Mind the gap: care for the elderly

Socio-health professionals today find themselves operating in increasingly complex and demanding contexts, especially given the increase in elderly, chronic patients and those suffering from varying degrees of social fragility. From the need to support these professionals, and to guarantee the best possible technical and relational assistance, and thanks to the structured and interdisciplinary collaboration between the Faculty of Medicine and Surgery and the Faculty of Philosophy of the Vita-Salute San Raffaele University, the project "Home, hospitals, humans: the impact of space and time in long term care delivery and aging", among the winners of the Cariplo call for "Social research on aging: people, places, relationships" 2018. Project coordinator is Prof. Roberto Mordacci, Dean of the Faculty of Philosophy and Ordinary of Moral Philosophy UniSR. 

The main purpose of the project is to investigate the impact of places, times and relationships on the well-being of social and health workers, to the extent that this in turn falls on the well-being of the person hospitalized or assisted in the area.

As part of this project, we collect the reflections of Dr. Federico Pennestrì, collaborator of HHH, PhD in Philosophy and Mind Sciences and professor of "Rehabilitation in the world" (Master's Degree in Rehabilitation Sciences for the Healthcare Professionals), "Sociology of Health Organizations" (Master in Management for the Coordination of Health Professions) and “Bioethics” (Master's Degree in Medicine and Surgery; IMD Program; Master's Degree in Nursing (Bergamo Venue)).

Italy, a country of healthcare professionals and fragmented institutions

Italy is the fifth OECD country [Organization for Economic Cooperation and Development, Editor's note] in terms of life expectancy at birth, but it is among the first in terms of disability and chronic ailments over the age of 65. This means that you live longer but often you live worse. Italy is a country run by excellent healthcare professionals, whose work is penalized by a profound institutional fragmentation, especially in the case of patients who most need continuous (as they have chronic disorders), multidisciplinary (as they present more than one disorder at the same time) and integrated (as they need to be guided) assistance. What the English doctor Julian Tudor-Hart described in 1971 as inverse care law: the more you need assistance, the harder it is to access it.

More and more international evidence underlines how the elderly "fall through the gaps" of the fragmentation of care, and how this risk increases in proportion to the degree of morbidity and fragility of the patient. The problem is therefore not Italy, but the presence of a different assistance offer with respect to the emerging epidemiological, social and demographic needs, precisely within those countries where the population has been able to access the maximum therapeutic and preventive potential expressed by the medicine in its golden age. In other words, we are experiencing “the side-effects of a health epidemic”.

Risks and needs of patients

In England 20% of patients turn to their general practitioner, first of all presenting problems of a social nature. In Chile (a significant country because it was among the first in South America to have a European-inspired health system, and perhaps for this reason characterized by one of the highest life expectancy at birth in the world) a study on 51 hypertensive subjects demonstrates the importance that chronic patients grant the time and encouragement received by their healthcare professionals, even regardless of the appropriateness of the treatment prescribed.

On the one hand, this exposes fragile subjects - even more so if they are elderly - to the risk of non-professional advice and behavior: time does not in itself equal the quality and safety of the care received; on the other hand, it emphasizes the existence of a need that does exist: that of being listened to and enjoying an accessible point of reference. According to a meta-analysis of 148 studies conducted on a total of almost 310,000 participants, the further away from your reference point you live, the more you are exposed to all causes of preventable mortality, with an increase in risk that grows up to 50%, superior to risk conditions such as obesity, smoking and chronic physical inactivity.

More stress = inappropriate medicalization

The data, recalled in a post last summer published by Harvard Women's Health Watch precisely to underline the link between social isolation and mortality, illustrates to what extent the sense of security can affect one's life as much as the effectiveness of individual treatments aimed at prevent the onset of preventable diseases and complications.

Sometimes even more: when you feel you don't have control over your health, more medicalization can generate more stress, and more stress translates more easily into more inappropriate medicalization. This can happen more easily, for example, in the case of polypharmacological treatment, repeted diagnostic services, frequent check-ups without professional coordination and frequent inappropriate access to the emergency room, as in Sweden, where patients left for themselves, once discharged from hospitalization often return to hospital in worse conditions.

This means that there is no financial sustainability - no effective investment in excellent care technologies if the psychological, logistical and social needs of the patient are not taken into account. Especially when these are elderly. And their point of view - existential priorities and care needs - is the first to be traditionally underestimated.

The data in this regard are infinite, many of which have been collected and interpreted in the latest work produced by the UniSR research group on spatial, temporal and relational determinants that affect care for the elderly ("Home, Hospitals, Humans: the impact of space and time in long term care delivery and aging "), published by Politiche Sanitarie - Italian Journal of Health Policy in the last issue published in June: Mind the Gap: the impact of welfare fragmentation on the well-being of the elderly, chronic patient and complex.

The care setting is as essential as the treatments prescribed

The study supports the hypothesis that the context within which the elderly is cared for can affect his well-being as much as the effectiveness of the prescribed treatments, especially when the elderly must avoid going to the hospital and returning as much as possible; and proposes preliminary policy experiences with a view to strengthening the territorial network:

• the importance of the general practitioner
• the support of the hospital specialist
• new models of identification of latent need (health population management)
• new models of proactive patient care (care management)
• new integrated financing models by path and outcomes (personal health budget)
• new models of functional rehabilitation at home (reablement) and social participation (social prescribing).

Their daily life is made up of places (where the elderly live, where they must go in case of need, the ability to move, architectural barriers, frequent transitions between places of care, or to long-term care or assisted residences), times (the times of taking charge, the daily routine, the waiting times) and people (having a ready and informal point of reference, an accessible and professional one, a context in which to feel as safe as possible, and the various professionals who eventually meets in the same transitions): the identification of contextual variables that affect the well-being of the elderly person represents a dutiful and cost-effective investment in terms of integrated and proactive management of the elderly person.

The well-being of the operators involved in the daily care of the elderly, in turn, is significantly affected by the same variables: places (characteristics of the place where one works - hospital, clinic, assisted healthcare residence; travel times; spaces to be guarded), times (shifts, shift times between home and work, organization of the department) and people (relationships with colleagues, patients, relatives and the care network outside of one's own work setting). In this regard, the study proposal by the HHH research group was recently described and published in the 34/2020 issue of the Italian Journal of Nursing.