Contents
In Poland, the burden of caring for an elderly sick person falls on the family. But more and more often there are no volunteers – children work abroad or cannot. What about the senior who can’t cope on his own? – The state aid system is not ready to deal with such people – admits prof. Tomasz Kostka, national consultant in the field of geriatrics. There is no indication that the government has any idea how to change it. The consultant suggests a solution: family doctors should take over the greater part of geriatric care. Prerequisite: they must be educated in geriatric issues, entitled to commission various types of research and adequately funded.
- Hospital workers raise an alarm about a dramatic problem: there are more and more people whom nobody wants to look after, when they lose their health and fitness in old age
- Introduction of the so-called hospital networks will further limit older people’s access to geriatric care
- Family doctors have to teach geriatrics, but will primary care clinics require it, if there is a persistent lack of people willing to work?
Picture from the Bródno Hospital in Warsaw: Patient, 84 years old, goes to boarding school. He has heart trouble, lung disease, gastroenterological problems, and progressive lack of contact. After treatment, he should be discharged. The trouble is, there’s no one to look after him at home. There is no chance that his 80-year-old wife will help him get out of bed again. And there is no contact with children abroad.
But even when the children are in the country and there are several of them, when it is necessary to provide 24-hour care for a parent or grandfather, they look at each other. Hardly anyone wants to take on such an obligation, and not everyone can. Besides, there is no such compulsion or punishment.
Such a situation is a common everyday reality for hospitals. Elderly patients, often with Alzheimer’s disease or after a stroke, are in arrears, blocking places, and exposing the NHF to costs. Most hospitals, like the Bródno Hospital, employ social workers whose task is to quickly establish the situation of such a patient, reach his family, and in the event of refusal of care, arrange the formalities related to placing him in an appropriate care and treatment facility or a social welfare home. Sometimes the family insists on leaving my grandfather in the hospital. Staying in the center costs money and means you will have almost nothing left of your retirement pension. And the hospital is free.
The problem grows as society is aging. – We have more and more such patients. They often come from other departments: surgery, orthopedics or neurology. Because when you do not know what to do with a dependent patient, it is best to transfer him to geriatrics – admits prof. Tomasz Kostka, head of the Department of Geriatrics USK-WAM in Łódź.
Geriatric wards defend themselves against this because they are not long-term care centers. They are there to treat acute diseases such as pneumonia and anemia.
According to prof. Ankle, geriatric rehabilitation would be helpful. Such branches operate in many EU countries, for example in Scandinavia. A stay in such a ward usually lasts up to 30 days and is intended to prepare for a return to the home environment. There are no such medical services in Poland.
Hospitals not for the old
– The hospital is a very bad place for an elderly person – says prof. Cube. He believes that in the absence of geriatricians as well as rehabilitation services, primary health care should be used. – A family doctor should take better care of geriatric patients, so that they go to hospitals as little as possible. Hospital stays should last a few days, they can also take place on a one-day or home basis – assesses the consultant.
In the so-called coordinated primary care, the doctor in the hospital would receive from the family doctor information on how the patient has been treated so far, what the results of the examinations and the recommendations of specialists have been. There is still a lot of work to be done here – currently there are no IT systems enabling this information flow.
So an elderly sick person wanders from specialist to specialist. – He ends up in the hospital, on discharge he receives a recommendation card, which he often loses. What was the hospital commissioned? The primary care physician has no idea, the patient does not remember – says prof. Cube.
A study that exists purely theoretically
The so-called “Comprehensive geriatric assessment”, which, by the decision of the National Health Fund from the middle of last year, may be financed in all hospital wards, not only in the geriatric ones. What is this procedure? A patient who is at least 60 years old in the emergency room should have a quick questionnaire completed (VES-13 scale). If he qualifies, then in the ward he should be consulted by a geriatrician who will conduct the so-called comprehensive geriatric assessment, i.e. a set of tests diagnosing the state of physical and mental health and social situation. However, as there are no geriatricians, there is no one to make a comprehensive assessment. Even if there was a geriatrician, this procedure is not paid for separately by the National Health Fund. The hospital receives one pool of money and the hospital director decides whether a geriatric evaluation is the most urgent need or if there are other, more important expenses.
