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Caring for an ageing nation

Dr Diarmuid O’Shea, Consultant Physician in Geriatric Medicine at St Vincent’s University Hospital, Dublin, has served as Clinical Lead for the HSE National Clinical Programme for Older People (NCPOP) since 2010.

During this time, the number of people in Ireland aged 65 years and over has continued to increase rapidly; by more than 20 per cent, in fact.

The April 2016 Census shows that over half a million people in the 65-and-older age category live in private households, an increase of almost 20 per cent since 2011.

According to the HSE, the over-65 population is growing by approximately 20,000 each year, while the over-85s population, which have the largest need for HSE services, is growing by some 4 per cent annually.

The HSE states that “older people with care and support needs should be provided with a continuum of services such as home care, day care and intermediate residential care to avoid unnecessary acute hospital admissions and have their required treatments and supports delivered within their local community at primary care level in as far as is possible”.

But meeting this objective remains a challenge for the HSE as it grapples with budgetary concerns, a medical and nursing recruitment and retention crisis, the closure of 1,400 hospital beds in the last decade and a growing population of older people.

“Society and healthcare needs to make hospitals and healthcare services more age-friendly and age-accommodating so that older people have both easier and fairer access to the type of services they need,” Dr O’Shea tells the Medical Independent (MI). 

He strongly believes that the care of older people is everyone’s responsibility, not just that of the HSE, and that more advocacy for older people is needed.

Population demographics show there is a need for services for older people to be ready to treat people and look after people now, but also into the future, Dr O’Shea adds.

So, what is the solution to help meet increasing demand?

“From my point of view now in older persons care, if I was looking to move things on I would want the reports and the models of care that are there to be implemented. We then need to improve how we all work together. You could call it new ways of working together, but we need to be innovative about the way we work together. The key role in helping support a frail, older person at home in the community is that they have access to the correct services when they need them and that they have easy access to those services,” Dr O’Shea explains.

Planning

The NCPOP is a joint initiative between the HSE Clinical Strategy and Programmes Division and the RCPI, where Dr O’Shea is registrar. It aims to improve and standardise the quality of care for older people in Ireland.

This year, the Citizens’ Assembly met on the complex topic of how best to respond to the challenges and opportunities of an ageing population.

Delegates heard that State spending on the care of over-65s fell from €3,514 per capita in 2009 to €2,612 in 2015, or from 12.4 per cent of the HSE’s non-capital spend to 11.3 per cent.

Dr O’Shea concedes that NCPOP developments have been slow in the past, but says that progress is being made.

“It’s slow but steady progress. The progress has been increasing apace in the last couple of years.

“I understand money is tight… but society and the general public need to be involved in this because if they are supportive, that makes it easier for the HSE and the Department of Health to look for resources.”

‘It effectively means that instead of having a whole focus about how improvement is being delivered centrally, we’re actually looking at how it’s being improved and delivered locally. There are some fantastic areas of excellence around the country’

Despite the HSE’s financial problems, the NCPOP has had many achievements since it inception in developing models of care and in helping to increase awareness of older people’s services. It has also boosted education and training for healthcare workers.

In more recent times, the focus of the NCPOP has changed somewhat, moving from a central emphasis to a local one, Dr O’Shea explains.

“It’s funny, the journey I’ve travelled over the last seven years in this role. When I started, I would have been very focused on really important topics like polypharmacy, falls, dementia, stroke, frailty,” Dr O’Shea comments.

“Now I am looking at it through a different lens and thinking, if you had a clear, dedicated governance group in each area and region tasked specifically with improving integrated care for older people that would work across the community and hospital system, and was focused specifically on what the patient wanted; truly integrated care, truly person-centred care that was appropriately resourced, I think that governance group would help drive a huge change.

“It effectively means that instead of having a whole focus about how improvement is being delivered centrally, we’re actually looking at how it’s being improved and delivered locally. There are some fantastic areas of excellence around the country.”

This approach is beginning to happen in different areas nationally through the Integrated Care Programme for Older Persons, introduced in 2015, and the HSE Frailty Education Programme, pilots for which commenced this year. 

