Friday, 25 August 2017


“WHAT BIG DEAL, PATIENTS GET RE-ADMITTED”, MANY ARE TOLD

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.

Tuesday, 15 August 2017

DYING THE RIGHT WAY



I had few moments of reminiscing my long stint of encountering the process of death. This is because today I had to attend three deaths within a matter of half an hour, a sort of record. Kumar Chandran (67), Vaidyanathan (72) and Gopal Rao (81). All of them died in my care home within an hour, as if it is an auspicious time for death. I am proud that myself and my fellow gerontologist, Ms. Soumya Nair had the privilege and mandate to  see 1000’s of deaths at close quarters. This is why I want to talk about death, and more specifically, ‘Dying the right way’.

Padma Mamee wanted to be remembered as someone who didn’t give up. Harinathan Uncle said some of his favorite times were playing golf with his rotary club members. Eddie Uncle, though a chronic bachelor said he was the luckiest man in the world, as he had the company of three dogs. Narayan Mama summed it up this way: “You have a one-way ticket. Don’t waste it!” They were all nearing death. Some were old, some young.

On many occasions, they shared their biggest regrets, favorite memories and greatest loves. I wanted to know their perspective on their lives, their dreams and their deaths. The recurrent themes were not surprising. Many talked about gratitude, family, relationships. And, of course, love.

These days we're living longer and surviving more health scares, even in old age, due to the improvements in medical technology. Most of the lives I encountered had no plans in old age thereby encountering untold miseries. Most of the afflictions, hardships and agony are man made and there fore it could have been avoided if some preparation was there. Many of my long-term care patients came to the care facility by the quirk of fate, not by intent. But as the days pass by they all get used to the care and love they received at the care center.  More important, perhaps, it is the need to ensure that they live a full, healthy, happy life that's low on stress, poor nutrition, sedentary behavior and medical interventions – and high on healthy eating, physical activity and preventive care.

Our health care system prevalent in the country try ‘preserving’ the life, knowingly well that of the futility of treatment disregarding the miseries inflicted on the patient and the out-of-control health care costs. Hospitals and Doctors conceal the truth about the treatment options and the real prognosis and ultimately the futility. Relatives narrate stories how the hospitals overcharge by inflated bills and end up paying to the tunes of couple of lakhs. You have the right to know the treatment options, the right to choose and the right to deny. Are we able to exercise our rights when it comes to long-term care.  Ending on a sound note is what everyone look for in the fag end of their life. 

We, as social gerontologists, actually have a different view; a perspective that suggests drugs and medical procedures that prolong life for a short time aren't the  answer. We subscribe to the idea of a more natural death with appropriate care at the fag end, facilitating with soothing and comforting factors playing the vital role.  We are the proponents of different school of thought, approaching death in a different way which suggests that you are less likely to die in a hospital, less likely to undergo surgery at the end of your lives and less likely to be admitted to intensive care compared to the general population. Imagine someone close to you is dying of a chronic disease – or even of natural causes (old age). How much effort – and time, and money, and emotion – should you, your loved ones and your health care team exert to prolong that life?

Is the death less worthy of our attention – remember, as the longevity increases, a person does not go gently, smiling sweetly, into adieu. ‘Dying sucks. Cancer, Alzheimer’s, Parkinson’s sucks’, Soumya, my colleague says form her experience facilitating hundreds of deaths in the past. ‘Try to mitigate the misery and not to let it rule you and take over everything’.

Before preparing this article, as part of my research, I have seen some videos uploaded in the you tube, one worthy of mentioning is ‘My last Days” (Zach Sobiech) series. I am happy that such videos are spurring conversions about death and dying and we need more discussions like this in our country. Majority of  people say they hope to die at home, yet only 30 percent actually do (Few Lucky Ones), often because people, I say, ill prepared to plan until it’s too late. We spend billions of rupees on medical treatments in the last lap of our life, too often these treatments achieve nothing but leave patients too ravaged to say goodbye to the people they love. I call dying in distress. 

Our ancient philosophers and even religions have taught us to accept the fact that disease, pain, and death are inevitabilities of the human condition. Straight, honest discussions about how to grapple with the darkest of realities—the kind Zach Sobiech shares—are helpful for people who are figuring out how to cope and for people who will eventually have to—which is pretty much all of us. We need good geriatric counselors for how to talk openly with doctors, nurses, caregivers, family, and friends about the worst of the worst ways that human bodies can go wrong.

With a growing elderly population everywhere and advances in medical treatment that prolong life (often without quality) for disease sufferers, more and more of us are facing head-on confrontations with mortality even before our own time comes. As a nation, we remain bad at talking about the most difficult facts of life—how we want to go, and what we want to be done about it. Many of us, myself included, have been schooled in an emotional style that prefers to stay away from the dark, icky facts of human life. And talking about sickness and death is undeniably difficult. My experience tells that it is definitely not possible in a hospital to die peacefully, and especially in an ICU set up.


Is it possible to have a “humane and honorable” death? YES, Very Much. Provided, we accept it’s reality and initiate an honorable exit plan. 

