Community geriatrics and hospital at home

With continuing advances in technology and medicine, and a greater understanding of how diet and good social care affects quality of life, it is anticipated that by 2037 there will be an 83 per cent increase in the 75+ population to 779, 000. Today this stands at 425,000 and already poses challenges to our health services and social services, owing to the fact that people living longer often have complex health problems and multiple co-morbidities. It is hard to imagine that at the beginning of the last century, people often died before 50 years of age. We have become victims of our own success and the budget for the NHS has been described as a bottomless pit!

The NHS is one of the largest employers in the world, second only to the Chinese army and Indian rail company. Currently NHS Scotland has approximately 150,000 employees. To address the ever increasing demand on services integrated social care and health care organisations, such as REACT (Rapid Elderly Access Care Team), have been created to optimise care at home.

REACT currently operates in West Lothian, but similar services will be rolled out all over the country in due course. It is funded by the Scottish Government’s “the change fund,” hoping to address some of the challenges arising from a growing older population.

We have run REACT in West Lothian for the last two years. It is unique in that many GPs and Consultants work together. The benefits of this practice were recognised by Brotherston in 1965, leading to GPs and consultants manning hospital clinics collaboratively. It was on this model that the REACT team is based. 

It significantly enhances communication between primary and secondary care, improves consistency and forward planning, while optimising disease management.

Our aim is to keep the frail older patient at home, if appropriate. We have the ability to administer fluids and IV medication and can access investigations from home or on an urgent outpatient basis if needed. We are able to give expert end-of-life care and support to patients and families. Our doctors also have input to the community hospital and day hospital. We therefore represent an excellent example of continuity of care, which is vital for older people and it has the further benefit of reducing unnecessary admissions. We liaise well with our local GPs and many work for the service.

I have worked as a General Practitioner in West Lothian for 21 years. West Lothian is unusual as many General Practitioners are dual-qualified and work in local practices as well as covering sessions in the District General Hospital.

In 2013 I became the first Community Geriatrician in Scotland. This involves input to REACT, where we aim to care for and treat older patients with frailty at home, with the support of consultants, GP’s, nurse practitioners, physiotherapists, occupational therapists and social work colleagues. 

On admission, patients require a “passport” which includes admission details of past medical history and a full medical and nursing assessment. Medications are rationalised, family contacts noted, mental function, depression scores, falls risk, assessment of hearing and vision, discussion on capacity issues and resuscitation status, if appropriate, are recorded. 

In the home setting, we are able to administer IV medication and antibiotics, fluids and/or oxygen at home if needed and can optimise mobility with the help of our physiotherapy and occupational therapy colleagues. Advice is given on home safety and equipment supplied, if this assists safe mobility and improves independence.

We are also involved in the running of our local day hospital and some of our patients can be investigated there on an outpatient basis. We can perform Xrays, ECG’s, ECHO’s, 24 hour tapes, CT scans and most of the investigations which are usually done as an inpatient.

If all of the above options are unsuccessful, I run a 30-bedded interim care Community Hospital in Linlithgow, into which I can admit patients. This is basically if patients are unsafe at home and do not improve after a one week input from REACT. The hospital has 24-hour nursing cover and I visit daily, with remote backup cover from my GP colleagues at other times.

If patients are so ill that they require 24 hour medical presence, they are not suitable for admission to our community hospital.

The nursing staff often deal with frail individuals who need nutritional, fluid support, skin care and assistance to mobilise. Their tolerance and patience with some very complex patients is humbling to witness. As the population ages, many of our patients, as well as having medical problems, have cognitive impairment or dementia. The nurses take the time to reassure these patients and encourage them to do as much as possible for themselves, working closely with their families. Many of these patients are frightened by change and their loss of independence. This sometimes results in behavioural challenges, which the staff take in their stride. The nurses here are also experts in end-of-life care, dealing with cancer and end-organ disease with a holistic approach. 

Our tea lady and domestic staff have been with us for years and their astute observations on who ate what or did what can be very informative. We are a close-knit little team and each individual is valued for what they offer to the service.

We can have contact with patients and relatives at all stages of care: home, Day Hospital and Community Hospital. 

Consequently, we have the opportunity to develop a good relationship and understanding of the patients’ conditions and families’ views.

Continuity of care is essential and often results in stopping unnecessary investigations and treatments, once a relationship and trust is established. 

It is often worth considering what an admission into an acute care ward will achieve. 

Older people with frailty can do badly in this noisy setting, getting little sleep, being frightened to mobilise in an alien environment and eating less than normal. Medical problems, hearing and visual impairment as well as infections acquired in acute hospital, resulting in prolonged admissions and delayed discharge,

We routinely check whether patients would like to attend our day center, wish for spiritual support, or to benefit from pet therapy, hand massage, music therapy or a range of services from the lovely volunteers at St Michael’s church. We are very grateful for our contact and long standing relationship with Linlithgow parish, without which many of our patients would have a much poorer experience at what is a very challenging time in their lives. Reverend Cheryl Mckellar-Young has been like the good fairy, coordinating all of the above.

We have extensively surveyed patients, carers and GPs and have had a 90 per cent satisfaction rating.

We believe that this approach to care in the frailest members of our community will soon be rolled out all over the country and that West Lothian has been at the forefront of these pioneering changes with REACT, and its enhanced use of our Day Hospital and Community Hospital. In November 2014 we won the health board award for Celebrating Success Team of The Year. It has been a privilege for me to be given this unique opportunity to help our frailest citizens.