Health, social, and \201 nancial sequelae. Failures of treatment may have long-term wide- ranging effects (eg nursing home fees > 800/week) Co-pathology is common. For example, in the older patient with pneumonia and recent atypica l chest pain, make sure myocardial infarction (MI) is excluded (sepsis precipitates a hyper dynamic, hypercoagulable state, increasing the risk of acute coronary syndromes; and a prop ortion of atypical pain is cardiac in origin) Lack of physiological reserve. If physiological function is \200\230borderline \200\231 (i n terms of impacting lifestyle, or precipitating symptoms), minor deterioration may lead to signi \201 cant disability. Therefore, apparently minor improvements may disproportionate ly reduce disability. Identi \201 cation and correction of several minor disorders may yie ld dramatic bene \201 ts Investigating older people \200 Investigative procedures may be less well tolerated by ol der people. Thus the investigative pathway is more complex, with decision-making dependent on clinical presentation, sensitivity and speci \201 city of test, side effects and discomfort of the test, hazards of \200\230blind \200\231 treatment or \200\230watchful waiting \200\231 an d of course the wishes of the patient Consider the signi \201 cance of positive results. Fever of unknown cause is a common pres entation, and urinalysis a mandatory investigation. But what proportion of healthy, communi ty-dwelling, older women have asymptomatic bacteriuria and a positive dipstick? (A: around 30 % , depending on sample characteristics). Therefore in what proportion of older people p resenting with fever and a positive dipstick is urinary tract infection (UTI) the signi \201 cant pathology? (A: much less than 100 % ) The practical consequence of this is the under-treatment of non-urinary sepsis. ILLNESS IN OLDER PEOPLE 11 Treating disease in older people When treating disease in older people, they: \200 May be ne \201 t more than younger people from \200\230invasive \200\231 treatments \200\224 eg thrombolysis. On a super \201 cial level, think \200\230which is more important \200 \224 saving 10 % of the left ventricle (LV) of a patient with an ejection fraction (EF) of 60 % (perhaps a healthy 50 year old) or of a patient with an EF of 30 % (perhaps, an 80 yea r old with heart failure)? \200\231. Note that the signi \201 cant criterion here is more the LVEF than the age, the principle being that infarcting a poor LV may cause long-term di stress, morbidity, and mortality, whereas infarcting a part of a healthy myocardium may be without sequelae May bene \201 t less than younger people. Life expectancy and the balance of risks and bene \201 ts must be considered in decision-making. For example, the priority is unlikely to be control of hypertension in a frail 95 year old who is prone to falls May have more side effects to therapies. In coronary care: B -blockade, aspirin, angiotensi n-converting enzyme (ACE) inhibitors, thrombolysis and heparin may all have a greater life (and quality-of-life)-saving effect in older patients. Studies show these agents are underu sed in MI patients of all ages, but much more so in the elderly population. The frequency o f side effects (bradycardia and block, profound hypotension, renal impairment and bleeding) is greater in older people, although a signi \201 cant net bene \201 t remains May respond to treatment less immediately. Convalescence is slower, and the doctor may not see the eventual outcome of his/her work (the patient having been transferred to rehabilita tion, for example) \200 The natural history of many acute illnesses is recovery independe nt of medical intervention, particularly in the young. Beware false attributions and denial s of bene \201 t: \200 The older person frequently bene \201 ts from therapy, unwitness ed by medical staff The younger person recovers independent of medical efforts, though his/her recovery is falsely attributed to those interventions (by staff and patient) This page intentionally left blank 13 Chapter 2 Organizing geriatric services Using geriatric services 14 Acute services for older people 16 The older patient in intensi ve care 17 The great integration debate 18 Admission avoidance schemes 20 Day hospitals 22 Specialty clinics 24 Intermediate care 26 The National Service Framework for Older People 2 8 Community hospitals 30 Domiciliary (home) visits 32 HOW TO Do a domiciliary visit 33 Care homes 34 HOW TO Advise a patient about residential care 35 Funding of care homes 36 Delayed discharge 37 Home care 38 Informal carers 40 Other service s 42 Chronic disease management 44 Primary care 46 Careers in UK geriatric medicine 48 Dipl oma in Geriatric Medicine (DGM) 49 14 CHAPTER 2 Organizing geriatric services Using geriatric services Geriatric services have developed rapidly since the