| 4. In which ways is the initiative creative and innovative?
This initiative of elderly care is the first in the gulf in its components. Initially, there was reference to international standards of geriatric care as we have a lack of them in our institute. However, these standards were adjusted and reformed in a way to suit the eastern conservative background and culture.
After a lengthy review of the existing systems in the area and internationally , we did not find any other experience that we can replicate to help us in achieving our goals . So we worked on the international standards and created a full geriatric assessment booklet. This booklet has several sections for all the needed subspecialties including : physician, nurse , physiotherapy, dietitian , and social workers. Each section has to be filled by the same subspecialty for each patient.
Then we created software where we can enter all the data collected in order to create a database. This database was analyzed and helped in producing the necessary information for further planning for decision makers. There is continuous update for these protocols to acclimate the dynamic changes and advancement in their care.
The specific elements of the program consisted of the following:
a) A multidisciplinary team specialized for geriatric care
b) Developed a booklet to record all information concerned with their care and follow up
c) The main tertiary hospital and other peripheral centers were combined in a way to provide a systematic and organized care to the patient.
d) Continuous education of all the involved personnel about the geriatric care
e) Very motivated team ‘, we invested in the human factor
f) Getting all services available and all stakeholders together to create the best picture of geriatric services
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The project is implemented by
1. multidsciplianry teams in primary and secondary care and post acute and long term facility services
2. the mobile geriatric units
3. team in psychiatry hospital
4. it involved personal with different specialites : geriatric physicians , psychiatry, nurses, dietetion , physiotherapy, occupational therapy , social workers and allies health
the population affected by this program :
1. all the geriatric population and resident in the kingdom of Bahrain
2. who are in acute care, pot acute care in secondary care hospitals
3. who are attending local health centers
4. who are attending psychiatry hospital
5. who are living in nursing homes and day care facilities
| 6. How was the strategy implemented and what resources were mobilized?
The strategy of improving geriatric care was implemented according to the clear mission and objectives defined in the Kingdom of Bahrain MOH 2030 vision. At all times, our central goal was to improve all services provided to the elderly population of the country.
The initiative was conducted according to two phases:
a) Planning: October 2010- June2011 a group of meetings took place between the head of the initiative Dr. Jameela and the officials of the MOH. The plan, mission, vision and goals were discussed. The deficiencies in the field were clarified and set according to priorities. The personnel involved in the program, each was given a specific task to carry out to bring out a final plan and vision. The agreement on the strategy logo was done too. Part of the planning was to sit educational preparations to be part of the strategy. A communication was done with Ministry of Development and Social Affairs to mingle them in the strategy as they already have contributions to the geriatric population in more of social aspect. We started by recruiting health care workers who has experience in the geriatric care and we created the main team which covered Salmaniaya medical complex, Muharraq geriatric hospital and the rehabilitation center .
b) Scaling: June 2011-June 2012 those involved in the program were given a month period to achieve their assigned duties and a regular follow up was done by the head of the program to check the feasibility, accuracy and efficiency of the program. The program was started in Salmaniya medical complex for evaluating all the inpatients in the geriatric age group who needed a geriatric care . they were evaluated to provide the full care , improve their length of stay , prepare them and the caregiver for going back home or plan for their stay in the rehabilitation center or if not possible to the long term facility. Then we started applying to more inpatients by decreasing the referral age to all above 60 years as our team was more capable of running the service .
Then we applied the same process to all patients in the geriatric hospital with the long term stay. Then we expanded our services and had meetings and education to the personnel form ministry of social affairs who are involved in geriatric care.
Now it is covering all secotrs of services
c) Monitoring and Refinement:
- Since June 2012: the program was continuously monitored.
- Daily walking rounds on the cases refereed
- Regular weekly meeting in both salmaniya medical center and Muharraq geriatric hospital to discuss the cases and make sure that the program is going smoothly
- The data were collected on a timely manner and entered in the software for analysis
- Different leaflets/ brochures were created and distributed in the hospital and other periphery centers to define the team goals and encourage others to be part of it.
- In addition, multiple lecture and teaching sessions were done for different departments who encounter elderly patients to introduce them to the program and clarify to them the challenges faced by this population.
- Along the way, any deficiency or defect was re-adjusted to suit the goals of the program.
- Meeting with provides of services in primary care
The improvement of geriatric health care strategy was fully supported by the MOH. It was a great challenge to convince the authorities to support this program. The strategy was a new vision with long term goals and significant results on medical and social understanding on geriatric care.
