managed healthcare of the elderly

Changes occurring in Health care delivery and Medicine are the result of social, economical, technological, scientific forces that have evolved in the 21st century. Among the most significant changes are shift in disease patterns, advanced technology, increased consumer expectations and high costs of health care. These factors have redefined medical practices to fit into the changing health delivery system. Thus, medical profession is ‘Accountable’ to the society. i.e,obliged to the laws regulating the professional activity.

This ‘accountability’ is usually spelt out in “patient Care Documents” established by hospital associations and medical associations or councils of every country. In addition, medical profession has defined its standards of accountability through a formal code of ethics. There has been a recent significant increase in the number of elderly patients in palliative care units of hospitals in U.S.A and every healthcare delivery system aims to provide the elderly community in need of many services including physical therapy, speech therapy and chemotherapy due to many disabling and terminal diseases. But most of these elderly patients prefer to receive their end life care in a hospice rather than in palliative care units of hospitals.

Hospice –a managed healthcare for the terminally ill elderly papients

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Hospice is a coordinated programme of inter disciplinary care provided primarily in the home of the terminally ill patients. The palliative care is the comprehensive care for patients whose disease is not responsive to cure and hence are terminally ill. In the past two decades there has been a study of enormous magnitude in the palliative care segment and various factors have been identified like, respecting patient’s goals, preferences and choices, attending to the medical, emotional, social and spiritual needs of the person, using strengths of interdisciplinary resources, acknowledging and addressing concerns and building mechanisms and systems of support.

Many terminally ill elderly patients suffer only when they do not receive adequate care for the symptoms accompanying their serious illness. This is significant in the changing health care scenario where the patient is well informed, has the right to accept or refuse a treatment, issue advance directives and even appoint a proxy directive. Managed care for the elderly population is relevant in the present day health scenario where euthanasia and physician assisted deaths have found a legal niche as in the State of Oregon.

The managed care advantage

Any health care delivery system is primarily committed to the principles of patient self-care on the principles of Dorothea Orem (1971) with emphasis on client’s self-care needs. Self-care, according to Orem, is a learned, goal-oriented activity directed towards the self in the interest of maintaining life, health, development and well being. The ultimate emphasis of Orem’s theory is on client’s self care. Accordingly, care is needed when the client is unable to fulfill biological, psychological, developmental or social needs and the health care giver determines by duty why a client is unable to meet the needs or what must be done to enable the client to meet them. Health care of elderly population demands enormous resources of time, energy and money. Hence, every family looks up to any such programs with some faith element.

Care of terminally ill population is  still more stressful for the family in a hospice setting and any hospice setting requires a inter disciplinary care provided primarily in the home of the terminally ill patients. Such patients are usually immobilized and it is not medically advisable to take them to a hospital for therapies. Thus, the significance of the services being taken to the patient’s home, especially the elderly, by health care organizations is the need of the hour and future with the time constraints faced by many families in the super fast world in taking these elderly people for a regular therapy, the advantages the patients get in terms of pain relief, effective communication capacity and symptom relief.

This feature distinguishes the program from the rest of the health care programs that are currently available. The implementation schedule, i.e., the chronological sequence of events and activities that need to be achieved over a defined period of time to achieve the Goals and Objectives has to be defined by the Organizational Structure of the healthcare delivery system which identifies and describes the role of individuals, and their relationships in the system, who are key to the success of the program.

The disadvantage

There is a perennial shortage of occupational, physical and speech therapists in the health care system in the USA. Thus, there is a growing demand and proportional short supply of professionals. Cognitive impairments pose a serious barrier on the reliability of geriatric assessments (Weiner et.al, 1999). Some of these patients may be marginally competent and some may be incompetent. Effects of cognitive impairment on the reliability of geriatric assessments has been studied recently to explore the relationship between cognitive status and reliability of multidimensional assessment data. The studies have proved that the reliability of the patient’s communication and sensory ability are affected by cognitive status. Thus, any such program aimed at the elderly population should be implemented with care with documented informed consent.

Reference

• Addington Thomas et.al, ‘Ethics and communication with the Terminally ill’, Vol 7(3), 267-281, 1995, Health Communication.
• Anderson Christina et, al, ‘Continuous Video recording; a new clinical research tool for studying the nursing care of cancer patients, Journal of Advanced Nursing, Vol 35(2), 257, July 2001.
• Astudillo Wilson et, al ‘How can relations be improved between the family and the support team during the care of terminally ill patients?.’ Supportive Care in Cancer Vol 3(1), 72-77, Jan 1995.
• Barrington Dianne et, al, ‘Facilitating communication and interactional skills with terminally ill patients’ -Teaching and Learning Forum 97, Australia.
• Chochinov Harvey Max et.al, ‘Prognostic awareness and the terminally ill’, Psychosomatics, Vol 41, 500-504, Dec 2000.
• Weiner D et, al, ‘Chronic pain associated behaviors in the nursing home : resident verses care giver’s perceptions’, Pain, Vol 80(3), 577-88, Apr 1999.

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