Service availability in the region of Päijät-Häme

In the year of 2017 10,6% of the population of the region of Päijät-Häme was aged 75 or more, while the average percentage across Finland was 9,1%. The need for services in-creases due to the aging population, causing a significant lack of sustainability. Aging rate

at the region of Päijät-Häme is high (between the years of 2018 and 2040 the number of people aged over 75 and 85 years will increase by 76% and 148% respectively). The de-pendency ratio is currently the highest in Päijät-Häme, comparing to the rest of the coun-try. Most of the Päijät-Häme elderly reside in the city of Lahti. (Olkkonen-Nikula 2018, 11-18.)

Functional capacity of the elderly population in Päijät-Häme is on the same level with the country’s average, thus, the need for services for the population is medium. The biggest concerns in the area are loneliness, feeling insecure, moderate to severe memory illness, substance abuse and mental health problems. (Olkkonen-Nikula 2018, 19-26.)

Across Finland, slightly less than 90% of the people aged over 75 reside either at home without regular home care or with home care services, Lahti being one of the cities with the most people living at home (Linna, Mikkola, Peltokorpi & Tyni 2016, 32-33). 17,5% of the aged over 75 years population of Päijät-Häme are regularly using elderly care services (home care, 24-hour facility care, family or formal care) (Olkkonen-Nikula 2018, 27-28).

According to the Act on Support of the Functioning of the Elderly and on Social and Health Services for the Elderly, the municipality shall provide counseling services in support of the well-being, health, functional capacity and independent living of the elderly (Laki ikääntyneen väestön toimintakyvyn tukemisesta sekä iäkkäiden sosiaali- ja terveyspalve-luista, 12 §). In Päijät-Häme, Palvelu-Santra provides the region’s population with guid-ance regarding the availability of both private-sector and public services. If the client's situ-ation in the initial survey is demanding, the client's matter is referred to the client counse-lor. Contact can be anonymous and the customer's information is not recorded, if wished.

When the situation requires, the client supervisor/counselor makes a home visit to the cli-ent, where the service needs are assessed and based on that a service plan is drawn.

Customer counseling is responsible for organizing the services, their coordination and provision of interdisciplinary consultation if required. (Olkkonen-Nikula 2018, 36-39.) Evaluation, follow-up and rehabilitation health care facilities are available. Existing hospital network capacity is evaluated to be sufficient. The Acute geriatric emergency ward AK-KUNA unit operates in conjunction with the Päijät-Häme Central Hospital, which carries out a comprehensive geriatric assessment of elderly patients arriving to the hospital via the Emergency department. In addition, patients can be referred to the Emergency ward for the follow-up care. So-called “Home hospital” operates in collaboration with the Emer-gency department providing hospital care is at the patient's home, which can also be a nursing home. Treatment is always temporary and of short duration and is aimed at re-placing inpatient care. (Olkkonen-Nikula 2018, 52-57.)

4 UNITS SPECIALIZED IN GERIATRICS 4.1 Acute geriatric emergency ward

The Acute geriatric emergency ward (later mentioned either by this name or as “AK-KUNA”) is situated in the Central hospital of the Päijät-Häme region. The ward is special-ized in treating those residents of the region that are over 70 years old and need immedi-ate hospitalization and round-the-clock monitoring (PHHYKY 2019a). Additionally, pre- and post-operative care of hip fracture patients aged over 70 is offered, the number of hip fracture patients taken care at the ward simultaneously is limited to 4 out of the 10 patient-placements available (as per Autumn of 2019). Patients arrive to AKKUNA via the Emer-gency department of the Päijät-Häme Central hospital, in case if after being assessed in the Emergency department they cannot be discharged home (for example in case of an acute infection, acute delirium, heart failure, general condition deterioration). Before ad-mitting a potential patient to AKKUNA, the staff of the Emergency department also evalu-ates the patient's age (over 70 years old), lifestyle, ability to function (rate at which for, ex-ample, home care services are used), and baseline disease status in order to gain an in-sight whether AKKUNA is the right place for the patient in question to receive treatment (PHHYKY 2019a). Along with treating the condition diagnosed at the emergency room or diagnosing a yet undiagnosed condition and then treating it, the idea is to screen for the elderly living in the region that would benefit from a comprehensive geriatric assessment (CGA).

