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