Effect? The provision is a fiction because it is practically not implemented outside of geriatric wards. Patients are not selected in admission rooms, because why, if later geriatric examination is not performed anyway.
The situation will worsen even more, because in the so-called the hospital network does not provide for geriatrics wards in hospitals, the so-called first and second level of reference. This means that most of these wards will soon disappear, only geriatric wards in clinical hospitals will remain.
Train and give qualifications
– The health care system should shift to senior care. However, despite many discussions, incl. as part of the presidential National Development Council, changes are too slow – says prof. Cube. – We must accelerate them, because in 15 years’ time people of retirement age will already constitute one third of the society and will consume two thirds of all medical services.
In his opinion, primary health care must undergo the biggest changes. – The primary care physician must also be a geriatrician. He should order a whole series of tests, not refer each disease to other specialists by multiplying the number of referrals and documents. Otherwise, the patient will not get help – says prof. Cube.
He also gives examples: bone densitometry in osteoporosis does not necessarily have to be ordered by an orthopedist. This basic checkup in seniors should be at the discretion of the GP. Another disease of old age is, for example, arterial hypertension, which affects 70% of people. seniors. There is no need for all these people to go to hypertensiology specialists. The same applies to diabetes, which affects more than 20 percent. elderly people. Routinely, treatment should take place at the level of a family doctor, and only more difficult cases to a diabetologist.
Of course, there must be more primary care physicians, they must also have thorough knowledge of geriatrics. Because, according to prof. Most family doctors during their studies and specialization did not receive an adequate preparation for the care of seniors. Moreover, the problem is that in primary health care, family medicine specialists account for only 30 percent. The remaining part of such specialization does not exist, and an ophthalmologist or a doctor without specialization is even less aware of the problems of the elderly than a specialist in family medicine.
Nevertheless, Agnieszka Jankowska-Zduńczyk, a national consultant for family medicine, supports the idea. – There is no doubt that seniors want to be treated by one doctor closest to home and it is the most beneficial for them. A hospital should only be reserved for those who require intensive medical attention. Such a strategy of holistic care is implemented by many countries, e.g. in Scandinavian countries.
In her opinion, family medicine specialists are already prepared for comprehensive care of geriatric patients. On the other hand, doctors of other specialties who work in primary health care should supplement their knowledge in the field of family medicine.
Dr. Jankowska-Zduńczyk emphasizes that medical care for the elderly should be complemented by a social offer, i.e. activating seniors, so that even while walking on crutches or a walking frame, they could, for example, leave the house. Unfortunately, this is also missing.
From the report of the national consultant in the field of geriatrics (January 2018)
The most important problems of geriatrics are:
– a constant increase in the demand for treatment, rehabilitation, nursing and care services related to the aging of people and the increase in the number of elderly people,
– insufficient number of personnel and facilities providing medical and nursing care services,
– insufficient funding of geriatrics.
The number of geriatrics specialists increased – from 201 at the end of 2008 to 417 – at the end of 2017, but it varies across the country. It is especially urgent to replenish staff shortages in the following voivodeships: Lubuskie, Opolskie, Pomorskie, Warmińsko-Mazurskie, Zachodniopomorskie.
The number of geriatricians and geriatric beds (approx. 900) in Poland is several – several times smaller than the European average. This results in limited availability of services and hospitalization of the elderly in non-geriatric departments.
Introduction of the so-called hospital networks may result in further limitation of access of older people to qualified geriatric care. There are no geriatric wards at the XNUMXst and XNUMXnd degree security level, which poses a real risk of lack of financing and the inclusion of the existing wards in the network of internal medicine wards.
– In order to improve the availability of geriatric services, it seems necessary to create contracted geriatric beds within internal medicine departments and to transform internal medicine into internal and geriatric departments (with a geriatric contract).
– Specialization in geriatrics is not favored by the lack of a coherent vision of the senior care system in our country and the role of geriatric specialists in this system. The best example is the foreseeable inability to prescribe free prescriptions to patients aged 75+ by a doctor from a geriatric ward and clinic.