While being a ward specialized in geriatrics on its own, AKKUNA is operating under the same management as the Emergency ward (not to be confused with the Emergency de-partment). As the result of this collaboration the wards share the head and the assistant head nurses, physiotherapists, pharmacist, secretaries, maintenance workers and the dis-charge nurse. The aforementioned specialists are not necessarily introduced into every patient’s care paths, but rather are involved upon a request of either the patient’s own nurse or the doctor. Most of the nurses working at both AKKUNA and the Emergency ward do job rotation, meaning that they are equipped to work in both wards. Generally, the patients are divided between 3 nurses in the morning shift, 2 nurses in the evening shift and 2 during the night shift. In charge of the ward is a senior physician specialized in geri-atrics, a geriatrician. Otherwise the ward does not have a permanent attending physician.

Specialized or specializing in either acute care or gerontology physicians do job rotation in the Emergency department, the Emergency ward and the Acute geriatric emergency ward. During the office hours (8:00am to 4:00pm) of the weekdays (Monday-Friday) there are two physicians (the senior physician and the attending physician) dividing their

round-ups. During weekends and national holidays, only one attending physician is available at the ward. Outside of the attending’s working hours, a triage doctor and an on-call doctors are available. Depending on the patient’s underlying conditions or symptoms an attending physician may consult other medical field specialists, like a surgeon or internist. Further-more, services of a gerontologist, are at the disposal of the ward.

The multifaceted assessment done at the ward during a patient’s stay is aimed at improv-ing the overall quality of life of elderly of the region, as the demand of health care ser-vices, such as nursing homes and home care, has been growing exponentially during the past few decades (THL 2019b). The ultimate goal of the comprehensive geriatric assess-ment is to preserve an elder's ability to live at home, possibly, with the help of home care services (Finne-Soveri 2013).

In addition to assisting patients in performing daily tasks (mobility, hygiene, nutrition, med-ication intake), nurses perform certain assessments that are a part of the comprehensive geriatric assessment (MNA, Audit65, orthostatic test, gathering of the background infor-mation). With the help of physiotherapists, nurses also play an important role in rehabilita-tion and mobilizarehabilita-tion of patients whose mobility is temporary limited (hip fracture patients, pain management patients). The average hospital-stay at the ward of AKKUNA lasts from 2 to 4 days, after which the patient is either discharged home with the help of home care services, or without those, if they are not needed or the patient’s care path continues at another follow-up care ward (PHHYKY 2019a). Upon one’s discharge from the ward, the attending physician sums up the provided care and draws up the follow-up care instruc-tions or interveninstruc-tions in the patient’s discharge papers. Patient’s own nurse takes care of the discharge process by organizing or coordinating the needed follow-up services.

The aforementioned information is based on the data available from the open internet sources, like the Päijät-Häme hospital’s page, as well as it is based on one of the text au-thor’s experience as a nurse at the ward in question.

4.1.1 Common causes of hospitalizations amongst elderly at AKKUNA

In 2015, the most common admission reasons for an Emergency department of Päijät-Häme, amongst individuals aged over 65 years, were general feeling of weakness/tired-ness, followed by pulmonary issues, gastrointestinal pain, chest pain and heart rhythm disorders, fever, vertigo, leg pain, urinary symptoms, paralysis. Patients are often pre-sented with more than a single problem. The cause behind the visit could also be related to social problems, loneliness, fears and increasing alcohol use. (Hiekkanen & Orre 2015.) The city Tampere recorded over 3300 elderly patient visits throughout the years

2011-2012, due to the deterioration of the general state, the reason for which were more often the following conditions: indisposition, pneumonia, urinary tract infection, pyelonephritis, bladder infection, unspecified fever, heart failure, infectious gastrointestinal conditions, bronchitis and vertigo (Haapamäki, Huhtala, Löfgren, Mylläri, Seinelä, Valvanne 2014, 19-20). Approximately half of the elderly patients attending Emergency department is dis-charged home, while roughly another half is hospitalized (Haapamäki et al 2014, 18-19, Hiekkanen & Orre 2015.).