inception of t he specialty in the 1950s. They have different forms, depending on local resources, experts , and enthusiasts. Every district will offer different serv- ices, each with a different sp ectrum of options. There are some broader national differences within the UK; services in S cotland and Northern Ireland lean more towards rehabilitation and long-term care than those in England and Wales. The following is intended as a generic guide to utilizing geriatric services in the UK. Diversity will limit applicability. Services for acute problems Urgent assessment of the acutely unwell patient, where the dise ase process is new and severe (eg acute MI, stroke) or the deterioration is rapid (eg delir ium). Examples: General practitioner (GP) emergency services (see b \200\230Primary care \200\231, p.46) Emergency departments (EDs; see b \200\230Acute services for older people \200\231, p.16) Acute medical admission service \200 Rapid Access (admission avoidance) services (see b \200\230Admission avoidance schemes \200\231, p.20) Urgent domiciliary visits (see b \200\230HOW TO Do a domiciliary visit \200\231, p.33) Choosing which is most appropriate will depend on patient characteristics (eg if unstable, then an ambulance to an ED is appropriate; if no change is expected over a few days then ur gent outpatient assessment may be used) and local service characteristics (availability of urgent clinic slots etc). Services for sub-acute problems Assessment of a patient with a progressive disease process (eg increasing falls, worsening Parkinson \200\231s in a frail patient) or unexplained pote ntially serious problems (eg iron de \201 ciency anemia, weight loss) or for diagnosis and management plan (eg cardiac failure). Examples: Routine outpatients \200 Specialty clinics (see b \200\230Specialty clinics \200\231, p. 24) \200 Day hospital (see b \200\230Day hospitals \200\231, p.22) \200 Intermediate c are facilities (see b \200\230Intermediate care \200\231, p.26) \200 Elective admission (to acute hospital, rehabilitation wards or community hospital) Domiciliary visits (see b \200\230HOW TO Do a domiciliary visit \200\231, p.33) Agai n, choice of service will depend on patient factors. Single organ problems can be referred to specialist clinics, less well-de \201 ned medical problems to a geriatric outpatients, and problems suggesting the need of multidisciplinary input to the day hospital. Local avai lability, waiting times and consultant interests will also affect choice \200\224 while mo st cardiologists have chest pain clinics, not all will run heart failure services, which ma y be provided by general physicians or geriatricians. USING GERIATRIC SERVICES 15 Services for chronic problems This includes active, elective management of slowly progressi ve conditions by GPs, community teams, specialist nurses, and secondary care physicians (se e b \200\230Chronic disease management \200\231, p.44) and the provision of care for estab lished need. Care may be provided by a number of means: \200 Informal carers (see b \200\230Informal carers \200\231, p.40) \200 Home care and care agencies (see b \200\230Home care \200 \231, p.38) \200 Day centers (see b \200\230Other services \200\231, p.42) \200 Respit e care (in care homes or hospitals) (see Box 2.1) \200 Care homes (see b \200\230Care ho mes \200\231, p.34) Allocation of these usually long-term services is generally after an as sessment of need and \201 nancial status by a care manager. Most patients will pass through many aspects of this care spectrum with time, and a \202 exible, reactive service with good communication between providers is essential. The \202 ow diagram (Fig. 2.1 ) schematically represents possible patient \202 ows through the sy stem. Fig. 2.1 An example of a comprehensive geriatric service. 16 CHAPTER 2 Organizing geriatric services Acute services for older people Since older people present atypically, and are at high risk of serious sequelae of illness, high-quality acute services that fully meet their needs ar e essential. In any setting, older people have special needs. Their needs, and the conseque nces of not meeting them, are ampli \201 ed in the setting of acute illness. Speci \201 c areas meriting attention include pressure area care, prevention and treatment of delirium, and optimal nutrition and hydra- tion. Accurate early and comprehensive diagnosis(es) is e ssential. An acutely unwell older person may present to one of several services depending on: \200 Local service provision \200 The individual s understanding of the s ystem \200 Advice from others (eg relatives, health professionals, NHS Direct) Any servic e aiming to diagnose acute illness in older people must have access to immediate plain radi ography, electrocardiography (ECG), and \200\230basic \200\231 blood tests (including prom pt results). Specialist clinical assessment (geriatrician, urologist, neurologist, etc.) an d more advanced diagnostics (eg ultrasound, computed tomography (CT), magnetic resonance im aging (MRI)) must be available on a prompt referral basis, although may be on another site. Emergency department (accident and emergency) Older people present commonly to the ED with falls, fractures, \201 ts, and faints, as well as a broad range of acute surgical and med ical problems traditionally referred directly by GPs to surgical or medical teams. Direct r eferrals of such patients to ED are increasing, as a result of changes in GP out-of-hours s ervices, advice by agencies such as NHS Direct, and changing public behavior. 