Monday, 24 July 2017

Never Overlook Hygiene in a Care Facility

Never Overlook Hygiene in a Care Facility
Soumya Nair

The phrase “respect your elders” is ingrained in most minds. This phrase, however, has been lost its sheen over the years and a recent visit to ‘Aseervatham’ endorses it. ‘Aseervatham’ claims to be a care home for elders and it was sort of a first time experience for me of what all things can go wrong in a care home.  You cannot compare it with a pigsty as pigsty gets cleaned everyday.  It was a shock to me that children have no qualms in admitting their parents to such care homes overlooking the unhygienic conditions. The inmates, who need help to do even the most mundane of daily tasks, are often disregarded and left in unsanitary conditions for long periods of time. Who bothers? Remember, cleanliness is an attitude.

Life threatening conditions can develop when care homes do not keep up with their sanitation needs. When germs and bacteria spread, vulnerable elders can be affected in a negative way. This is especially important because these infirm elders are most likely to have medical conditions that, along with poor hygiene, can wreck havoc on their health.

It is of utmost importance that care facilities maintain  high standards of cleanliness and personal hygiene for all their residents. Poor hygiene in a care facility can often be a cause of serious health complications for the patients living there. This can be especially dangerous for patients suffering with debilitating diseases such as cancer – where even something as simple as a cold can lead to massive medical complications. Moreover, the bacteria and germs all over the place can also affect the senior citizens under care, compromising their immunity, which will exasperate their medical complication. The increasing age of elder patients further inhibits their body’s ability to counter such diseases.

Most infections prevalent among care home residents are attributed to poor hygienic conditions. Moreover, nurses and other staff members neglect providing optimal care such as changing bandages, diapers, etc. on time, which is something that can also lead to medical emergencies. Lack of hygiene and sanitation can cause them to suffer preventable diseases that could be avoided by the nursing home that practices proper hygiene. In many cases, the reason why a nursing home might not be putting the appropriate attention to hygiene is because of a lack of staff or resources to keep up with this important daily task.

The care home’s staff often fails to recognize the importance of hygiene given their lack of training and basic awareness. Many times, due to understaffing, employees may come under excess workload and may simply forget to carry out their necessary duties to ensure they provide professional care when it comes giving patients a bath, serving them food, etc. For example, not washing hands can lead to numerous problems such as infection and other types of problems that sensitive patient will not be able to bear. Training is therefore a big must when it comes to successfully running a nursing home.

Not only can care facilities disregard the patients’ needs for cleanliness and basic personal hygiene, but the care facility itself may also be lacking cleanliness. The physical environment is also an area of concern for care homes where proper hygiene is important. It is possible that toilets, showers, bathtubs, bathroom floors, and rooms are not properly sanitized. This can lead to the propagation of germs which could ultimately cause disease and infections.

The kitchen area, where food is prepared and served to care home residents, is also a place where it is vital to have the utmost cleanliness possible. The kitchen staff needs to be properly dressed for the job and take all the necessary measures to handle food hygienically. Also, the dining area needs to be sanitized, including the tables, chairs, buffet tables, floors, and every other area that is touched or handled by the residents.

Most aged care facilities have insufficient number of caring staff thereby compromising the caring standards. Lack of basic maintenance and janitors could be the cause of poor cleanliness in caring facilities. Healthy patient-nurse ratio must be maintained otherwise, the caring staff feels exhausted and they overlook hygiene. When there are many urgent situations going on at once, a nurse might forget to wash her hands between treating different patients. This is how germs can easily spread throughout the facility, affecting everybody living there.

Management has the responsibility to train staff to take proper hygiene measures to ensure the health of the residents. Care homes with the right amount of trained staff are less likely to have issues with poor hygiene. Cleanliness is of vital importance in this type of facility and cannot be overlooked. Relatives who wish to admit their parents should be observant and seek hygiene protocols of the facility and can also personally inspect the facility. In many western countries, care facilities can be liable for improper care of their patients due to lack of hygiene, which is not the case with our country.

(Soumya Nair is from Bangalore, India and is a practicing Social Gerontologist at advantAGE seniors.  She is the co-founder of this 17 year old company. She has been a social gerontologist since 2002, which was her inspiration for writing this well researched article. She loved being with her elderly patients, and she wrote this article highlighting the importance of hygiene in care facilities as she noticed the appalling conditions in few existing care homes. She insists that the ‘consumer’ of long-term care definitely deserves more personal hygiene and a clean environment.  Soumya hopes country’s long-term care needs overhauling changes so that elders would receive the best treatment that is necessary and so much deserved to elders.)


Friday, 21 July 2017



HOW TO CHOOSE A CARE HOME FOR YOUR PARENT?
                                                                                     Soumya Nair

MOVING an elderly parent from home into a residential facility can be one of the most difficult things a family goes through. We can share our advice for taking the pain out of the process. Deciding to make the move to a care home can be a difficult decision and families usually play a vital role in helping their elderly relative pick the right one. The move from one’s own home into a care home can be upsetting, even traumatic, for both the elderly relative and their family. Relatives can feel guilty about assigning the day-to-day care of their loved one into the hands of others, and anxious about the level of care and support they will be receiving. Though it is painful, our options are limited as the parent may need more professional care or you simply cannot extend care for various reasons.