As patients admitted to AKKUNA arrive via the Emergency department, the causes of their arrival to the ward corresponds with the ones mentioned in the previous paragraph. It is also common to admit elderly that have been experiencing gait issues and, as result, end up falling (without having trauma requiring surgical intervention) and are in need of re-habilitation and, if needed, pain management. Additionally, hip fracture patients’ pre- and post-operative care is one of the specialties of AKKUNA.

4.2 Examples of other specialized in geriatric medicine heath care units across Finland

Every municipality is to provide its residents with adequate specialized medical care upon the need (Erikoissairaanhoitolaki, 3 §). The following chapters describe some of the exam-ples of units specialized in geriatric medicine across Finland. There is, however, no similar geriatric-led emergency ward that operates around the clock in Finland (Luustoliitto 2019).

4.2.1 Tampere, Pirkanmaa

Tampere University Hospital provides geriatric care in an out- and inpatient ways in the Hatanpää hospital. The Acute geriatric emergency ward V3 works in a similar manner with the Acute geriatric emergency ward AKKUNA. Geriatric patients arrive via the Emergency department and are in need of the hospital stay because of an underlying condition and for the geriatric assessment. In a form of specialized outpatient polyclinical care, in the Geriatric center geriatric and neurological illnesses and syndromes in the elderly are being looked into. A referral from a doctor, typical reason for which is suspected memory illness, impaired functioning, or need for proper memory diagnostics, is required. (PSHP 2019.)

4.2.2 Turku, Varsinais-Suomi

The Geriatric outpatient clinic of the city of Turku is intended for the local elderly people who are unable to be examined and treated at home or in a local health center, but do not, however, need emergency care. A referral to the clinic is required from a local health care

clinic or home care worker. Interdisciplinary and multidimensional geriatric assessment is being done throughout a single day while the patient resides in the clinic. Around half of the assessed patients can be discharged home, 45% of the assessed ones is transferred to Acute care wards, 2% to rehabilitation wards and another 2% to Turku University Hos-pitals. (Turun kaupunki 2017.)

4.2.3 Vantaa, Uusimaa

Peijas Hospital, as a part of the Helsinki University Hospital, has two wards specialized in acute geriatric care, AKOS1 and AKOS2. The ward AKOS1 has the capacity of 20 place-ments and AKOS2 has 28 patient-placeplace-ments. The wards are primary admitting elderly patients in need of either emergency assessment or short-term, not requiring specialized care, hospital stay. Typically, a newly admitted patient may suffer from acute case of con-fusion, general state deterioration or an infection. Patients mainly are referred to the wards via the emergency polyclinics. (Vantaa 2019.)

Additionally, the Katriinan hospital’s Ward 1, has the capacity of 25 placements and works as both geriatric assessment and rehabilitation unit. Special attention is paid to muscle strength training, balance improving and good nutrition. Outpatient care geriatric assess-ments are done also in the Katriinan hospital. A referral from a doctor is required. (Vantaa 2019.)

5 FAMILY’S INVOLVEMENT

In social work, family has always been considered an important partner and a unit pos-sessing significant impact on the quality of lives of the people living together, which is par-ticularly true for the more dependent members of the family (Larivaara, Lindroos, Heikkilä 2009a; Larivaara, Lindroos, Heikkilä 2009b). Relatives are an important source of care and support for patients, especially the elderly ones (Pennbrant 2013). The availability of support from relatives can be of the similar level of importance and usability as the help of aid services (Creer, Sturt & Wykes 1982).

5.1 Family’s role in life of an elder

Involvement of family, other relatives and friends in an elder’s life, is one of the corner-stones of the well-being of an older person, as a part of staying socially active (THL 2019d).

As becoming older, an individual becomes more prone to acquiring quality of life changing somatic and mental illnesses, the treatment or management for which also becomes bur-den on both primary and specialist care. The need for a variety of life aiding tools, such as glasses, hearing aids, canes, rollators, and other mobility aids for the home, increases.

With an increase of changes and deterioration of the general ability to perform daily tasks, an elder’s reliance on his or her family members rises respectively along with the general need of help with performing daily tasks. Family members, especially the spouse and chil-dren, are the most important means of support for elderly. However, due to demographical changes occurring within modern societies (smaller families, decreased number of chil-dren, common-law marriages) and narrowing of the concept of the family the availability of support has declined significantly for many. The lesser availability of offering support for elderly is often accompanied by the fact that the children themselves may be old and have their own illnesses, or may live a busy life of their own, live far away, even abroad. (Lari-vaara et al. 2009, 177-182.)