2The ED is po tentially inhospitable and dangerous for older people. The environment may be cold, uncomfo rtable, disorientating, and lacking dignity and privacy. There is a risk of pressure sores developing due to long waits on hard chairs and trolleys. Provision and administration of f ood and \202 uid may be neglected, or inappropriately prohibited on medical grounds. A me dical model of care may presume serious illness, prioritizing immobility, invasive monitori ng and treatments, at the expense of a more holistic approach that appreciates the downside of these interventions. Staff may be experts in emergency medical management, but their ex per- tise in geriatric medicine and nursing is variable. Deadlines and targets that minimiz e time spent in ED on trolleys (eg the 4hr wait rule) may well bene \201 t older ED users. Strategies to optimize care for older people in ED might include: Close liaison with geriatric medical and nursing specialists \200 Medical and nursing rot ation between ED and geriatric medical wards \200 Focus on optimizing food and \202 uid provision and pressure care \200 Provision of alternative modes of admission and assessm ent, eg Rapid Access Clinic, direct admission to geriatric ward \200 Provision of specialist geriatric assessment unit \200 Occupational therapist, physiotherapist, and social worker with expertise in older people based in ED THE OLDER PATIENT IN INTENSIVE CARE 17 The older patient in intensive care With the aging population and a reduction in overt and covert ageism, a greater proportion of intensive care unit (ITU) and high dependence units (HDU) beds are occupied by older patients. However, they remain a rarity with <3 % of most ITU admissions in the UK for patients aged > 85. 2Age alone is a weak predictor of outcome and should not be used as the sole reason to deny ITU/HDU care. Frailty scores provide more accu- rate prognostic information. Patients with multiorgan failure especially in the cont ext of frailty will not do well on ITU. Older patients with the following should be considered for ITU/HDU: Postoperative \200 Septicaemia \200 Post cardiac arrest/life-threatening arrhythmia \200 Acute drug effects or overdose \200 Intensive monitoring eg acute MI or stroke thro mbolysis \200 Ventilatory support, eg pneumonia or pulmonary oedema If in doubt discuss y our case with ITU physicians. Even where patients are unsuitable for admission to ITU, the intensive care specialists and their outreach team may be able to offer advice. The use of early warning scores (EWS) (which are designed to detect patients in pre or peri- arrest si tuations) in parallel with escalation/trigger systems (to prompt timely management decision s) is growing. This trend may well increase the involvement of intensivists in the manageme nt of critically unwell frail elderly people. 2Remember that older, frailer patients are mo re likely to refuse inten- sive treatment so always enquire, from the patient if possible, or the rela- tives about any advanced refusal of intensive treatment (see b \200\230Advanc e directives \200\231, p.664). 18 CHAPTER 2 Organizing geriatric services The great integration debate There has been a longstanding debate among UK geriatricians ab out the best model of care for older people in hospital. Historically, age-related care gre w out of workhouse facilities and the advent of care provided in mainstream institutions wa s a major step against ageism. The provi- sion of age-related services on the same site and with equal facilities to facilities developed. This de \201 ed the label of ageism and pr ofessed other advantages. Traditionally care has been divided into either \200\230age-rela ted \200\231 or \200\230integrated \200\231 but there are many shades of gray in between t hese two extremes, usually developing locally in response to manpower restraints, ward avai lability, and the enthusiasm of individuals. The two \200\230pure \200\231 systems may be described as follows: \200 Age-related care . A separate team of admitting doctors to dea l with all patients over a certain age (varies \200\224 commonly around 75 years) who then