Wednesday, 15 November 2017

Why Certain Care Homes Are The Worst Places For Our Elderly.

Why Certain Care Homes Are The Worst Places For Our Elderly.                                                             Soumya Nair  

An investigation by Soumya Nair, has shown that the knowledge, skills and availability of care workers in care homes (nursing homes) are ill-matched to the care needs of residents. She was appalled at the “shocking evidence” of understaffing, bad practice and poor care. This article is an eye-opener to the policy makers as well as to the public about the  woefully inadequate care standards and practices in many so-called “Care Homes”.

Soumya as part of her study has underlined the inadequate quality of care in examples of Indian care homes that failed their standards. She found a “systematic failure in all areas of assessment and monitoring of people’s care, resulting in risks to people’s health and wellbeing”.

Care-Homes, rightly as the name suggests, it should be a Home with Compassionate Care, no matter what it takes. Elderly care home business is the upcoming next big business to corporate hospitals. and other allied  health care sectors. Past decade, what was known to us as simple old age homes have converted into fancy elderly care homes. Many failed real estate businesses has refurbished and sold as elderly care facilities, with fancy resort like features, sans care. Increasing demand is certainly an influencing aspect. Many factors attribute to this new phenomenon like increase in number of older adults who needs care, shrinking urban filial support system, space constraints, complex medical conditions that demands institutionalized care, challenges to provide professional care at home or simply because the older adult seek independent community living after retirement. Whatever be the compulsion, once chose to live in an institutional set up, your health and well-being is directly proportional to the professional care standards followed by the respective institution.

I was visiting old age homes in the city as part of my study on care settings and standards for elderly. I happened to visit an old age home, which operates out of an enormous three-storied building with a signboard, said Ashirvad old age home.  On my arrival I was shocked to my wits to see the entire building is locked up, including the gates, doors and the windows, building had balconies in every room but found them tightly shut making it impossible for fresh air or light enter the building!

Let me introduce Ganapathy, a hapless inmate who caught in the vortex of an unfortunate situation called ‘messed up old age’.  I found this frail old man holding to the gate railing with a broken walker in front of him. Shabbily dressed with ruffled hair not combed for days, his sharp sweat stinking body odor was a clear indication that he had not had his bath for days. I advanced a conversation to make an inquiry if I can meet someone at the premises to get information of the old age home, the first thing he said without bothering to lend an ear to what I asked him “can I have something to eat”? It terribly shocked me. Though I was hurt for that moment, held back my saddened face made a special effort to sound everything was normal, hurried to the car to fetch him my lunch box with an encouraging smile.

After he ate the food in one breath, I tried speaking to him to understand the realities. He is a stroke survivor with minimal dependency but needs assistance for bathing, eating and toileting, he says he is not been given bath since one week and not fed since days. He walked me through his family dynamics and about his dispassionate children. He broke down into tears before he completed what he was saying. Ganapathy is a retiree from the Armed forces served the country from the extreme difficult border areas. A widower survived by a son and a daughter. Mr. Ganapathy is a pensioner and both his children are well provided for. Son is a videography professional and an entrepreneur, daughter an acclaimed teacher in a famous school in the city. Though Ganapathy toiled all his life at the boarders fighting for the country to make sure his children will get a good living and education. He ensured both the children are educated and well settled, he believed his children would become a solace when he really needs help but his children failed his old age plans. Being confident about the children, he never had a plan B.

He complained to his son about the poor care and dirty living conditions at the old age home and expressed his desire to leave the place but there was no hope. Ganapathy’s only son finds this place economical and the incurred expenses are covered well within his father’s pension, so that he doesn't have to chip-in. However, Ganapathy proudly says his son is a  successful a business man who employs around 200 people in his office, mismatch to his present plight.

Seeing an old man at the gate in such a devastating situation, I fairly got an idea about the happenings inside. Barged-in, looking around to find none but a strong foul smell of urine welcomed me. I quickly opened a room and peeped in and found an old lady lying in the pool of urine with no clothes on her. “She keep passing urine and her clothes get dirty often” the old women who is the facility manager justifies the unbearable stench. One does not really need any professional expertise to understand that it was a clear violation of human right of an infirm elderly person.