5.2 Family’s role in the care path of an elder

In elderly care, a patient- and family-centered approach is essential for achieving quality care. When working with an elderly person it is important to gain a comprehensive insight on the individual’s situation. In the health care settings, it might often occur to be challeng-ing to interview an elderly due to many illnesses that slow down activity in one way or an-other or vision and hearing impairment. At the stage of planning or starting any treatment, it is also important to identify the family member who is most responsible for the patient

and gain an insight on the situation from the caregiver’s perspective without, however, ne-glecting or impairing an elder patient’s own rights. Family history is often not as informa-tive from the perspecinforma-tive of heredity, as it is from the perspecinforma-tive of understanding social support structures and this will include knowing which family members are involved (Blun-dell & Gordon 2015, 3). Social history is essential to building an understanding regarding arrangements for formal or informal care, functional capabilities, living circumstances and the impact of the illness on the people involved (Blundell & Gordon 2015, 3). If there is a chance of interviewing the elderly spouse, it is very helpful to meet them together, natu-rally respecting the patient's wish. Old couples are often very interdependent, both physi-cally and emotionally. (Larivaara et al. 2009, 170-180, 183-188.)

In practice, the co-operation with the patient’s relatives starts when an elder arrives to any health care unit’s reception with a relative involved into his or her life and with whom most of the conversation may have to take place. From the outset, it is important to establish that the communication occurring with the relative does not exclude the patient himself from the entire picture. While a family-centered approach to care for the elderly is essen-tial, one has to bear in mind that is often the case that the elderly may not want to involve his or her members into more intimate or uncomfortable matters. Therefore, the elderly should also have the opportunity to have a discussion with a health care professional face-to-face, as it is also sometimes the case that the elderly themselves have a more re-alistic picture of their lives. (Larivaara et al. 2009, 183-188.)

In addition to providing reliable information on the quality anamnesis and participating in elderlies’ lives, relatives have also been lately heavily relied on when an elderly patient is discharged from hospital care to home care (Pennbrant 2013).

6 PURPOSE AND GOAL OF THE THESIS

In order for the thesis to be relevant and functional, it is essential to identify its purpose and goal. A goal represents a general and long-term vision that are desired to be

achieved. Meanwhile, a purpose defines strategies to achieve the already identified goals.

(Lapin ammattikorkeakoulu 2014-2016, 5.)

The purpose of this practice-based thesis is to produce a quality guideline primary aimed at educating the relatives of the patients but also the patients themselves admitted to the Acute geriatric emergency ward regarding the specifics of its work. In theory, the availabil-ity of the guideline will benefit not only the patients and their relatives but also the nurses in the Emergency department (who often have the initial contact with the patients and sometimes their relatives) and the nurses at the Acute geriatric emergency ward that can give the hand-out guideline to the relatives coming to visit their loved ones. Thus, while the purpose of the thesis is to create a guideline, the overall goal is to establish a better communication line between the patient’s relatives and the staff of AKKUNA and units in-volved into its work by informing the relatives about the specifics of the work being done at the unit.

In addition to producing a guideline, the thesis itself is going to be used as a report used to justify the guideline. Information on the elderly health care services and work behind the Acute geriatric emergency ward is to be documented based on one of the thesis’ authors as well as with the use of online available evidence-based resources. In addition to those it will be elaborated based on what criteria the final product of the thesis, meaning the guideline, has been created. The thesis will be primary using information applicable to the Finnish population and services, not comparing it to the global trends.

Another goal behind the creation of the final product of this thesis is to provide the afore-mentioned guideline available in the following commonly used in Finland languages: Finn-ish, English and Russian, as the number of clients who are native to other than Finnish language has been increasing (Väestöliitto 2019).

6.1 Practice-based thesis

The thesis in question is a practice-based one. The idea behind such a type of thesis is to produce, for instance, an object like a poster or a booth, event such as exhibition, activity or product like a manual or guidelines and write an explanatory report along with it. As the name suggest, creation of this type of thesis is usually correlated to the working life, which