care for these patients on designated geriatric wards \200 Integrated care , In truly in tegrated care, specialists will all maintain additional generalist skills. These generalist s will admit all medical patients regardless of age and continue looking after them on gene ral medical wards, in parallel with specialist clinical commitments (See Table 2.1 for advantages and disadvantages of each system.) The debate has never been fueled by any evidence (there are no studies comparing systems) a nd it has become less fevered recently as the reduction in junior doctors \200\231 working hours has made it impractical in many hospitals to run two entirely separate teams. As a re sult various hybrid systems have grown up, managing patients pragmatically and sampling the best aspects of both the systems. A common compromise is that there is integrated acute assessment, with a single admitting t eam, but rapid dispersal to the most appropriate service \200\224 gastroenterology for a p atient with acute gastrointestinal bleed, cardiology for acute MI, and acute geriatric medi cine for a confused elderly patient etc. This dispersal may be done at a variety of levels and times, again depending on local service strengths and constraints. Models include triag e of need ( \200\230needs \200\231 or \200\230function \200\231 related segregation) by an appropriate person immediately after admission (admitting specialist registrar (SpR), expe rienced nurse, bed-manager, etc.), dispersal by a ward allocation system after removal from the admitting ward or over a period of a few days (by inter-specialty referral) as the spe cial needs become apparent. As individual systems evolve, the debate recedes and energies are invested into providing t he best possible care for all patients through innovation and \202 exibility within a cer tain hospital structure, rather than in drawing boundaries and maintaining rigid de \201 n itions. Vigilance against ageism in these evolving systems remains essential. THE GREAT INTEGRATION DEBATE 19 Table 2.1 Comparison of age-related and integrated care Age-related care Advantages Potential drawbacks All old people seen by doctors with a special interest in their care Possibility of a two-tier standard of medical care developing, with patients in geriatric m edicine settings having lower priority and access to acute investigation and management fac ilities Less specialist knowledge in those doctors providing day-to-day care All old people looked after on wards where there is a multi-disciplinary team May be stigmatizing for all patients of a certain age to be de \201 ned as \200\230geriat ric \200\231 Even apparently straightforward problems in older patients are likely to have social rami \201 cations that are proactively managed May be less kudos and respect for geriatric medicine practitioners Integrated care Advantages Potential drawbacks Many generalists will not be skilled in the management of older patients, so those under th eir care may not fare as well As the majority of patients coming to the hospital are elderly, it maintains an appropriate skill base and joint responsibility for their care Specialist commitments are likely to take priority over the care of older patients There is equal access to all acute investigative and maintenance facilities, as older patie nts are not labeled as a separate group The multidisciplinary team input is harder to coordinate effectively where the patients are widely dispersed Trainees from all medical specialties will have exposure to and training in geriatric medic ine assessment Sharing of specialist knowledge is more collaborative and informal Management of the social consequences of disease tends to be reactive (to crisis) rather th an proactive 20 CHAPTER 2 Organizing geriatric services Admission avoidance schemes Admission avoidance schemes (AAS) are very variable in content and name. Schemes may be divided into those that do and do not offer spe- cialist geriatric assessment (provided by a geriatrician, a GP with a special interest, or a geriatric speci alist nurse). Non-medically based schemes These may include emergency provision of carers, district nurse , occupa- tional therapy and physiotherapy, delivering, eg, prompt functional assess- ment and increased care after a fall. As medical assessment is not a part of the scheme, treatab le illness may be missed. As a minimum such schemes should incorporate assessments by healt hcare professionals who can rec- ognize the need for specialist geriatric assessment and ca n access such services promptly. Schemes with a medical assessment \200 Variously titled Early Assessment, Rapid Assessmen t, Emergency or Rapid Access clinics All aim to provide a prompt response to medical need in older people, with acuity falling s omewhere between immediate admission and more elective