Care models and environments support older people across the system
There was broad recognition that improving care practices required a systematic and system-wide approach. This was challenged by existing professional and governance structures, which are based around “organs”, disciplines and acuity, leading to siloed practices and disjointed systems within and beyond the hospital.
“Why is it that cardiology isn’t also a good place for an older person and why is it age that determines whether you go to cardiology or not?” P4, geriatrician, clinician “This team comes and looks at X, and this team comes and looks at Y, but how are we all sort of pulling it together?” P14, nurse, academic
Respondents recognised the need for better relationships and communication beyond the hospital, particularly with residential aged care. Respondents admitted to poor mutual understanding, leading to assumptions and conflict in transitions between providers.
“People in both sectors are throwing their hands up in the air, saying “we’re just not being told what we need to be told.” P11, AHP, academic
There was tension between care of older people being a specialty versus being usual care, including some tension between geriatricians and general physicians. Staff with specialist skills could provide mentorship and support for generalist staff, but could also increase complexity, and the concept of specialist care models was challenged by the large number of older patients.
“Maybe all older people need a geriatrician just to look at, to watch over them, not necessarily be the primary carer but to actually have input into their care.” P2, nurse, manager “Sometimes [emergency department outreach service] is involved, [community interface service] is involved, the geriatrician’s involved and throw in the Older Persons’ Psychiatrist as well and then there’s a lot of varying opinions sometimes. I think we need to look at who is owning the patient.” P19, geriatrician, clinician
Respondents valued comprehensive screening and assessment for older inpatients, but recognised that screening could be inconsistent, and did not always translate into care practices. Reasons included professional boundaries and expectations, limited support systems, and balancing time spent between screening and delivering actions.
“Even the new care plans that we’ve got in place, it talks about cognition but it’s not clear. It’s just another ticked box. It refers to using the CAM [Cognitive Assessment Method], but then they don’t have the CAM and they don’t have that training.” P20, nurse, clinician “Most of the time, you do the assessment, you do the discharge planning, and there’s so little time left for the really proper targeted goal-oriented therapy” P10, AHP, clinician
There was a developing awareness of evidence-based environmental design features for older people, particularly by respondents with experience in residential aged care and specialist older person’s wards. However, staff were often circumspect about their influence over decision makers, and whether the principles would be realised in practice.
“We don’t actually think about what we do in these hospitals. We think about colour combinations as being something that is pleasant, whereas it’s not necessarily that functional from an older person point of view.” P2, nurse, manager “We are fighting to get that ACE [Acute Care of Elders] ward… It is being constructed, but it’s the colour code and the dining area and the toilet design… Hopefully it’s going to be the way we have planned.” P5, geriatrician, clinician