More unpleasant surprises awaited me when I was escorted to different rooms in the building. Shabbily kept rooms, dust bins over flowing with soiled diapers, fallen hair strands in black and pepper hanging from the stair ways, water filled flower pots were mosquito breeding sectors, at the corners of the hall ways found garbage pile and red spat of pan masalas, seems to be the exaggeration but that was the reality. With zero housekeeping, what else you can expect! Most inmates were just bundle of bone and skin due to undernourishment and dehydration. The medication management and timely health care was surely an alien thing as I found most were not even seen by a doctor in ages.  No qualified nursing staff and professionally trained carers were appointed by the facility.

This care facility has around 20 inmates and had just three staffs who juggles between many chores like cooking food, washing clothes of the inmate, housekeeping, bathing each patient, changing their diapers, ambulating them, feeding them, and what not!  To cut the long story, the three available staffs were playing the roles varying from cook to a physician. To make the matters worse, the home’s owner lives in Chennai and he visit the place once in three months.

Mr. Ganapathy was one ill-fated man ended up in such a horrific place. There are other thousands like him, may be lived a better life than him but one thing common for all of them was they all had families who atrociously care about them. Ganapathy's story is not any strange, when one fails to plan his or her old age the next to kin plans it for them. Many a time children want their parents to get excellent care at their fag end of their parent’s life. But, in few cases “Price” is preferred over quality. However many do not know what it means to be a qualitative care home? What to ask for? What to look for when we admit our parents in a place? How to ensure zero abuse and neglect? Over and above, remember, most of these care homeowner’s are novice into the business of caring and zero passion other than making profit.

My journey continued and never stopped at ‘Ashirvad’ and in many places the story is no better. Residents were monitored too little given their health needs, and nurses did not always act promptly when an inmate developed abnormal clinical symptoms. Staff did not give people their medication on time, manage their wounds properly or always help them eat and drink. People were at risk of infections as the home was not clean. People’s rooms, bedding and flooring were visibly dirty.

Staffs were not always kind and remember this prime quality when somebody chooses to be in the geriatric realm. Again staffs are woefully illiterate about the nuances of elder care. People did not always have the ability to call for assistance and staff had little time to talk or support people with activities or socializing.

The examples of poor care and a culture of inappropriate, institutionalized practice highlighted by my study are wholly unacceptable.  With the lack of appropriate care standards, the care extended will be inferior. Most of the places lack emergency protocols, lack of preventive care plans or inadequate inmate-care staffing ratio can be a contributing factor for diminishing quality of life of the older adults.

Choosing a right care home is one of the crucial decision that ensures quality to rest of your beloved one’s life. Of course, many excellent nursing homes provide outstanding care for seniors, but some don't. Just as with anything else in life, if you or a loved one need a living place that provides you with care, you'll want to do your due diligence to make sure you find a location that provides quality elder care. 

Sunday, 22 October 2017



Roshan Jacob

A simple omission can be disastrous is what I learned when Sateesh Reddy explained me how his brother in-in law got into coma stage. Past eight months, Prabhakar is lying in a coma stage in a hospital. Prior to his unconsciousness, he consulted three doctors complaining about neck pain radiating to shoulders. All the doctors prescribed him analgesics and some pain balms and could not find anything suspicious.  Prabhakar overlooked his fall from bike few months ago and never mentioned it to the doctors who he consulted.  Untreated cervical hairline fracture due to the fall resulted in the coma. The information (history of fall) was crucial for the doctors for further investigations, and this omission is in one way resulted in the mishap.   It is widely taught that diagnosis is revealed in the patient's history. Above mentioned scenario involving inadequate history taking leads to serious consequences illustrate the importance of medical histories in diagnosis and here Prabhakar’s case is the classic example of the value of history. 

Recently I interacted with three retired consultants, two physicians and a surgeon on the sidelines of a conference and when I broached the subject of the value of history taking, with no dissent, all of them expressed their dismay at their denigration of the importance of proper history taking in clinical practice. Modern day doctors, mostly nudged by managements give preference to ‘investigations’, and happy to go with figures rather facts. As champions of evidence based medicine can they produce evidence that taking a proper history is "unhelpful"?

Extracting a proper history means listening carefully to what the patient has to say, followed by relevant systematic and constructive questions. As examples of clinical situations in which this discipline yields rich rewards we would cite the elucidation of chest pain or the recognition of da Costa's syndrome, where a proper history could save expensive and anxiety-producing investigations.