outpatient services Few schemes aim to provide same-day assessment, most aiming to see patients within 1 week of referral, and at best the next day \200 There is an assumption that patients are midway between \201 rst symptoms and severe disease, and that early intervention may prevent decline, permit less a ggressive or invasive treatment, and permit the patient to remain safely at home Services are best accessed via telephoned, faxed or electronic referral, with prompt assess ment of the content of and response to referrals by an experienced professional 2There is a risk that acutely unwell older people who need emer- gency assessment or treatm ent are referred to AAS rather than admitted immediately. If in doubt, admit to the emergen cy medical/geriatric medi- cine team. Delirium is an example of a presentation where admiss ion to hospital from home is usually required. \200 In practice, most AAS do have to admi t a modest proportion of patients to hospital directly. In some cases this represents optimal care, but in others it introduces a dangerous delay to a clinical situation \200 AAS staf \201 ng usually incl udes senior medical staff ( junior support). Experienced nursing assistance is invaluabl e, perhaps in the form of a nurse practitioner. Nursing roles are variable but may be very extended, to include history taking and physical and mental state examination Most commonly, AAS are housed in \200\230general \200\231 outpatient facilities. Examples of problems managed here include anemia or breathlessness A more comprehensive geriatric response (see b \200\230Comprehensive geriatric assessment \200\231, p.70) is facilitated when AAS is housed in or adjacent to outpatient multidiscipl inary services, eg Day Hospital ADMISSION AVOIDANCE SCHEMES 21 AAS should have prompt (ideally same day) access to occupational and physiotherapy services , to support the patient at home whilst the effect of medical interventions become apparent . Patients with complex needs are best managed in this environment, eg Parkinson s disease with on/off periods 22 CHAPTER 2 Organizing geriatric services Day hospitals Day hospitals (DHs) provide services that lie somewhere between outpa- tients and inpatients. Patients stay for half or a full day and the primary aim is to regain or i mprove independence for a group of frail elderly people with complex needs. The case mix and interventions vary widely between units but can include: \200 Medical \200\224 new patient assessments, eg for falls, weight loss, anemi a, as well as chronic disease management, eg heart failure, parkinsonism Nursing \200\224 eg pressure sore and leg ulcer treatment \200 Physiotherapy \200\224 e g following stroke, fracture, surgery \200 Occupational therapy \200 Diagnostics \200 \224 facilities for usual blood tests, radiology, et. and also speci \201 c therapeutic trials, eg levodopa Treatments \200\224 eg blood transfusions, intravenous furosemide infusions A \202 exibl e and holistic attitude is required and many DH clients will take advantage of multiple dif ferent services in a \200\230one-stop-shop \200\231 approach. There is usually a mixture o f new patient assessments, rehabilitation, and chronic disease management. Patients may be referred directly from the community or from other outpatient settings or may be booked for a follow-up after an inpatient stay. Some units have designated sessions for speci \201 c patient types or services (eg movement disorder clinic, admission avoidance clinic). Multi disciplinary teamwork and comprehensive geri- atric assessment (see b \200\230Comprehensiv e geriatric assessment \200\231, p.70) and functional goal setting are all important tools. History and evolution The \201 rst DHs were set up in 1960s. In their heyday many units h ad col- lected a huge number of patients who were very frail but had little active interven tion and used their visits as social occasions or respite for carers. Unacceptably long wai ting lists hindered ef \201 cient running in some units. Transportation problems often pro ved to be a weak point, with patients spending lengthy periods of time waiting for, or duri ng transportation. The monitoring/supporting role has now been largely taken over by day centers (see b \200 \230Other services \200\231, p.42) and modern DHs tend to have a high ratio of new:old pati ents and a rapid turnover. Increasing pressure on acute hospitals has opened up the role of rapid access admission avoidance clinics and early supported discharge schemes. Intermedia te services development, following the national service framework (NSF), has sometimes augm ented services (eg falls services) and sometimes denuded them (eg where outreach services h ave taken over). DAY HOSPITALS 23 Cost effectiveness Pressures to justify the expense of day hospital places led to a \202 urry of