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3ON THE PROBLEMS OF PROVIDING PRIMARY MEDICAL CARE TO THE ELDERLY
Abstract
Unprecedentedly increased human lifetime due to advances of medicine changed the directions of healthcare systems activity in different countries. The problems of labour organization, staff, regulatory, legal, methodological and psychological provision and the motivation of the personnel when delivering medical and social care in Belarus are analyzed.
Keywords
medical and social care, elderly, nurses, principles of care, management decisions
AUTHORS
Tatiana Matveichik
PhD, Associate Professor at the chair of Public Health
and Healthcare Belarusian Medical Academy of Post-Graduate Education
Minsk, Belorussia matveichik51 @rambler.ru
Eduard Valchuk
PhD, Deputy Director for
Clinical Activity, Republican Scientific and Practical Centre for Medical Expertise and Rehabilitation, Minsk, Belorussia
Svetlana Novitskaia
Senior teacher at the chair Department of Public Health
and Healthcare Belarusian Medical Academy of Post-Graduate Education Minsk, Belorussia
The necessity of increasing the extent and the quality of medical care to the people aged over 65 years is considered to be the real practice of medical institutions activ'ty. It is conditioned by unprecedentedly increased human lifetime by 20 years during the last 50 years due to advances in medical and social technologies.
Within the period from 1960 to 1990, in European Union, the number of people aged 80 and older increased from 5 to 12 million. UNO prognosis testifies to the fact that by 2025 the share of people over 65 years will make the tenth of humanity. This forecast is realistic for the Republic of Belarus, too, because the share of population aged 65 and older makes more than 14% in the country.
Global problems of ageing, common for the whole civilization the Republic of Belarus including, require developing a strategy for rendering medical care to the elderly. Multiple medical and social institutions deliver the care to the elderly and old people. WHO points out that delivering primary medical and social care is a laborious process, in which nurses and midwives play an important role. In such demographic situation, medical and social care to the people over 65 years is rendered by ambulatory, outpatient, inpatient and specialized healthcare as well as social protection institutions. The increase of the healthcare system effectiveness is based on the core values, with the health being an integral right and resource of every human being, with responsibility and accountability of medical institutions for the health status of the society, with justice and solidarity in delivering medical care. The activity of 4670 institutions of the Ministry of Health including 16 republican scientific and practical centres, 4 higher educational establishments, Belarusian Medical Academy of Post-Graduate Education, 17 medical colleges, more than 40 000 physicians, 2 000 pharmaceutists, 4 000 pharmacists, 108 000 paramedical professionals is based on general principles:
*maintaining the bases of state medical care system with gradual increase of private medical services;
*securing and protecting the patient's rights;
*strengthening the health and preventing the diseases;
implementing evidence-based medicine;
*updating the healthcare system according to international standards;
*using system approach and scientifically grounded priorities while solving healthcare problems.
Despite certain achievements in improving medical care to the elderly and old population, the analysis of the activity of healthcare services revealed a number of problems, which have to be considered.
1. Organizational and administrative problems of rendering medical care to the elderly.
First of all, they result from inadequate coordination between various public sectors caused by the lack of system continuity in rendering medical and social care.
1.1. Organization of labour
Recently, in developed western countries, the number of nursing hospital beds increases with decreased general number of hospital beds, and, respectively, increased share of nursing beds to the total number of beds (up to 30%).
A similar redistribution as part of restructuring the number of medical and social beds as well as implementing new inpatient care substituting technologies takes place in our country. This direction is economically profitable and strategically correct, but some factors hinder using day hospitals and other day-stay forms of primary medical care (PMC) fully:
*insufficiently developed inpatient care substituting technologies, low awareness about the advantages of day hospitals together with decreased mobility of the elderly in rural area due to transport problems;
*the mentality of the elderly and old people oriented to the rent relations with the state and healthcare system that hampers implementing and improving economically effective inpatient care substituting forms of medical care. Besides, the level of mobility and self-service ability are known to decrease from 93% for people aged 60-64 years to 20-23,7% for those aged 80 and over. It is also suggested that by 2025, the common potential of adults able to look after the elderly and old people will start to decrease. If this trend goes on, the whole society is to assist the state structures in provision of the population with social services in order to prevent the overwork of official caregivers.
