Age-sensitive hospitals: Need and opportunity

Currently, India has the second largest elderly population in the world. There has been a progressive increase in both the number and proportion of aged people. The proportion of the population aged 60 years or more has been increasing consistently over the last century, particularly after 1951. The size of the elderly population has risen from 12.1 million in 1901 to approximately 77 million in 2001. According to official population projections, the number of elderly persons will rise to approx. 140 million by 2021. Over the next four decades, India’s demographic structure is expected to shift dramatically from a young to an ageing population resulting in 316 million elderly persons by 2050.
Along with the rising numbers, life expectancy is also increasing. The expectancy of life at birth during 1996-2001 was 62.3 years for males and 63.39 years for females. The projected longevity for the periods 2006-11 and 2011-16 are 65.65 and 67.22; and 67.04 and 68.8 years, respectively for males and females.

Geriatric consumers’ needs have specific characteristics. The common ailments are hypertension, heart diseases, cancers, osteoarthritis, hearing impairments, cataract, respiratory problems, nutritional problems, diabetes, tuberculosis, and mental morbidities. Elderly persons in India often die from preventable conditions like bronchitis, asthma, and pneumonia. An absence of human and institutional capacity for geriatric care in the Indian healthcare system contributes to variations in morbidity and access to care. Both outpatient visits and hospitalizations of the 60+ age-group are more than three times that for the general population leading to higher expenditure on healthcare. 20%  of doctor’s visits, 30% of hospital days and 50% of bedridden days are related to elderly patients. India’s old are hospitalized for an average of 32 days. This population takes an average of six prescription drugs concurrently and often suffers from adverse drug reactions. Increase of morbidity associated with chronic non-communicable diseases due to increased life expectancy requires providers to keep pace with the higher demands of the ageing population on the system. “Health & Ageing”, the WHO theme for 2012, with the slogan of “good health adds life to years” is also an attempt to highlight this urgency.

Geriatric specialization is popular among the healthcare professionals in the developed world, such as the US. Till recently, in India, only one educational institution in Chennai offered a PG degree in geriatric medicine. Others such as IGNOU offer a one year part-time, PG Diploma in Geriatric Medicine (PGDGM) and IMA AKN Sinha Institute offers a certificate in Geriatrics.  In terms of infrastructure, India has very few geriatric hospitals. Though some hospitals have outpatient clinics for the old, most hospitals do not have separate geriatric care specialities and most of the elderly patients are treated in general medical wards. To address these gaps, the government has planned a massive upgradation of the infrastructure and healthcare manpower under the NPHCE (National Programme for the Health Care of the Elderly) launched in early 2011. It envisages establishing geriatric wards and geriatric clinics at various levels of the district healthcare delivery system. Geriatric units with 10 beds at district hospitals and elderly clinics twice a week at the CHC level are planned. In addition, the following eight regional centres with geriatric wards and manpower training are being established across the country:

• All India Institute of Medical Sciences, New Delhi;
• Institute of Medical Sciences, Banaras Hindu University, Uttar Pradesh;
• Sher-e-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir;
• Govt. Medical College, Thiruvananthapuram, Kerala;
• Guwahati Medical College, Guwahati, Assam;
• Madras Medical College, Chennai, Tamil Nadu;
• SN Medical College, Jodhpur, Rajasthan; and
• Grants Medical College & JJ Hospital, Mumbai, Maharashtra.

Among the private sector, Apollo Hospital, Chennai has a department of geriatric medicine. Hyderabad-based Heritage Hospitals also have a separate geriatric department. Many hospitals in the metro cities such as Max, Fortis, Rockland, Pushpanjali, Crosslay and Jaipur Golden in Delhi have started programmes targeting geriatric care. Small standalone geriatric hospitals such as Vindhya Geriatric hospital in Bangalore and Aastha Hospital in Lucknow have been started.

Organizations can utilize this demand and focus on customer satisfaction through quality care. Key factors to their success would be to:

Adopt a suitable biz model
Successful models could vary from establishing exclusive geriatric centres to upgrading the existing facility, as listed below.  

• Specialized geriatric care hospitals - catering to all specific medical needs of the elderly.
• Extended geriatric care centres within the existing facility.
• Integrated geriatric care centres within the existing facility.
• Satellite centres attached to the speciality hospitals.

Extend scope for specialized geriatric centres
Although WHO defines age 65 and above to be the geriatric age group, 50 years and above could be targeted given the similar needs and disease profile.  Additionally, this will increase the volumes to the centres. The hospitals also need to identify the diversity within the elderly age group. The ‘young old’ (60-74 years), ‘old’ (74-84 years) and the ‘old old’ (85+ years) would have different requirements for support and nursing.

Provide comprehensive care
To be successful, the geriatric care centres need to provide complete and holistic care from diagnostic services, screening, curative services, rehabilitation and palliative care in the form of old age homes for assisted living to home-based care. The services need to cover the entire gamut of needs of the elderly:

• Maintenance of Respite Care Homes and Continuous Care Homes
• Running of Day Care Centres
• Physiotherapy clinics for older  persons
• Helplines and counselling centres for older persons
• Continuous training focused on elderly care for the care givers and family
• Awareness generation programmes for older people and care givers
• Mobile medicare units to enhance accessibility
• Formation of senior citizens associations etc and associal support systems.

Adopt elderly-friendly practices
With age, there are different physical and emotional needs. These must be addressed with equal priority. Hospitals can benefit from adopting simple and friendly practices and enhance patient satisfaction. Particular areas of focus can be:

• Facility design: The specialized centres need to be age-sensitive and designed with understanding of the physical requirements of the elderly to minimize inconvenience. To promote an age friendly environment measures such as wide corridors, ramps, railings, grab bars, anti-skid tiles, adequate illumination, bed rails, calling bells, toilets for the disabled and elevators should be implemented in both outpatient and inpatient facility.

• Processes and procedures: Simplified OPD, admissions, discharge and billing processes would facilitate quick and hassle-free interactions between the patient and the system. Adopted technology needs to be age-friendly. Geriatric care management models can be adopted. Under this model, Geriatric care managers need to be assigned to a group of patients to form a link between the system, the physicians and the elderly. These managers can also work to increase the operational and administrative efficiency of the hospital by smoothing out the processes.

• Patient assistance: Escort systems to provide assisted care from entry to exit for the fragile aged. This also could be extended as home care in specific cases.

• Trained staff: Medical and paramedical staff specialized in geriatric medicine and gerontology services must be present. There needs to be a promotion of an in-house culture of care to ensure the health promotion of the ageing.

Tie up with public sector, insurance cos and NGOs
More than 65 per cent of India’s old live in rural areas and are illiterate and economically dependent, which makes them the most vulnerable. About 36 million people in India fall below the poverty line each year as a result of healthcare costs. The influence of cost constraints on decisions to seek or continue treatment is high among the aged. Any attempt to improve the quality of geriatric healthcare in India must address these financial barriers to access. This can be achieved through public- private partnership models and increasing the penetration of health insurance from the current level of 20 per cent. To effectively reach out to the local community, the geriatric centres would gain by tying up with organisations/NGOs active in geriatric care.  

Target medical tourism
The median age of the global population is steadily rising, with the number of people aged 60 years and more expected to double by 2025 and triple by 2050. While this trend of population ageing is inevitable and is likely to accelerate by further declines in mortality and fertility, investing in elderly care could be a source of long-term, sustained revenues. Addressing these elder care challenges will not only be crucial to India's continued social and economic development but will also establish India as a popular hub for elderly medical tourism. India’s image as a country with a joint family culture focused on elderly care combined with its cost-effectiveness could further promote this tourism.