Establishing an integrated model of subacute care for the frail elderly

Abstract

The current health system in Ontario is not designed to meet the needs of frail older adults. This is particularly true for older adults hospitalized due to exacerbation of chronic illness or medical crisis. This article describes the Subacute Care Unit for the Frail Elderly (SAFE) program, one which is designed to serve frail older patients who are at risk of deconditioning or disability associated with prolonged hospitalization but who may safely return home or to a retirement home following up to 4 weeks of subacute care in a restorative environment. The program centres on an intense restorative and integrated care delivery model. The patient population is medically complex, requiring medical supervision and regular adjustment to the care plan to optimize medical status. Individuals are no longer acutely ill and are considered stable or stabilizing. Care and services are designed to improve outcomes for hospitalized frail older adults by proactively addressing the conditions that contribute to alternate level of care before the deconditioning associated with prolonged hospitalization is experienced.

A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care

“…The Sub-Acute care for Frail Elderly (SAFE) Unit is a novel transitional care program offering function-focused care designed to address the persisting capacity issue within Ontario's hospitals. 13 It is located within a large, 450bed nursing home in Ontario, Canada, which primarily services aging Canadian veterans. As Canada is facing a decline in its older veteran population, the facility established the SAFE Unit in 2018 in partnership with local hospitals to explore how it may broaden its spectrum of care and add value to the local health care system.…”

“…Under this new program, hospitalized patients are transferred to the specialized 20-bed unit within the nursing home, where they can access the medical and restorative care provided by an interdisciplinary team consisting of nurses, internists, geriatricians, physiotherapists, and social workers to recover and return to their place of residence. 13 In addition, early discharge planning makes SAFE Unit unique from other existing transitional care programs; patients who may be eligible for the SAFE Unit are assessed and identified with return-to-home being the primary goal of care shortly following their admission to the hospital. 13 Furthermore, following their admission into the SAFE Unit, patients undergo cognitive screening and an overall frailty assessment to determine if there are other issues needed to be addressed during their stay.…”

“…13 In addition, early discharge planning makes SAFE Unit unique from other existing transitional care programs; patients who may be eligible for the SAFE Unit are assessed and identified with return-to-home being the primary goal of care shortly following their admission to the hospital. 13 Furthermore, following their admission into the SAFE Unit, patients undergo cognitive screening and an overall frailty assessment to determine if there are other issues needed to be addressed during their stay. This is especially important for older individuals with cognitive impairment or dementia, who may be discharged to the community without the provision of adequate supports that they may need.…”

Gestão de planos de cuidados a idosos: percepões de profissionais da saúde e assistência social acerca dos desafios e possibilidades de superação

“…A força desse movimento é chamada por Berntsen et al (2019) de "silver tsunami" ou "tsunami prata". Muitas sociedades não estão preparadas para atender às condições complexas que compõem a atenção aos idosos frágeis (Boutette et al, 2018;Berntsen et al, 2019). Além disso, problemas de saúde e vulnerabilidades em idosos tendem a ser mais frequentes (Paranhos;, impondo crescente demanda por serviços e desafios ao cuidado dessa população (Osborn et al, 2014;Nurjono et al, 2019).…”

“…Foi demonstrado que a participação em atividades de lazer, música e arte melhora o bem-estar físico, social e emocional dos pacientes idosos e aumenta o senso deles de pertencimento a uma comunidade. Ao serem oferecidos cuidados subagudos a pacientes idosos frágeis em um ambiente domiciliar, com cuidados prolongados, os pacientes podem restaurar sua funcionalidade com uma abordagem integral à pessoa, culminando em melhores resultados a um custo reduzido para o sistema de Saúde (Boutette et al, 2018). Berntsen et al (2019), Paranhos e Oliveira ( 2018), Kamei et al (2017) e Kuusisto et al (2019) propõem modelos de cuidados a pessoas idosas.…”