The foundation of a true history is nothing but a smooth communication between doctor and patient. Here patient should not show any inhibitions and the doctor is a good listener. Listening is at the heart of good history taking. The patient may not be looking for a diagnosis when giving their history and may even have irrelevant aspects and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.

There was a time not long ago; often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A classic example is with the complaint of headache where the diagnosis can be made from the narration of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations for an experienced consultant.

To acquire a plausible, representative account of what is troubling a patient and how it has evolved over time, is definitely not an easy task. It takes practice, patience, understanding and concentration. The history as told in the beginning is a sharing of experience between patient and doctor and certainly time consuming. A consultation can allow a patient to pour out his agony. They may be upset about their condition or with the frustrations of many other aspects of life other than the present affliction and it is important to allow patients to give vent to these feelings. Ultimately how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool is what matters.

The traditional method of detailed history taking and physical examination and thinking about what tests to be ordered, (if any) are needed may take somewhat longer time with the patient, but must remain the cornerstone of clinical practice. The content of the history involved in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history.

However the general framework for history taking is as follows:
    First is the presenting complaint.
    History of presenting complaint, including investigations, treatment and referrals already done and provided.
    Significant past diseases/illnesses, surgery, including complications, trauma.
    Medications now and past, prescribed and over-the-counter, allergies.
    Family history must be enquired to especially parents, siblings and children.
    Social history also matters. Here we find many habits and his addictions like  smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
                Finally, the systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.

Let’s go back to the coma patient Prabhakar. Prabhakar, who went and consulted three doctors but never mentioned his fall from the bike, thinking that it is insignificant. He thought the presenting complaint; neck pain is not even remotely connected with the fall, which happened three months back. None of the doctors have any leading questions to this effect like, ‘did you have any fall in the past?’ sometimes you may have to ask some wild questions when you as a doctor have no other suspecting reasons. The doctors set no agenda in this case and they missed the vital clue, which finally ended in a tragedy. 

After taking the history, it's useful to give the patient a run-down of what they've told.  For example: 'So, Prabhakar, from what I understand you've been getting this pain since one month and you are sure no incident worth mentioning like any fall in the recent past. Is that right?'. This summarizing or leading question could have helped Prabhakar mentioning the history fall, which he felt trivial.

It is vital to remember that a good elicitation of the patient’s history, in his own words coupled with few leading questions from the doctor can help the latter to arrive into ‘provisional diagnosis’. This does no suggest the patient doesn’t need any detailed evaluation.   History alone cannot lead into a definitive diagnosis unless until validated by other pertinent tests. Having said that, history taking has an integral and irreplaceable role in the appropriate diagnosis.  'Listen to your patient; they are telling you the diagnosis' is oft quoted aphorism. In olden days, it is widely taught that diagnosis is revealed in the patient's history.  It is true even today, provided the doctor is willing to listen.

Sunday, 8 October 2017

You can get quality elder care but be prepared to pay for it. SOUMYA NAIR


Aged care in a care facility is no more cheap. But when you think about it you are paying for somewhere to live, your meals, laundry, electricity and a number of people to look after you around the clock. The good news is that it is actually a lot of comfort and support in the fag end of life when the aged person needs assistance with daily living. Majority starts cribbing about the cost as if they are caught unawares.

Sharon D’Souza never dreamt that elder care can be such a difficult thing. Past two years with her bed ridden mother’s long term care, she learnt a different lesson. Sharon’s mother is bed ridden and needs round the clock care. But when a care home bill tops 45000/- a month, the best-laid plans get tossed aside unless you anticipate. Like others faced with the stunning cost of elderly care, Sharon did the math and realized that her mother could easily outlive her savings, a nightmare haunting her. Experience taught her She had followed the expert advice, planning ahead in case she wound up unable to care for herself one day.

Even with her mother’s savings, 78 year old Mrs. D’Souza, a rheumatoid arthritis patient who is bed ridden past two years still had to top up with around 15000/- every month to cover her care in a care home in Pune. "An awful financial situation," said her daughter, Sharon. For the two-thirds of middle class Indians over 70, who are expected to need some long-term care, the costs are increasingly exorbitant. The cost of staying in a decent care home has climbed at twice the rate of overall inflation over the last five years, according to our experience. One year in a private room now runs a median Rs. 300000/- a year, while annual cost for home-health aides runs Rs. 250000/-.