1.2. Staffing of outpatient departments (OPD) with specialists-gerontologists does not take into account psychological and physiological peculiarities of the elderly. In this connection, the necessity of additional wage-rates for a psychologist, a rehabilitologist, an exercise physiologist (a massage nurse) must be grounded, and this will considerably improve the quality of medical care. There is an evident need to increase the number of hours in curriculum for training physicians, because this category of patients presents with complex multi-morbidity and requires an individual approach with respect to medical treatment.
1.3. Regulatory and legal problems are due to the lack of precise regulation of norms satisfying the needs of OPD in transportation and small-scale mechanization means as well as facilities for the disabled because of their specific mobility. There is also a lack of regulatory and legal acts determining the staff policy and providing occupational health of medical professionals.
A gradual updating of small-scale mechanization means facilitating the work of nurses and improving the quality of life of the elderly will contribute to improved quality of medical care at OPD.
In one of his messages to the Belarusian people and the National Assembly, the President of the Republic of Belarus noted: «It is necessary to shape the overall quality culture in the country; to educate in our people a strong desire to live, work, study, and perform professional duties effectively. It must become a way of life! Because the quality
does begin with each separate individual, with each of us - with our qualification and responsibility».
2. Medical and social problems of the elderly and old people:
2.1. Decreased functional status with impaired physical, cognitive, behavioral, social and psychological characteristics. According to a research, the proportion of population requiring assistance when taking meals, dressing, moving is constantly growing. Thus, these patients make 4,6% at the age of 60-69 years and 14,2% at the age of 70 years and over. According to P. Fioritto, in the USA, the impaired functional status is noted in 60% of patients aged over 60; 55% of people who are 85 have difficulties in housekeeping.
From the medical point of view, curable functional impairments in the elderly and old people are to be early revealed and then adjusted. This task is difficult because some peculiarities are typical for this category of population and their diseases patterns:
* chronic character with a severe course;
* multi-morbidity with high complication rate;
* severe incapacitating consequences with the threat to lose the autonomy;
* difficulties when using modern household appliances, Internet, credit cards;
* decreased communication skills, poor attention, irritability;
* loneliness resulting in depression in 29-38% of the elderly.
When acting together, social, cultural, and religious organizations can solve these problems successively and, thus, assure a complex rehabilitation.
3. Methodical problems in rendering medical care to the elderly:
* developing methodical guidelines on division of tasks and functions of day-stay and 24-hour stay medical institutions on the stages of ambulatory, outpatient and inpatient care;
* establishing common methodological approaches for using the resources in day -stay forms of medical services;
* developing standards for professional activity of nurses through the introduction of the nursing process;
* learning the foundations of the scientific organization of labour of staff in medical and social institutions;
* special care training for nurses and introducing the position of "caring nurse" at each district.
4. Problems of staff's motivation, especially, of those rendering care to the elderly and old people. The motivation is an intrinsic condition of a human being related to his/her needs, which activates, stimulates and directs actions towards the goal to be achieved. The basic motivations are as follows: payment system and rewards, compensation and social payments, organization of the workplace and information space (F. Hertzber). The incentives are career, personal professional growth and self-realization. The system of motivation comprises fixed and variable elements of remuneration and intangible factors of motivation. If a medical institution can not change its payment system, intangible factors of motivation (social policy, corporate culture, communication, competition) come out on top. The motivation becomes one of the areas of management, because when trying to achieve the best results with the least expenditure of human and, respectively, material resources, the only choice is «to get body, mind and soul of an employee».
In practice, the motivation of the staff is a complex medical and psychological task:
1. Human needs are mobile; they vary not only from person to person, but from situation to situation.
2. The motivation and the attitude to the work depend on one's health and mood.
3. The motivation is differently expressed in beha^or. Two people with similar pronounced need to be secure may proceed with caution and avoid responsibility, but one
of them for the fear to lose his/her job and the other one for the fear to be appreciated as an unnecessary or bad employee.
4. Different reactions to the satisfaction of the same needs: one worker encountering the obstacles is upset and stops working, and the other will redouble his efforts.
The incentives can be applied only in the case of systematic use of internal and external rewards.
Possible incentives for PMC professionals:
* empowerment and responsibility;
* awakening of interest in work;
* opportunity for personal growth;
* formation of devotion to organization;
* formation of the spirit of cooperation and corporate culture;
* fair rewards and additional preferences for difficult conditions of work, often with severe cases (disabled, persons with partial disabilities, and so on).