publications looking at effectiveness and cost-effectiveness. While this area remai ns controversial a systematic review in 2008 found that DH patients did have less functiona l deterioration, lower rates of institution- alization and hospital admission than control groups receiving no care. However DHs did not prove superior to other comprehensive care se rv- ices (eg domiciliary rehabilitation). DH care is costly but this may be offset by decre ased inpatient bed usage and institutionalization or social care costs. It is very importan t to ensure this expensive resource is targeted effectively and regularly evaluated to ensu re cost-ef \201 ciency. Further reading Forster A , Young J , Lambley R , Langhorne P . ( 2008 ). Medical day hospi tal care for the elderly versus alternative forms of care . Cochrane Database Systematic Review 4 : CD001730 . 24 CHAPTER 2 Organizing geriatric services Specialty clinics Every region will have different resources, but most will have some speci alty clinics run by geriatricians, by other specialists, or occasionally combined clinics r un by more than one specialty. Examples of clinics are shown in Table 2.2 . The advantages of specialty clinics are many: \200 Usually simple referral protocol \200 Concentration of expertise \200 Increased training opportunity for juniors \200 Often specialist nur sing staff \200 Increased patient education and awareness of the condition \200\224 thro ugh meeting others with the same diagnosis, through the work of specialist nurses and throu gh the availability of information lea \202 ets May utilize a rapid access investigation slot on a regular basis (eg carotid Doppler ultrasound in transient ischaemic attack (TIA) clinics) Increased use of protocols (may improve quality of care) \200 Often rapid turnover Where the same clinic is offered by different specialties, or where you are unsure if a referral to a geriatrician or an organ specialist is most appropriate, ask the following: \200 Is this a new or urgent problem? There are an increasing number of clinics with a protocol-de \201 ned maximum waiting time for the urgent assessment of pati ents. These may prevent admissions and allow rapid outpatient management of many conditions (eg TIA, chest pain, possible malignancy) but are prone to being overwhelmed with referral s thereby rendering them less responsive to the needs of the truly urgent cases. Non-urgent cases should be referred to standard outpatient clinics Is the diagnosis likely to be clear-cut? A \201 t patient with cardiac sounding chest pai n should go to a cardiology-run clinic, as they will have the fastest access to the appropr iate expertise and investigations. If the pain is more nebulous, then waiting for a chest p ain clinic appointment only to be given the diagnosis \200\230non-cardiac chest pain \200 \231 is unhelpful. Such a patient is better seen in a more general (usually geriatric) clin ic \200 Does this patient have a single problem? If so, then they are likely to do well in a clinic run by an organ specialist. If, however, they are frail, with multiple pat hologies then a geriatric clinic may be better. Here there is time to for example, undress the patient properly, and assess them fully as the allocation time per new patient is likel y to be longer. There is also less likely to be a protocol driven response to a single prob lem without looking at the wider picture (eg prescription of multiple medications for angin a in a patient prone to falls) Is this patient already attending a geriatric clinic for follow-up? If so, most new problem s can be addressed by that team rather than referring to another specialty SPECIALTY CLINICS 25 Table 2.2 Examples of specialty clinics Clinic Run by TIA/stroke Geriatrician Neurologist Stroke physician Movement disorders (Parkinson \200\231s) Geriatrician Neurologist Chest pain Cardiologist Cardiac failure Geriatrician Cardiologist General physician Abnormal chest X-ray/haemoptysis Chest physician Lower gastrointestinal bleeding/query lower gastrointestinal malignancy Gastrointestinal surgeon Upper gastrointestinal bleeding/query other gastrointestinal malignancy Gastroenterologist Breast lump Breast surgeon Leg ulcers Dermatologist Geriatrician Falls/syncope Geriatrician Memory Geriatrician Psychogeriatrician Neurologist 26 CHAPTER 2 Organizing geriatric services Intermediate care There is no universally acknowledged de \201 nition of \200\230intermed iate care \200\231. It is used to describe almost any sort of care which lies between an ac ute inpatient stay and usual primary care. The term \201 rst came into general use in 200 1 after the NSF described it as a major strategy for improving healthcare and the UK govern ment promised to invest 900 million over 5 years to implement it. In many instances this led to a re-badging of existing services