Frailty

Indeed, a growing area of interest in older persons services is the concept of frailty — the frail older person, Dr O’Shea notes.

According to data from the Irish Longitudinal Study on Ageing (TILDA), almost one-fifth of Irish people aged over 65 living in the community are frail, while 57 per cent of public health nursing service users aged over 65 are frail. These figures will only increase as the older population continues to rise.

Over the last year-and-a-half, the NCPOP, the HSE Acute Medicine Programme and the Emergency Medicine Programme have been working with TILDA and the Office of Midwifery and Nursing Services Development (OMNSD) in creating a programme for the frail older person.

The project hopes to provide an insight into frailty and to establish a frailty education programme to encourage nurses, doctors, physiotherapists, pharmacists, GPs, occupational therapists and other allied healthcare professionals in the community to work together for the betterment of care for the older person.

“One of the priorities we’ve focused on in the last year or so in collaboration with these other programmes is in building the expertise which can provide healthcare professionals with an improved understanding of frailty and frailty assessments, thereby helping support earlier recognition of frailty and improved healthcare and better outcomes for those people, either by providing services for them and support and help in the community, or when they come into hospital, having a programme of care that gets them out of hospital as quickly as possible,” Dr O’Shea states.

“A really important part of that whole concept is the concept of medication rationalisation, attention to detail on polypharmacy and looking at how you can maximise the appropriate medication that people are on and minimise inappropriate medication, because there is little doubt that also contributes to problems.”

Overall, the frailty education programme is looking at ways of identifying, recognising and beginning to support people with frailty.

It is specifically looking at initiatives around the country and what actions to take when a frail older person has to come into hospital and how to provide them with comprehensive geriatric assessment and integrated care.

As the pilots continue, frailty education seminars are taking place and to date, frailty education days have been delivered to three HSE Hospital Groups and almost 100 nurses nationally.

These trained nurses are effectively serving as “frailty ambassadors”, Dr O’Shea relates, as they return to their hospitals to deliver frailty education to colleagues.

“We’ve had funding for this from the HSE and we will be looking for additional funding because we haven’t covered all the Hospital Groups… we’ve started small and we’re trying to grow a network.” 

Models of care

The Specialist Geriatric Services Model of Care was published in 2012 and provides a blueprint for services nationally.

The model aims to improve access for “frail older patients to specialist geriatric teams (doctors, nurses and therapists), day hospitals, specialist inpatient beds and rehabilitation beds”, according to the HSE.

Dr O’Shea says that elements of the model and comprehensive geriatric assessments are now being used to improve services in hospitals nationally, which has led to a gradual increase in services.

The model of care seeks to improve patient outcomes and reduce delayed discharges and deaths, among other aims.

“While some hospitals will start to implement the model in its entirety, other hospitals will concentrate in the first instance on some aspect of the model where they have an important gap in service,” the model states.

In relation to dementia specifically, MI recently revealed that a new clinical lead at the National Dementia Office (NDO), Dr Suzanne Timmins, is due to take up the role this month, two years after the Office was established.

Dr Timmins, a geriatrician and Senior Lecturer in the Centre for Gerontology and Rehabilitation at University College Cork (UCC), has a special interest in the area of dementia and delirium care in acute hospitals.

Meanwhile, more than 55 GP dementia workshops have been conducted nationally with 227 GPs via a unique project arising from the National Dementia Strategy.

The NDO is currently conducting a review of all dementia-related education currently available in Ireland, to identify gaps in education provision and promote cross-collaboration.

It is also planning to roll out primary care team (PCT) dementia workshops nationally this year and in 2018.

Meanwhile, funding has been secured by the Office to progress the development of a national dementia registry, which is listed as a priority within the Strategy to improve the recording and coding of dementia.

Advocacy

Dr O’Shea believes in the ability of local improvements to influence general change and in the strength of advocacy to drive change.

But advocacy for older people, while noting the great work undertaken by charities such as Age Action Ireland, is not without its challenges, Dr O’Shea says.

“Being an advocate for cancer care treatment or for stroke treatment; the public listens differently to that than they listen to advocacy for older people.

“For some reason, we all think we will never get old. But we would all hope to get old and to age well.”

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