Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Skill Building
- Ned Hoke (3 July 2003)
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chronic disease management and long term care
- Paddy Quail (5 July 2003)
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Looking at careers rather than episode
- George E Pickett (10 July 2003)
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Chronic Disease or chronic health?
- Sue B R Hood (15 July 2003)
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not a case for private care
- gareth h jones (29 July 2003)
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Ned Hoke, Ecological medicine/private Western USA
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Cost focus and clinical realities argue for such thoughts as these. The excitement and heroism in acute care in the vastly productive past century remain functionally poorly schooled in chronic care management except in layering pharmaceutical strategies. This simply isn't enough and is often wrong-headed or only fractionally significant. The genuine medical needs cost human time and attention. Less gives a factory floor cold feeling to the process. Competing interests: None declared |
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Paddy Quail, Clincal Assistant Professor University of Calgary 301, 1640 16th Avenue NW Calgary Alberta T2M0l6 Canada
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I applaud Dr Kanes initiative. Nursing homes make excellent laboratories for new health services initiatives and research. Not only do they have a mostly compliant patient base but also an in-house resident staff that can provide a high level of surveillance, monitoring and intervention. Having an advanced practice nurse or nurse practitioner who can respond to episodic clinical need would seem to make intuitive sense in the early management of a change in chronic disease state. Of course the ability to effect significant change in clinical outcomes is based partly on a higher mortality and shorter length of stay within the nursing home population ( average length of stay was 2.1 years in the Calgary region in 2001) . Our patients are coming in 'quicker and sicker' as the popular aphorism goes. The more critical question to be addressed is what are the individualized care and treatment wishes of our patients? How will a specific treatment improve a patients quality of life and how might it extend or diminish a patients remaining life? This of course is not meant to imply clinical nihilism. We have witnessed many improvements in clinical care in our nursing homes over the past 10 years for example through more aggressive influenza outbreak policies , more critical anti- psychotic use and a greater understanding of end of life dementia care. The most pressing issues facing nursing homes today are those of inadequate human resources across the sector, an aging workforce and a cultural move away from facility based care. In other words the incentives to work or reside in our facilities have changed. Long term care in many ways is under siege and is now mostly the preserve of the most disabled and the most needy. I would ask Dr Kane what the cost of his intervention was in terms of staffing and staffing mix ( if presumably more intensive care is required for that 50% who were not transferred) and where does the clinical responsibility lie in regard to the attending physician staff and the nurse practitioner? I would argue that we need greater physician participation in this care not less to effect meaningful change for our patients at the bedside and at the policy development level. As our nursing home bed capacity grows at a slower rate than the population we serve we are experiencing heavier personal and professional care needs and even shorter lengths of stay. Avoiding hospital admission, therefore, is increasingly a palliative choice not necessarily the result of earlier clinical interventions from staff with advanced training or from in-house medical staff. My contention would be that chronic disease management needs to be considered and initiated at an earlier age in the dementia and chronic disease trajectory. I would suggest this occur in the community through partnerships with community based nursing, enhanced specialist access, decentralized clinics and through the leadership of family physicians and general practitioners. In our demonstration projects in the Calgary region we are using such models to provide support to family physicians where it really counts, in the community at the doctors offices. I propose that we concentrate our efforts in this direction and look towards improving the quality of life of our nursing home patients. Dr Rosalie Kane [1] described parameters one might use to measure such quality of life in the Gerontologist in 2001. She challenged the reader to consider quality of life over quality of care in support of more meaningful patient based care. In a climate of shrinking health care budgets and patient choice I would advocate a greater emphasis on the dimensions of care she has outlined i.e. dignity, privacy, autonomy, choice, meaningful activity, relationships, comfort, enjoyment , individuality, functional competence, sense of security, and spiritual well being. Furthermore I would suggest that this may be preferred to a greater medicalization in the management of chronic disease in the nursing home setting at the end of life. [1] Kane RA. Long-term care and a good quality of life: bringing them closer together. Gerontologist. 2001 Jun;41(3):293-304. Dr Paddy Quail MB CCFP Medical Director Home Care Calgary Health Region 403 221 4370 Competing interests: None declared |
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George E Pickett, Retired, consultant Charleston, WV 25301
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Dr. Kane has provided yet another splendid insight into American Medical Care. Newer, organized systems of medical care focus on transactions and episodes. This can only lead to heightened concern for productivity and through-put. It is essential that we begin to consider "career" costs and outcomes both for chronic and acute care. Competing interests: None declared |
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Sue B R Hood, Medical Admin Tekhnicon House Braintree CM7 2YN
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Prof Kane makes a move in the right direction but could go further. What is needed is to determine what causes those with chronic problems to relapse. It may be that we need to look at health rather than disease. What are the factors that cause deterioration? Is drug usage implicated in illness - does medication interact or produce adverse effects (for example dizziness) which lead to loss of welbeing. Is the development of "illness" the only way that the elderly get attention? The sick model may be outmoded - we may need to concentrate on what factors cause the change from just about coping to "ill" and intervene before it is too late. Care staff rather than nursing staff may need the training and the responsibility for this. They may also be able to supply the solution in terms of more contact or encouragement or simple patient advocacy! Competing interests: None declared |
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gareth h jones, retired consultant psychiatrist none
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EDITOR- Richard Smith's News1 of Prof. Robert Kane's Evercare programme for the frail elderly needs to be examined critically.
In a closely related field, systems of care for psychiatric patients, often in sheltered accommodation, have been subject to controlled trials. Assertive Outreach2 is the latest of these, designed to support at home, to review regularly, and to avoid hospital admission by intensive home care when necessary. This has all been developed within the NHS, so that private healthcare is not necessary. Indeed, the PFI replacement of the Edinburgh Royal Infirmary3 has been so expensive that its early problems have affected the healthcare resources of the rest of Scotland4. Another USA "Carve-out" program in Tennessee for psychotic patients5, designed to contain costs, led to a loss of the continuity of their antipsychotic therapy due to a lack of continuity of doctors and nurses employed by the programme, though other States may have done better. Gareth H. Jones 1 Smith R. Improving the management of chronic disease. BMJ 2003;327:12. (05 July.) 2 Burns T, Firn M. Assertive Outreach in Mental Health: a manual for practitioners. Oxford: Oxford University Press, 2002. 3 Dunnigan M, Pollock A. Downsizing of acute inpatient beds associated with private finance initiative.BMJ 2003;326: 905. 4 Black E. Inspection at new hospital reveals series of problems. The Scotsman 2003: Mon 30 June. 5 Ray WA, Daugherty JR, Meador KG. Effect of a mental health "Carve- out" program on the continuity of antipsychotic therapy. NEJM 2003;348: 1885-94. Competing interests: None declared |
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