The contribution of intermediate care to crisis response and acute admission avoidance in Catalonia
Marco Inzitari is a geriatrician and Director of Healthcare, Research and Teaching at Parc Sanitari Pere Virgili, Barcelona, and Associate Professor of Medicine at Universitat Autònoma de Barcelona. Here he descibes “Subacute Care Units” which have been set up in Catalonia. He tweets @marcoinzi An “unbelievable pressure on acute hospitals, with winter on its way…the rapidly ageing population and the increasing number of people with complex long-term conditions, frailty or dementia” describes the English healthcare situation, according to David Oliver’s recent post for The Kings Fund. This scenario perfectly fits the reality of Catalonia, Spain. A predominantly bed-based intermediate care system is well established in Catalonia: aside from the traditional aim of facilitating early discharges from acute wards, new pathways have been implemented to reduce the pressure on acute hospitals and avoid unnecessary hospitalisation for older patients. In A&E, when older adults cannot be discharged home because of needing more intensive monitoring or treatment, and perhaps due to insufficient social support, they should be quickly admitted to a “comprehensive geriatric assessment bed” (G Ellis et al, BMJ 2011). This idea is behind the creation of the “Subacute care Units”, intermediate care resources that, in Catalonia, admit patients with decompensated complex conditions, either from A&E or from home. Here are some functional details of these units:
- Target patients are older adults with exacerbated chronic diseases (i.e. COPD or heart failure), or with a decompensated complex condition (i.e. urine infection in a patient with dementia). Selection criteria include: hemodynamic stability, a sufficiently clear diagnosis, not requiring complex investigations, and an expected length of stay of under 10 days.
- A geriatric approach is provided, with multidisciplinary teams (pivoting around expert nurses and geriatricians, available 24 hours), comprehensive geriatric assessment and an individualized therapeutic plan. The added value here is the ability to treat the acute condition while preventing and managing frequent geriatric syndromes, such as delirium. For example, in my facility, a physiotherapist assesses 100% of admitted patients at an early stage, and sets a plan to preserve function.
- These units are low-tech, for both diagnosis - basic X-ray, laboratory investigations, ECG - and treatment - oxygen therapy, i.v. fluids and drugs, etc.
- Capacity (dedicated beds) is generally flexible, being maximum during winter.
- The electronic healthcare records, shared with the referring acute hospital and with 90% of primary care, facilitate integration.
In the “Subacute Unit” of Parc Sanitari Pere Virgili in Barcelona (34 beds maximum capacity), during 7 months of 2015 we admitted 460 patients (mainly for respiratory problems, heart failure or urinary infections); 50% had dementia. The majority (75%) returned home after a mean of 8.5 days, 7% died, 14% were discharged to long term care. Only 3% returned to the acute hospital, a critical indicator of appropriate selection and effectiveness of the unit. We have been exploring if simple geriatric screening tools might help to refine selection in A&E and we found that the Identification of Seniors At Risk (ISAR) was independently associated with destination at discharge from intermediate care, and showed the best predictive validity, although only poor-fair, among other tools.