), whose care needs are markedly different from younger patients could benefit from the CGA, monitoring and advanced care planning delivered in a Day Hospital setting offered in an arguably more appropriate, unhurried and timely manner than in primary or secondary care.
Interventions to target frailty transitions and potentially reverse or prevent onset of frailty may also be best delivered in a Geriaric Day Hospital. A randomised controlled trial that assessed the effectiveness of CGA and subsequent intervention in pre-frail and frail community-dwelling older adults based on the Fried’s criteria, found that CGA and subsequent intervention showed a favourable outcome based on frailty status and the Barthel Index of activities of daily living (Li et al.,2010). More recently, randomised trial data has shown that targeting pre-frailty using two-staged frailty screening followed by more detailed assessment with tailored multi-factorial interventions may slow progression to frailty (Serra-Pratt et al.,2017) and is acceptable to community-dwelling older adults (Van Velsen et al.,2015). Similarly, programmes that promote active and health ageing that improve outcomes in randomised trials such as the ‘I am active programme’ (Mendoza-Ruvalcaba, and Arias-Merino,2015) could be coordinated or delivered in Day Hospitals.
The use of innovative ICT solutions to improve care for older adults attending the Day Hospital may represent the next step in re-purposing the construct. There is growing consensus that these new approaches can drive active and health ageing (Illario et al.,2016), and it is argued that the use of ICT in ambulatory care settings (including Geriatric Day Hospital) could be used to promote this through improved diagnostics, individualised telemedicine and by enhancing connectivity, social engagement and continued learning (eHealth literacy) among older adults (Beard and Bloom,2015). This use of ‘silver innovations’ to support active ageing and healthcare stratgeies has already proven useful in community-based samples in countries ranging from the Netherlands (O’Caoimh et al., 2017b) and Italy (Lattanzio et al.,2014) to the United States (Gardner, Kamber, and Netherland, 2012) and Japan (Obi et al.,2013), though these innovations require educational, financial and policy supports to suceed (Obi et al.,2013). Although the extent to which ICT can be promoted and implemented in a Day Hospital setting is unknown, its success is likely to be similar to its use in a home care setting (Lindberg et al.,2013). The expected shift to greater use of remote monitoring using mobile ICT health technologies is predicted to require more infrastructure (Helbostad et al.,2017), particularly for older adults who will require greater support to utilise these services. Traditional services like the Geriatric Day Hospital could be leveraged to this new purpose by providing a ‘hub’ to assist and supervise this for appropriate patients rather than require the building of new and likely commercial infrastructure, which may not have the means or interest to serve this distinct and specialised group. Given that older adults attending a Geriatric Day Hospital in Ireland rated their experience with ICT as limited (Scanlon et al.,2015), eHealth literacy would also need to be fostered in this setting. This is echoed by evidence that a supportive environment attuned to the needs of older adults is required for them to effectively use ICT (Hickman et al.,2007).
In a time of limited resources, the Geriatric Day Hospital is as important as ever. Current healthcare systems, under pressure from ageing demographics, should re-examine its role and the evidence base for the care it provides, which has arguably not received the attention and recognition that it deserves. Day Hospitals have the potential to evolve and manage the care of older adults with complex care needs across the spectrum of need from active ageing to pre-frailty and from established frailty to end-of-life care. While they should continue to focus on providing CGA, capitalising on the growing evidence for a frailty syndrome that has helped ration this limited resource more appropriately (Romero-Ortuno and O’Shea,2012), Day Hospitals should focus increasingly on providing innovative and proactive, preventative approaches including those that use new mobile ICT technologies to promote health ageing, address pre-frailty and prevent or reverse frailty at an early stage, before the onset of functional decline (Illario et al.,2016). Day Hospitals can also be used to promote a system wide integrated programme of care and education for older adults and healthcare professionals. Thus, although in the future the Day Hospital is likely to remain clinically focused, given its flexibility, it should be able take on new role as a connector ‘hub’ to link primary, secondary, social and public health care, promote the use of new ICT developments to screen, monitor and manage the care of community-dwelling older adults and to advance educational initiatives and eHealth literacy to encourage active and healthy ageing well into the 21st century.
Keywords: Day hospital, Frailty, pre-frailty, Comprehensive Geriatric Assessment, Geriatrics, Ageing
Received: 15 Aug 2017;
Accepted: 23 Jan 2018.
Edited by:Helena Canhao, Unidade EpiDoC, Epidemiologia de doenças crônicas, Portugal
Reviewed by:Antony Bayer, Cardiff University, United Kingdom
Lisa Robinson, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
Copyright: © 2018 O'caoimh, Kennelly and O'Shea. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Dr. Rónán O'caoimh, NUI Galway, Clinical Sciences Institute, Costello road, Galway, Ireland, firstname.lastname@example.org