but there were also an assortment of new and often innovative approaches. While many geriatricians welcomed the emphasis on non-hospital-based geriatric medicine oth ers have warned against intermediate care being a covert form of ageism which allows ration ing of acute hospital medicine in favor of less expensive and often less effective care. Intermediate care is for patients who do not \201 t into either acute or chronic/stable c ategories, although these overlap. The emphasis of intermediate care tends to be not primar ily medical but multidisciplinary and holistic. There are two main bodies of patients: \200 Those requiring rehabilitation, re-housing, or both in a post-acute illness setting \200\224 usually recruited from acute wards \200\224 \200\230step-down \200\231 care Community dwelling patients who require nursing/therapy input, often following an acute or subacute deterioration, in order to avoid a hospital stay \200 \224 \200\230step-up \200\231 care or admission-avoidance The arrangement of intermediate care teams has been developed locally and varies enormously in staf \201 ng, facilities, ethos, and access. Some projects concentrate on very speci \201 c groups (eg post-surgical fractured neck of femur in the > 70 year olds) while others are more generic. Most regions have several complementary services. Examples of popular mo dels are: \200 Discharge coordinating teams \200\224 nurse, therapy or social work teams that bridge the interface between hospital and community based services. They often act as gatekeepers for rehabilitation/community beds or supported discharge schemes Hospital-at-home schemes \200\224 where intensive nursing and/or therapy input in the pati ents home can allow a patient to receive treatment without the need for admission to hospit al or be discharged earlier Front door teams \200\224 that recruit elderly patients from accident and emergency and assessment wards to improve assessment (eg provide an occupational therapy (O T)/physio assessment following a fall) and to make referrals to other services such as soci al workers, clinics, etc. Purchase of care home beds \200\224 often with multidisciplinary or social worker input of ten for step-down of patients awaiting social care provision or care home placement Intermediate care can occur in different environments, eg: \200 Nursing outside the acute care setting in traditional community/cottage hospitals, nursing homes, or even residential homes Patient \200\231s own home \200 DH or other therapy-based sites INTERMEDIATE CARE 27 Interventions in intermediate care are often based around a comprehensive geriatric assessm ent (see b \200\230Comprehensive geriatric assessment \200\231, p.70) by a multidisciplina ry team. However, more specialized services can be pro- vided by individuals or teams that are missing some vital members (particu- larly medical or social work) and care is needed t hat important interventions (such as treatable illnesses or unclaimed bene \201 ts) are no t overlooked. The variety of different models makes it very hard to promote equity of access or research into the effectiveness and cost-effectiveness of the service. While it has been shown possi ble to provide almost all kinds of geriatric care in a community setting this does not nece ssarily mean that it is more effective, cost-ef \201 cient, or even preferable for patient , family, and staff. Research designed to answer these questions is sparse and contradictor y. Single assessment process This term was introduced in the NSF for older people. The idea is a simple one \200\224 \200\230multidisciplinary, interagency assessment of needs ensurin g that the elderly receive the relevant services, in an integrated way \200\231. The main a im was to avoid professionals duplicating their assessments, eg when a patient moves betwee n hospital and community settings. The initial milestone for introducing single assessment process (SAP) was April 2004. Unfortunately the assessment systems at the heart of health and social security proved much more resistant to change than was anticipated. Geographical variations in systems, distrus t between different agencies, as well as antiquated technology, has meant that the SAP curr ently exists only as multiple pilot schemes throughout the UK. Further reading Steinher A . ( 2001 ). Intermediate care \200\224 a good thing ? Age and A geing 30 \200\223 S3 : 33 \200\223 39 . Young JB , Robinson M , Chell S , et al . ( 2005 ). A whole system study of Intermediate care services for older people . Age and Ageing 34 : 577 \200\223 583 . 28 CHAPTER 2 Organizing geriatric services The National Service Framework for Older People This huge document (over 200 pages) was pub lished by the Department of Health in March 2001. It was one of the \201 rst NSFs to be p roduced and set out the government \200\231s agenda to improve health and social services f or the elderly with milestones (ie deadlines for service changes) stretching over the follo wing 4 years. There are eight standards. 