Here's our list of the 10 most important things to consider to make the transition as easy as possible.

1. TAKE AS MUCH TIME AS YOU CAN
Choosing a home in a hurry is never a good idea but often there can be pressure to find somewhere quickly, especially if a hospital is keen to discharge a patient. So last minute scurrying should be avoided. Because you know that after discharge or the health condition warrants a care home and he/she cannot be taken back to home.

2. DECIDE ON THE TYPE OF HOME YOUR PARENT REQUIRES
As mentioned in my earlier article, introducing the care facilities, there are four basic types of care possible and facilities and services differ, again the  prices will vary for each. If there is a strong possibility that your loved one may need greater levels of care in the future, it can be wise to choose a home where this extended care is possible, rather than having to move.

3. TALK TO YOUR PARENT IF POSSIBLE
A discussion with the parent is necessary to convince them about the need for a more professional care or the need to get admitted in a care facility. Most elders fear depending on someone and they dread loosing their comforts. That’s why we say a little bit forceful convincing is norm, saying we have few options left. If your parent is not well enough for this conversation, or is unable to communicate, discuss it with all your close relatives who know your parent well. Find out what the most important things to them are about the care home and what they would like the staff to know about them to help them care for them in the best way.

4. DECIDE ON WHERE THE HOME SHOULD BE
Think about the distances you, other family members and friends may need to travel and how easy it is to get there, including for those who don’t have their own transport. But this is again secondary because you are not going to be a regular visitor.  More than that, let’s know what kind of access do you need?
Many homes are in adapted buildings and even if they say they can offer a ground floor room, there can be steps into the lounge or dining room. Again it all depends on the availability.

5. WHAT FACILITIES ARE AVAILABLE ?

Some homes are very large and this can have its advantages, such as better entertainment facilities, including having a minibus and obviously, a wider social circle. If your parent is quiet and shy, however, they may be better off in a much smaller home. It all depends on the personality of the person and again the Bathroom arrangements can be very personal, especially access to one’s own toilet. Do they want access to a garden? Do they have specific dietary requirements? Many older people are inseparable from their cats and dogs and want to take them with them. If not, they want the presence of Dogs (therapy dogs). Knowing the preferences is important beforehand. Ask your loved one what's important to them.

6. COST FACTOR
Importantly, if your loved one will be a “self funder”, how much can they afford? Costs are escalating and eldercare is no more cheap. Prepare to shell out more for a decent stay and again cost vary depending upon what type of care you need. Fees will vary considerably between homes, and this can mean that families may want (or feel they need) to top up the fees from their own resources to secure the quality of care and environment desired. After determining what benefits and entitlements are available, the rest of the fees will need to come out of investments, savings or against the future sale of a home.

7. CRISIS  MANAGEMENT
Crisis is an event that is perceived as overwhelming and is something not ‘normal occurance’. A situation becomes a crisis when the client believes that they have exhausted their resources and coping abilities. What is perceived as a crisis by one person, may not be perceived as a crisis by someone else. It  can be a fall, infection, high temp, unconsciosness, occurance of a bed sore etc,. Some other social and financial aspects also can be turned into a crisis. It is important to know the protocols followed by the care facility to manage the crisis situations. You must evalaute the prepardness of the facility to seize the situation under control.

8. CARE AND HYGIENE STANDARDS
It is of utmost importance that care facilities maintain a high standard of cleanliness and personal hygiene for all their residents. The problem of poor nursing home hygiene is a serious one and a matter of real concern. The elders usually suffer from an array of conditions related to their advanced age and if they are allowed to live under conditions of poor hygiene, they are more likely to catch germs that can cause diseases that are then spread to other nursing home residents. In a nursing facility setting, the residents’ immune systems are usually more compromised than young people and they are more likely to become sick from having poor hygiene. Their immune systems are not properly equipped to handle an onslaught of germs that can arise out of having poor hygiene. Watch over these highly important factors which can compromise the health of your loved one.


9. STAFF APPROACH
An ageing population requires nurses to be fully equipped to care for their specialist needs. Health professionals’ values, beliefs and attitudes towards older people affect how they view and approach those in their care, which affect the quality of care that older people experience. Older people have special needs and dealing with an elderly person is no easy deal. Lot of attributes needed for a nurse or a para-medical to extend care to seniors. One should always be in a positive fame of mind while dealing with elders. Knowledge about the diseases, syndromes and its management should be there. Ideally the elderly should be nursed by staff trained in geriatric care who would understand the aging process and how it affects health, disease and rehabilitation. Finding out about the training and skill level of a potential caregiver is important.
10. REFERENCES

References of people who utilized the services earlier are a good way of knowing the competency of the establishment. Try getting some testimonies from the people who can guide you to take a final call.