Value care of older people
Most respondents believed that staffing and resourcing to support care of older people was inadequate, because it was a low organisational priority. The powerful competing demand of throughput, with an emphasis on emergency department wait times, length of stay and patient discharge, was a major disincentive to person-centred and quality-focussed resource allocation. At the same time, care for older people was reported as more difficult and complex, requiring more resources and disrupting task-driven care pathways. This created challenges articulating the value proposition for investing in care of older people.
“Everything’s about NEAT [National Emergency Access Targets]. They don’t realise that it’s actually what happens in between that effects NEAT” P19, geriatrician, clinician “The problem is that [geriatric interventions] are often quite expensive and how do we make them cost effective and show our bean counters that they’re actually of value?” P6, nurse, manager
Many respondents felt they were constantly arguing for resources for older patients, which were often secured in an ad hoc manner. Participants attributed successes to networking with other champions to pool resources and energy, and alignment with accreditation standards or other strategic policy. The consumer highlighted the under-utilised influence of politically aware older consumers.
“[Older consumers] are the guys that have the money, we’ve got the influence, and there’s lots of us, and we’re just starting to wake up to the fact that we’ve got to start making things a lot better for ourselves.” P7, consumer
DISCUSSION
Using in-depth interviews with key informants, we propose an action-focussed model for hospitals to improve the experience and outcomes of older people (figure 1). This model emphasises intersections between how older patients and families are seen and involved in care, how staff are trained and connected, and how the care environment is created. Our respondents highlighted substantial challenges and opportunities in leadership, workforce development, and implementation of EBP required to support these elements, and combat an ageist and efficiency-driven culture.
The central importance of patient and family involvement supports and extends previous OPFH frameworks (table 1). Engagement must go beyond eliciting patient preferences and sharing information with families9,10, to valuing older patients and their families as legitimate partners in care decisions and provision17. This is congruent with a systematic review of acute care experiences from the perspective of hospitalised older people and their carers18, which concluded that genuine engagement requires recognition, reciprocity, and involvement.
Previous frameworks have recognised the need for staff geriatric competencies, but our study indicates that compassion and teamwork are essential to complement geriatric knowledge, and require experiential learning. Consistent with other reports 19,20, our respondents reported lack of dedicated gerontology teaching time, and lack of expert teachers and mentors in undergraduate and graduate training across all disciplines. They identified that traditional teaching methods must be supported by opportunities for interdisciplinary training, and positive mentored experiences to demonstrate skills and values in practice. Creating such opportunities will require leadership11 and cooperation between education and health care sectors to prioritise gerontology curriculum and support effective mentors.
Respondents recognised the central importance of geriatric care principles (e.g. comprehensive risk assessment linked to integrated multi-disciplinary care planning) and how teamwork and the physical care environment could enhance or challenge delivery of this evidence-based care7,10. Many respondents were frustrated by perceived failure to translate EBP into everyday practice. This challenge has been recognised internationally, with poor uptake of effective demonstration models into other settings 3. Effective implementation of EBP for older people requires leadership support 21 but our findings illustrate the complexity of providing leadership in a system traditionally organised along disciplines and organ-based specialties. This leads to reliance on motivated individuals forced to build their own skills and networks. Strategic collaborations which empower and connect these individuals, encourage cross-disciplinary partnership, create legitimate capacity for role modelling for other staff, and advocate for investment in implementation of EBP could enhance organisational capability in care of older people. Robust systems for measuring and monitoring outcomes would support visibility and facilitate improvements7.
Our three key enablers of leadership, training and investment (Figure 1) are similar to the concepts of authority, awareness and resources identified in a review of successful dementia-friendly hospital practices 22. Clearly identifying the value of caring for older people in hospital is essential to activate these enablers, but remains challenging in a context which prioritises efficiency and throughput 23. In a time-driven system, staff can feel helpless and frustrated by complex care needs (e.g. due to cognitive impairment or disease complexity), and older patients can become isolated and ignored. Powerful social discourses about ageing support this behaviour 6. Our respondents recognised that these additional needs could not be convincingly framed within the prevailing efficiency paradigm, and that progress requires aligning with other powerful policy incentives such as quality standards and consumer expectations. Strong collaboration with older consumers, reliable data for monitoring outcomes and benefits, and networking between champions and policy and practice leaders are potential strategies to shape a persuasive case for the OPFH10. Careful selection of communication strategies is critical to ensure thoughtful discourse and avoid perpetuating ageist and negative stereotypes of health system “burden” rather than recognition of legitimate and specific healthcare needs 24,25.
Strengths of our study include a multidisciplinary steering group and diverse respondents from varied setting and disciplines. Informants engaged enthusiastically and provided a comprehensive view from multiple perspectives. Internal and external validity were supported by several researchers coding and checking themes, member checking with participants, and discussion with expert groups from inside and outside the participating organisations. Our hybrid approach using a recognised implementation framework helped us move beyond descriptions to actionable themes to inform improvement. We also recognise some limitations. Participants for this study were deliberately selected as knowledgeable advocates for older person care, who may not recognise barriers and enablers experienced by other staff and consumers. Despite a diversity of disciplinary and practice backgrounds, most participants were female. The stimulus (survey report) provided to frame interviews, and snowball methods of recruitment, mean that participants may have been aware of the perspectives of the research team, which may have influenced their responses. Pragmatic constraints on sample size mean we cannot be certain that data saturation was reached, although consistent themes were voiced across diverse settings and disciplines. Our settings were metropolitan, and we did not sample policy makers, which may have under-represented codes related to the outer setting. We only had one consumer representative participant, but other participants drew on their personal consumer and carer experiences, and findings are congruent with studies of consumer and care perspectives18,23.
Our findings inform actionable opportunities for clinicians, managers, consumers, academics and policy makers to work together to create hospitals which value care of the older person. Universities and training institutions should encourage access to gerontology curricula for all disciplines, and collaborate with services to provide mentored training experiences and practice teamwork skills. Clinicians and consumers must identify ways to engage older people and their families respectfully and meaningfully in care, and advocate for EBP. Hospital managers should recognise and promote local champions as key resources for training and translation, and invest in interdisciplinary teams and EBP, with age-stratified measurement of outcomes to monitor effectiveness. Policy makers must recognise that prioritising efficiency can create perverse cultural incentives with serious consequences for vulnerable older patients. Researchers can work collaboratively with all stakeholders to identify effective leadership structures for OPFH, implement EBP at scale, and validate reliable, feasible and responsive measures of care and outcomes that matter to older patients. Multi-level collaborative leadership is required to challenge ageism and truly value older people if we are to deliver OPFH.
ACKNOWLEDGEMENTS:
This work was supported by a Strategic Research Grant from Brisbane Diamantina Health Partners. The authors acknowledge Professor Len Gray and Professor Elizabeth Beattie for their contribution to the project expert reference group.
DECLARATION OF CONFLICT OF INTEREST:
The authors have no conflict of interest to declare
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Table 1: Examples of previously described older person friendly hospital (OPFH) frameworks, including definitions and key constructs