1 Rooting out age discrimination \200\230NHS services will be provided, regardless of age, on the basis of clinical need alone. Social care services will not use age in their eligib ility criteria or policies that restrict access to available services. \200\231 This key standard was widely welcomed and has proved useful in audits with the aim of remov ing explicit (written policy) ageism in, eg, access to diagnostic services or treatments. I mplicit ageism is harder to tackle. 2 Person-centered care \200\230NHS and social services treat older people as individuals a nd enable them to make choices about their own care. \200\231 This incorporated the introduction of the Single Assessment Process as well as some ideas a bout shared commissioning of care and equipment between different government agencies. Many of the goal \200\231s planned reforms in this standard have had, at best, patchy implement ation. 3 Intermediate care \200\230Older people will have access to a new range of intermediate c are services at home or in designated care settings to promote their independence pre vent unnecessary hospital admission and effective rehabilitation services to enable early d ischarge and prevent premature or unnecessary admission to long-term residential care . \200\231 This standard was accompanied by earmarked funding to develop services and run 5000 new int ermediate care beds. It was the most controversial of the standards with many geriatricians arguing that the result of such services would be reduced access to acute hospital care \200\224 indeed one target relates to a reduction in the rate of rise of older persons \200 \231 admissions. 4 General hospital care \200\230 appropriate specialist care by hospital staff who h ave the right set of skills to meet their needs. \200\231 All hospitals should have a specialist multidisciplinary team for older people with appropriate training. 5 Stroke \200\230 action to prevent strokes access to diagnostic services and treated appropriately by a specialist stroke service program of secondary prevention and rehabilitation. \200\231 This standard has helped drive the development of stroke units (required in all hospitals b y 2004 although not fully achieved) and TIA clinics. THE NATIONAL SERVICE FRAMEWORK FOR OLDER PEOPLE 29 6 Falls \200\230 action to prevent falls and reduce resultant fractures or other inj uries. Older people who have fallen receive effective treatment and advice on prevent ion through a specialist falls service. \200\231 The development of falls services has lagged well behind the suggested timeframe. 7 Mental health in older people \200\230 access to integrated mental health services To ensure effective diag- nosis, treatment and support \200\231 Promotes integrated depression and dementia services. 8 The promotion of health and active life in older age \200\230 through a co-ordinat ed program of action led by the NHS with support from councils. \200\231 Targets related to \202 u vaccination, smoking cessation and blood pressure treatment etc are largely implemented in general practice where they are reinforced by the new GP contra ct (Box 2.2 ). Medicines and older people An additional document on medicine and older people stated that older people should: \200\230 gain the maximum bene \201 t from medication and not suffer unnecess arily from illness caused by excessive, inappropriate or inadequate consumption of medicine s. \200\231 It included a drugstore-led \200\230medicines review \200\231 for at-risk elderly people. As with many other NSFs, translating policy into change has been only partially successful but there is no doubt that the older people \200\231s health and social services today have been in \202 uenced by this important document. None of the other NSFs exclusively address the health of older people but more recent docum ents, eg the NSF for long-term conditions (2005), the NSF for chronic obstructive pulmonary disease (COPD) (2009), have much of relevance to older people. There have been a series of UK government regulation and inspection bodies which use NSFs and other legal and quality standards as guides: \200 Commission fo r Health Improvement (CHI): 2001 \200\2232004 \200 Commission for Health Care Audit and I nspection (CHAI): 2004 \200\2232009 \200 Care Quality Commission: 2009 to date Further reading National Service Framework online : M www.dh.gov.uk . Evans JG , Tallis , R C . ( 2001 ). A new beginning for care for elderly people? \200\224 and related correspondence . BMJ 322 : 807 \200\223 808 . Healthcare Commission online : M www.healthcarecommission.org.uk . 30 CHAPTER 2 Organizing geriatric services