"If you have any money, you're going to use all of that money," a frustrated Sharon said. "Just watch how fast it goes." Sharon wonders how people manage the widening gap between their savings and the high cost of caring for the elderly? In India insurance doesn't cover long-term stays, so a large swath of elderly people wind up on the personal savings and ‘beg for charity from children’.

"Within the first year most people are tapped out," said Philip Cherian, a practicing chartered accountant and the director of two retirement homes in Bangalore. "Middle-class families, though cash rich, just aren't prepared for these costs." Cherian sums up.

Everything changes when, for instance, an aging father struggling with dementia requires more help than his wife and children can manage. Remember plans that looked solid on paper are no match for their bills. Cherian says plans for care and finance are equally important to prevent unpleasant happenings and inferior care.

Many of the retirement homes in the country just provide accommodation, housekeeping, food and this will be included as basic cost. Linen, laundry, physiotherapy, medical, consumables, TV, internet, grooming, maintenance, etc., are all charged extra and considered as hidden charges. On average, a shared room in a nursing home costs anything between 20k to 40 K without care. A private room, or a studio apartment can still costs higher. All the facilities collect deposits with various modes of deductions. Deposits range anything between 2 lakhs to 60 lakhs, depending upon the facilities and the size of accommodation.

Now comes the variables of the long term care industry. "The amount of care you need dictates the price," said Swetha Banerjee, a geriatric care manager in a care home in Kolkotta, "and there aren't that many ways around it."

Hiring an aide to spend the day with an elderly parent living at home is often the cheapest option, with aides paid a minimum of 15000/- a month in some parts of the country to 35000/- in few metropolitan cities. But hiring them to work around the clock is often the most expensive, Swetha said. "Needing help to get out of bed to use the bathroom in the middle of the night or patients with peg feeding or sleep disturbances means you need at least two attenders round the clock and in that case better to choose a nursing home," she said. She also points out to other costs like physiotherapy, and consumables like diapers, gloves and masks, catheter management, and other paraphernalia associated with long-term care. Last but not at all the least, now a day, as the medicines in old age are costly. Many elders have multiple conditions necessitating the consumption of many costly drugs.  This adds up to the cost.

Sushma Kavale, another Bangalore expert in long-term care has a different take on this so-called ‘awful financial situation’. According to her, for those solidly in the middle class, however, the answer is actually not very complicated, rather a hype. ‘Anticipate cost, and be prepared to spend and expect rising trend to continue’, she asserts.

After a close look at Sharon’s mother’s financial situation, there is no grim picture as the way it made out to be. Taking Sharon’s case study, Sushma wants to dispel the myth of ‘finance crunch’ for a middle class family. They have too much money for all the luxuries  under the sun but not enough to cover the typical few years of care of their ‘beloved’ mother.

When I told Sushma about me writing an article on the financial distress faced by many families, as a veteran in long term care, Sushma too admit that it is no easy affair, unless the old man/women plans well in advance. ‘You can get quality elder care but be prepared to pay for it’. Financial distress is the result of many factors. It can be the actual crunch. But according to her, majority of middle class and above have sufficient means or income but not willing to pay up.

Older adults those are deprived of the qualitative health care at their fag end of life, citing reasons like "too expensive" "poor affordability" "siblings doesn't go dutch" are unlikely and unconvincing excuses. Most elderly parents are made poor during infirmity by draining them off their resources by the children or immediate families. Many elders have some savings, assets or some little fall back from their life long hard work and earnings. In a household when the elderly parent retire from active life, assets and savings are parted among children either by persuasion or parents willingly share. In few cases parents hold some of their assets and savings. In a phase where they are infirm and bedridden no more able to run their finances on their own children chose how much to spend or what kind of quality care to offer, sadly its Price that's preferred over Quality leaving the older parent to inferior care. Considering a middle class elderly parent in India, majority got some assets or meager savings which actually can take care of their rainy days in a most dignified and graceful manner. Yet, they elders get deprived of it because their old age care is not their choice but their children's or someone else's.     

Having money and not spending it may be a problem lots of caregivers wish their families had, but it’s a problem nonetheless. “Money is a very emotionally charged issue,” Ms. Sushma said. “It’s hard for rationality to rule.” “I can’t afford it” provides a good all-purpose excuse.