5. Psychological problems of labour, especially for professionals rendering care to the elderly, due to an underestimated impact of social factors on the development of the burnout syndrome in medical professionals leading to errors and complaints from patients.
The same factors that influence the health condition in adults work in the elderly (61-75 years) and old age (76-90 years), but their importance varies. Because biological, socio-economic status and healthy lifestyle have already been formed, environmental factor becomes predominant. Different needs in health are due to different objectives of the elderly and old age.
If the working-age goal is to keep the opportunity to work, the senile one is to adapt to the environment. Misunderstanding the features of gerontological age, low motivation of doctors and nurses as well as the absence of system for preventing the burnout syndrome in medical and social professionals is partially the reason of low quality of the care. I. Kronshtadtsky wrote: «Compare your sadness with the troubles and sorrows of others, and you will realize how insignificant and small your sadness is». Training medical professionals able to meet the hopes of the elderly for the decent life is not only a pedagogical but a political and ideological task to assure the demographical security of the state.
The motivation of medical professionals can be enhanced by a fair surcharge for the quality and intensity of work; social guarantees of hours of work and rest in accordance with attached forces; empowerment and responsibility of a feldsher (doctor's assistant) when implementing the nursing process. All this will contribute to improving the quality of work.
6. Nurses errors as a security factor for the elderly patients, which result from the lack of a due interaction and coordination of efforts between outpatient and inpatient services. Stress, fatigue and time pressure, i.e. subjective factors, play an important role causing around 10% of errors. Inappropriate organization of work, lack of experience, ignoring the wishes of the patient, underestimation of the opinions of colleagues can be seen in almost every situation of an error. Most authors consider that from 60 to 83% of errors can be prevented on outpatient level of medical care.
To avoid errors, the equipment must be serviceable, a nurse must have a well-designed workplace, working load norms are to be regulated in order to prevent tiredness and physical fatigue; social activity must be assured, etc.
7. Pedagogical problems:
* teaching the nurses the foundations of medical rehabilitation of the elderly;
* gradual transfer to the ideology of personal responsibility of the elderly and old people for the health using mass media and nursing pedagogics at all the stages of rendering medical care. This corresponds to "Directions of strategic development of healthcare in the Republic of Belarus for 2011 -2015" and "National strategy of sustainable
social and economic development of the Republic of Belarus for the period up to 2020", other regulations and principles for rendering medical care recommended by WHO.
Despite a number of problems revealed, the elderly and old people require and will require primary medical care. So, impro^ng the conditions of labour at OPD should be continued.
In the Republic of Belarus, measures to render accessible primary medical care to the population, the elderly and old people including, are implemented via the system of state minimum social standards. First of all, these are changes in financing, allocation of funds for healthcare according to the budgetary provision of health expenditure per capita, approved each year: budgetary provision of the adult population with general practitioners and district doctors (1200 and 1700, respectively), hospital beds (9 beds per 1000 of population), pharmacies (1 pharmacy per 8 000 of population), etc.
Structural reform of the sector and intensification of the priority of PMC are implemented according to "Directions of strategic development of healthcare in the Republic of Belarus for 2011 -2015".
The system of long-term care for the elderly and old people can be more successful
if is:
• suitable for people of all ages with various degrees of physical and mental abnormalities;
• responsive to the needs of recipients and their families;
• dynamic in order to cope with chronic social needs;
• able to engage the family to provide care;
• able to grant options for housing and care requirements;
• able to make the patient more independent, including the right to reject health management and security.
The developed unified system of standards, protocols for diagnosing and treating patients according to the principles of evidence-based medicine, proposed for 24 groups of diseases, must be clarified in terms of the needs of the elderly and old patients.
Proceeding from the above, in terms of priority, the following social as well as medical and organizational problems should be solved:
Transition from cost control to results management
Redistribution of financial resources with prior emphasis on PMC; regulation of paid services and improving their pricing; reforming the system of financial remuneration of medical professionals taking into account the quality of their work. According to the forecasts, the expenditure for long-term care for the elderly and old people will be increasing by 2,6% from 2000 to 2040 every year. In European Union, the expected expenses will make 207 billion dollars by 2020 and 346 billion dollars by 2040.
