To provide context, Montreal is the largest city in the province of Quebec, with a metropolitan population of over two million. The McGill University Health Centre (MUHC) is the main academic health institution for McGill University and is spread across the merged institutions of the Montreal General Hospital, Royal Victoria Hospital, Montreal Children’s Hospital, Montreal Neurological Institute, the Montreal Chest Institute, and the Lachine General Hospital. The MUHC operates on average 880 adult and 120 pediatric beds, with a volume of 36,000 admissions and 600,000 ambulatory visits per year. Our Geriatric Medicine service has 38 inpatient beds on two distinct units. Our annual volumes involve approximately 400 inpatient admissions and 1,400 consultations in the Emergency Department. We have seven full-time equivalent physicians who provide these services.
There were a total of 11 articles and 14 webpages considered in the detailed literature review. The majority of articles are nursing practice-based. Analogous to the concept of children-friendly hospitals and in response to the World Health Organization initiative of Age-friendly Environments program(6)
and age-friendly communities,(7)
the concept of the ‘Elderly-friendly Hospital’ has been proposed by nursing management initially by Parke and Stevenson in 1999(8)
and by Parke and Brand in 2004.(9)
Subsequently in 2009, Chiou and Chen(10)
proposed a framework to promote the health, dignity, and participation of older hospitalized adults. After our review and analyses, we proposed a specific set of guiding principles. Rather than compartmentalizing the role of specialized geriatric services in order to respond to the challenges of managing only a portion of the hospitalized frail elderly, we propose that the guiding principles listed below be applied to the institution as a whole, so that all older patients, family members, and visitors can benefit. These principles, along with examples of their implementation, are as follows:
- A favourable physical environment.
- Integrate and implement designs that are age-friendly and respond to the needs of patients, families and visitors with a variety of impairments (physical mobility, endurance, visual, hearing, cognitive)
- Introduce innovative designs that promote the maintenance of function and independence in the hospitalized frail elderly(11,12)
- Zero tolerance towards ageism at all levels of the organization.
- The “Age-friendly” vision has to be fully endorsed as a strategic objective by the institutional administration
- Knowledge, skills and attitudes of all care providers are supportive of this objective, along with training opportunities to meet it(5)
- A marketing approach, such as linking this concept to the slogan “Age-aware means better care”, can potentially enable healthcare worker recruitment and retention, as well as be attractive to patients and their families
- An integrated process to develop comprehensive services using principles of the geriatric approach across the entire institution by implementing:
- A geriatric interdisciplinary consult team in the Emergency Department to help with the early identification of high-risk patients, following the concepts promoted by McCusker et al.(13,14)
- A systematized program such as the Hospital Elder Life Program (HELP)(15) to prevent delirium and functional decline for intermediate and high-risk patients
- A specialized unit for the management of patients with behaviour manifestations associated with dementia and delirium
- An Acute Care for Elders (ACE) unit for patients above a targeted age (e.g., 85 years)(16,17)
- Co-management by Geriatrics of patients within the services of orthopaedic surgery, vascular surgery, cardiac surgery, and cancer care
- A comprehensive nutrition support program, from food preparation to delivery, presentation, and including feeding assistance
- An elder-assist program to help patients remember their appointments, navigate the hospital services, understand the outcomes of health care discussions, and advocate for their choices
- Assistance with appropriateness decision-making (e.g., Levels of care and Interventions: Too much vs. Not enough).
- Interdisciplinary service to assess older in-patients and out-patients who are being considered for advanced surgeries and interventions. Interventions should be patient-centered and have measureable benefits
- Fostering links between the acute care hospital and the community.
- The right patient, cared for in the right place, at the right moment.
- Promote existing ties within regional health care jurisdictions to enable clinical excellence, teaching, and research opportunities
- Innovative programs of subacute and postacute care of the frail elderly and patients with multiple chronic conditions (rehab institutions, skilled nursing homes, other)
The aims of developing an age-friendly hospital are to promote excellence in hospital care for acutely ill older adults through the provision of evidenced-based service delivery and patient-family focused-care, and to ensure that the “geriatric approach” is incorporated into practice standards across all patient care programs and services within the hospital. While we are cognizant of the increase in human resources and associated costs needed to effectively implement an AFH program, we anticipate savings generated through a reduction in hospitalization-related complications, avoidance of inappropriate tests and procedures, decreased visits to the Emergency Department, and possibly decreased healthcare worker burnout. Programs such as the Hospital Elder Life Program (HELP) have already demonstrated a positive cost-benefit.(15)
Although the AFH program may not be initially cost-neutral, the recommendation at present consists in evaluating all components of the new proposed changes in care, including the perceived quality of care by our target population and their family members. Patient-reported outcomes involving accessibility and acceptability have been foundational concepts for hospital accreditation activities, such as those promoted by Accreditation Canada (www.accreditation.ca
) and should be seriously considered. An additional advantage of the AFH concept would be the positive ‘branding’ bestowed upon an institution, which could help recruitment and retention of skilled healthcare professionals.
Challenges and Potential Opportunities
One significant challenge is convincing hospital senior management of the value of geriatric services. Our personal adventures began after a gloomy discussion with hospital senior management during the Fall of 2008 when we were informed that Geriatric services were going to soon be designated as optional within the inpatient services setup. Our division responded by submitting a white paper outlining the guiding principles for the development of an elderly-friendly hospital. To our surprise, in January 2009, the same senior management and hospital redevelopment and planning committees accepted the principles outlined in our white paper. Serendipity also contributed to the start of an organization-wide clinical activities priority-setting exercise. After the reports from 92 hospital services were analyzed, Geriatric Medicine was placed at a medium priority and the age-friendly hospital principles were proposed as one of the cross-cutting pillars for the future.
Another significant challenge is fiscal. Administrative data is a strong potential ally. Drilling down into detailed patient tracking data has shown that when our Geriatrics unit is compared to a general Internal Medicine unit, the in-patient acute length-of-stay is predictably longer (28.7 d vs. 15.1 d), but patients discharged home were one-third as likely to return to the Emergency Department within 14 days of discharge (5.3% vs. 17%) and require re-admission (3% vs. 10%). A more detailed cost analysis of longitudinal health services utilization rather than crude episodic numbers would need to be done in order to determine the value proposition of investments required and operational sustainability of implementing some of the principles of an age-friendly hospital. Communication of ideas and concepts to patient support groups and government may also be fruitful. Our efforts captured the interest of the Quebec Minister for Families and the Elderly (Ministère de la famille et des aînés) who recently invested the amount of $300,000 as a grant to initiate our pilot project.