Friday, 25 August 2017


Anirudh is fed up with the frequent readmissions of his mother, Jayadevi and has no qualms of showing his frustration. ‘It is a painful process and especially I am far away in Bangalore and mother lives in Bhubaneshwar. Each time I have to fly down and imagine the inconveniences causing to my mother and my plight. Doctors give vague answers’. ‘What big deal’, the attitude of doctors and hospitals irks Anirudh.

Seniors continue to be readmitted to the hospital too frequently. But when it comes to explaining why, patients and providers are on Mars and Venus. The patients and relatives blame doctors and nurses. Doctors and nurses blame patients and relatives. And everybody blames the hospitals.

The problem, everyone seems to agree, is that hospital discharges are a mess. Patients don’t understand what they need to do after they go home: They don’t see their treating doctor (primary care doctor), they don’t take their medications properly, and they land back in the hospital. Do’s and Don’t are never explained. In short, no understanding of the clinical condition, prognosis, medications and management. That revolving door jeopardizes their health and costs patients crores of rupees, and more often inflict untold miseries.

Reducing readmissions should be a national priority, unfortunately in our country, even in the NABH, this is considered as a quality indicator with no penalty provision. Soumya Nair, my colleague who takes classes to nurses on transitional care practice emphasizes on the need for appropriate protocols for discharge. ‘Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential’, Soumya Nair, who is also a practicing gerontologist, underlines the importance of care transitions, viz discharge planning.

She continues to explain that even though the strategies seem relatively inexpensive, they require greater collaboration and communication beyond the walls of the hospital, and that while hospitals are investing resources to improve patient care, they may not be investing in all the right areas. A study by Soumya listed the top four reasons for hospitalizations.
1  patients not understanding their condition and diagnosis
2  patient mismanagement of medications, especially elderly
3  patients ignoring the importance of follow up  visits with their doctor
4  families unable to or not interested in the education for adequate supportive car

We have asked few of our known doctors and nurses who want to portray the patients, especially elders, in the dreaded term, non-compliant. From this health professional’s point of view, elders often are so anxious to leave the hospital the moment they stepped in and most of them are not honest about whether they can manage their discharge. ‘This hurrying and pressure from patients and their families is also another contributing factor. They say they understand instructions when they really don’t. They say they have caregiver help even if they are alone. Then, once they get home, they fall back on the same bad habits that got them hospitalized in the first place. And when they get sick, they go to the hospital and sometime to another hospital instead of consulting their primary care doctor’. Sums up one of the doctor we interacted who wish to stay incognito.

As we directly interact with infirm seniors, their story is completely different. Most of them dread hospitalization and considers overwhelming and terrifying. It is in the words of Byrappa uncle who is back from a two-week stay as  “an alien world.” They say doctors expect them to understand complicated instructions and make decisions while they are in pain or in the thick haze of medication. Instructions are written in jargon that may be second nature to doctors, but is incomprehensible to their patients. No one has the patience to explain or counsel.

A new diagnosis of a chronic disease can be frightening to older patients.   After the initial scare of hearing such news, they may need bit of counseling for understanding what to do. Most of the doctors assume patients who have been living with a disease for many years understand how to manage it, patients say they often do not (after all, if the disease was well-controlled, they probably wouldn’t be back in the hospital). Unlike the western nations, nurses have limited role in patient education in our country.

Another trend is that hospitals are under tremendous financial pressure to discharge patients quickly—a step that often puts more burden on discharged seniors to care for themselves. They are right. Hospitals are being pushed by insurance companies to both discharge quickly and prevent readmissions. This is a tricky situation. That’s why it is more important than ever that doctors and nurses learn to talk to patients and that hospitals vastly improve discharge programs that, too often, are the broken link in the health care chain.

Soumya recommends a solution that can help to eliminate these reasons for readmission and she says it is already at our disposal. Private nursing care is the key to effective post-hospital care. Private nursing care (Home Nursing) offers assistance with Activities of Daily Living (bathing, feeding, dressing, transferring, etc.) and can include assistance with light housekeeping, meal preparation, transportation and more. A skilled nurse oversees the care of each home care patient and can serve as an advocate to ensure the patient is meeting their recovery goals. This enables the client to focus on their recovery and eliminates anxiety over handling tasks on their own, all while drastically reducing the risk of hospital readmission. Again the immediate family who is busy earning a livelihood also relieved of the caregiving obligations.