The authors recommend being very careful with prognosis for the further 20 years. It is supposed that if the prevalence of diseases decreases annually by 1,5%, by 2040, the expenditures for a long-term care for the elderly will increase by 40%.
Improving the healthcare system via implementing economically effective up-to-date technologies with the leading role of primary medical care. It means improving inpatient medical care by using inpatient care substituting technologies and the institute of general practitioners; increased accessibility to highly specialized and expensive medical facilities by optimizing the activity of republican and regional healthcare organizations; developing effective mechanisms for integration and interaction between medical institutions.
Developing medical and social care via creating a unique multilevel information-analysis system for health monitoring. Developing and improving the international cooperation in the field of rendering care to the elderly and old people, with a good example of an effective joint project of the Belarusian Red Cross and the Consortium of
Switzerland and Germany Red Cross Societies, Austrian Red Cross «Strengthening the Visiting Nurses Service of Belarusian Red Cross».
The analysis of the international experience of medical and social care to the elderly patients allows revealing the following aspects:
• private insurance of the long-term care and enlargement of the spectrum of these services will be continued;
• financial regulations for conducting medical and social reforms will include tax exemptions for care-givers and recipients;
• state programmes will allow the patients or their families deciding how to cover the services;
• with the increasing demand for home care, the politicians will develop the ways for financing the social housing for old people with low incomes.
In the USA, there is the Law on medical leave and family leave. It provides caregivers who work for an employer who has at least 50 employees, a leave at one's own expense for caring seriously ill spouse or parents for the period up to 12 weeks per year. It is a way to show the awareness of the state how important is to involve families in care.
Developing the preventive orientation of medical rehabilitation
Gradually, the preventive orientation of rehabilitation should form the basis for the long-term policy in health protection. General practitioner, family nurses and doctor's assistants are here key players.
The development of preventive orientation of rehabilitation determining its social value for the elderly and old people can be based on:
• gradual transition to the rehabilitation in nursing hospitals according to the slogan "rehabilitation instead of care", formation of the institute of doctor's assistants as a mean of integration with European norms of medical care;
• complex application of both types of medical rehabilitation (in acute conditions and injuries as well as in chronic diseases), requiring additional skills - kinesotherapy, various types of massage and physical treatments etc - from medical professionals;
• cooperation between social, medical and public organizations within common programmes to provide the disabled with technical means for their rehabilitation;
• more active participation of nurses in medical rehabilitation by removing organizational and economic causes that will contribute to the increased quality of life of patients at risk of disability;
• thoughtful system of geriatric rehabilitation centres affiliated to nursing hospitals or day hospitals, greater extent of medical rehabilitation in nursing hospitals that would become the core element in improving medical care to selected categories of patients.
Conclusion
• The dynamics of demographic changes is taken into account when elaborating the strategy of the state allowing an adequate financing of the healthcare system. Planning the system of a long-term aid and care to the elderly and old people living alone is performed using the differential approach with consideration of the local demographic characteristics.
• The problem of continuity of healthcare and social protection institutions activity influenced a number of indicators of nursing hospitals work in 2008. For example, standard norm for general inpatient care (hospitalization rate per 1 000 people) was below the level achieved. In nursing hospitals, the inpatient care norm by the number of bed-days per 1,000 people was 94,4, with this indicator being 101,2 in the country.
• Due to underdeveloped system of continuity in rendering social care, medical professionals are forced to save long-term beds for the elderly. Creating a network of
social beds for the patients in need and disabled in some regions could solve the problem of rational use of beds in nursing hospitals. A proposal for co-financing of these patients stay in nursing hospitals should be considered by the Ministry of Labour and Social Protection.
* The elements of scientific organization of labor, technical means of rehabilitation for patients and small-scale mechanization of labour for medical professionals, based on the experience of other countries, rational use of workforce are mandatory when rendering primary medical care to the lonely elderly.
* System of training doctors and nurses with higher and secondary medical education corresponds to new requirements to the continuous educational process, where mastering practical skills is a priority.
* Risk factors of medical professionals for developing burnout syndrome include the age 40,7± 2,63 years and length of work over 10 years in the system of medical and social care. This factor must be taken into account when optimizing health and safety of labour for these professionals.
* Changing consumer attitudes of the elderly to their health and passive shifting problems in saving it on the shoulders of health workers and healthcare system in general is an important element of the long-term policy, aimed at secondary and tertiary prevention. Pestalozzi gave an advice: «To change the people, one should love them. To influence them means to love them».
Significant efforts of medical and educational professionals as well intellectuals in general are needed to change the formula of the behavior of most people from the slogan « I know what to do to be healthy» to « I actually use the knowledge useful for my health and life».
* Application of new labour technology in the form of the nursing process is of a particular importance at OPD for increasing the quality of medical care to the patients that was approbated during 40 years of experience in developed countries. For Belarus, this form needs to be widely disseminated and requires some organizational efforts:
* teaching post-graduates with nursing foundations;
* developing a package of documents in the form of nursing history and protocols for caring patients with various problems (dyspnea, constipation, bedsores, and so on).
A number of managing decisions on improving the primary medical care to the elderly seems to be perspective:
•in staff policy - gradual rotation to fill positions of chief and senior nurses by specialists with higher education that will ensure the correct distribution of work at OPD; modification of the powers and responsibilities of a specialist "doctor's assistant" with a corresponding change in the payment tariff rate;
* to plan social and medical study on the organization of labour in OPD when rendering care to the elderly patients, to make proposals on the list of equipment for nursing hospitals and classifying the nursing diagnoses. To purchase small-scale mechanization means for OPD, to calculate the norms of drugs use, including disinfectants, for this category of patients;
* to form a social order for the study and analysis of the organizations of health and social care in the Republic of Belarus and the system to encourage the personnel to work with seriously ill, bed-ridden elderly and old patients;
* to develop and to implement the protocols of examination, treatment and medical rehabilitation of patients with social needs.
The long-term healthcare strategy involves three components: conserving the areas of the health system with proven effectiveness, updating the sector according to international standards, improving the existing and implementing new organizational technologies.
When considering the perspectives of nursing care for the elderly, the following should be taken into account that:
• increased demand for trained nurses and caregivers for a long-term care of the elderly people with disabilities;
• technological innovations in the care and adoption of international standards to enhance the formal health care market;
• the need for training and involving the family and friends as the main caregivers who, in the nearest future, will render long-term aid to the elderly;
• participation of politicians in initiating proposals for developing multispectral home care;
• using nursing hospitals as institutions of charity and rehabilitation for the elderly with severe morbidity;
• developing a training course with additional incentives for professionals in geriatrics as well as proposing free education for those who render home care for disabled.
It can be stated that a steady course on improving people's health (the elderly's including) is provided by:
*monitoring the health indicators for the population, with the developed united network;
*interdepartmental integration of information resources for unconditional implementation of "The concept of implementation of the state policy for promoting the healthy lifestyles of the population of the Republic of Belarus up to 2020" and "National program for preventing alcoholism and heavy drinking";
*methodology for strategy planning within state guarantees based on the standards for rendering state medical services, revealing people at high risk of death for providing them with appropriate medical and rehabilitation assistance;
*improving the provision with social guarantees in budget financed medical care by revealing patients at high risk of death and targeted services to decrease the mortality;
*the growing influence of the Ministry of Health on public organizations to adopt measures aimed at important determinants of health according to the "Plan on promoting healthy lifestyles, preserving and strengthening the health of the population of the Republic of Belarus up to 2015".
To increase the prestige of nurses and social workers, the society has to change its attitude forwards the role and importance of these professions in solving medical and social problems. Volunteers and mass media as well as competitive salaries and career opportunities may be helpful. The salary is known to be an important but not the main factor in admission and retention at work, many nurses enjoy caring and feeding patients. They seek professional approval. Reasonable scheme of participation and involvement of assistants for planning the care for patients with chronic disabling pathology should be developed.
The degree of compliance with requests of the elderly and old patients and their relatives means the need for personal self-development of the staff. Establishing needs is not limited by services being rendered now, but allows understanding the perspectives of their progression in future. Focusing on the needs of external customers (patients, their families and friends) and internal actors (doctors, nurses, technical and operating personnel) means a constant desire to understand the needs, wishes and expectations of the patients, best known to those nurses who are always close to a patient.
In this regard, the proposal made in the report of the President of the Republic of Belarus at the 4th Belarusian National Assembly is appropriate: «...today everyone must understand: it is not enough to dream and to speak about a happy future. It should be created by people themselves. Rolling up sleeves. Starting today».
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