Recourses involved in the program:
1) Human: all human resources were mainly from Salmaniya Hospital and the periphery geriatric hospitals including Muahrraq Geriatric Hospital and Ebrahim Khalil Kanoo Long Term Rehabilitation Center. This involved all the needed subspecialties form these centers including : physician, physiotherapy , nurses , dietitian and social workers . the manpower in primary care and psychiatry hospitals
a. the brochures, leaflets and all lectures which were provided to the hospital personnel were arranged by the heads of the program and financially supported by the MOH.
b. The creation of the software was done by the team
c. The analysis of the data was done by the members of the team
3) Financial: the MOH fully supported the program. However, there was no separate budget for the strategy. It was included in the financial plan of the internal medical department. A main point which makes our program to stand out as an innovative project , is that it was done with no extra budget. On the other hand, we were able to save a lot of budget by providing this service whch facilitate the discharge of the patients and decreasing the length of stay.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The main stakeholders were three multidisciplinary teams, each team was in one facility ( the main hospital, the rehabilitation center and the long term facility ) The team in each center involved a group of:
1) Physicians: a group of geriatricians and other medical residents who are interested in the field. Physicians from other departments within the hospital who come across elderly patients were involved s part of the teaching lectures which were held at different timings. They were involved in daily rounds and taking care of the patients. They were involved in completing the geriatric assessment and entering the data and analyzing it.
2) Nurses: nurses from Salmaniya Hospital and geriatric centers were involved in establishing the initiative. They were major component of the program as they were involved directly in the elderly patient care. They were regularly updating physicians about the health status of the patient and whether any further intervention was needed to fulfill the goal of the initiative. They were doing the daily rounds on the patients , evaluating them and proving the needed care. There were involved in completing the geriatric assessment and entering the data
3) Nutrition: nutritionists were part of it too. Regular visits done to the patients in the wards. The feeding requirements were calculated according to a specific scale. They also helped in teaching care givers of the best method of delivering he food to the patients in the safest way e.g. oral, nasogastric feed.
4) Physiotherapist: in Salmaniya Hospital and peripheral geriatric hospitals and a group of physiotherapists were trained to asses all elderly patient and plan a program that suits their general status taking into consideration their co morbidities. In one center, an occupational therapist is available too. He is involved in creating re-creational activities to enhance their mental and behavioral capabilities.
5) Social workers: their main role was to deal with the in patient group particularly who had problems with their caregivers. Some elderly were socially neglected by their families or they belonged to poor families who had troublesome in providing the basic necessities to their elderly. The social workers helped in understanding the social circumstances of each patient and to try as much to overcome any obstacles that would put the patient at risk of negligence.
6) Administrators; they were involved in the initial creation of the team and in regular follow up of the progress of the team and gave all the support needed for all the functions.
7) Same stakeholders in primary care
| 8. What were the most successful outputs and why was the initiative effective?
The most successful outputs of the is project is to provide a high level of quality and an accessible services to this group of population that is usually was underserved. The result was an efficient experience entirely oriented to make sure that the elderly patients, their relatives and their caregiver are not left alone and they have a high quality services developed to them.
The most successful outcomes were as follow :
a) Increase in the number of discharged patients. As a group, all worked to fasten the recovery of admitted patients. One of the major points which helped in achieving this point was to involve the relatives in their care in the sense of having a detailed discussion about their underlying health problems and how it can be managed post discharge (e.g. bed sore care and nasogastric feed administration). The program has assessed almost 60 cases in Salmaniya Hospital and 7o cases in the geriatric hospital plus long term care hospital.
b) Improvement in the awareness of non-medical department of how to approach and address elderly population. Through a number of lectures and teaching sessions which were held throughout the year and involved doctors plus nurses, the key points of elderly care and when and how to investigate any existing or newly emerging problem. Total so far more than 400 people were involved in the teaching sessions with around of 15 workshops held. The plan is to extend these educational activities to include schools and universities.
c) Improve in the family communication with the assigned team. Such contact made it easy for all components to contribute to the patient’s long term care. Any concerns raised by the relatives were answered and as much addressed before the discharge.
d) We were able to decrease the length of stay for a lot of geriatric patients in the hospital , as most of them get admitted under different subspecialty and they received treatment for the admission diagnosis . On the other hand the primary care team , overlook the other aspects of geriatric care which leads to increase in the length of stay and increase morbidity and mortality related to hospital stay.
e) We had worked efficiently with the geriatric mobile unit in order to make this service available for all our patients who are in need for it. Collaboration with the geriatrics mobile team from the local health centers: the mobile unit had scheduled periodic visits to the patient at home once discharged. These visits were arranged by the social worker with the agreement of the caregivers. The unit assessed the patient fully including the vital signs and a quick general examination. Any queries were answered and the patient was advised to approach a primary or secondary care facility as needed.
f) A short term care was provided for a temporarily period in periphery centers such as Kanoo Rehabilitations Center. Patients were admitted there as a transition period between the hospital and going back home. During their stay, daily medical assessment is done and continuous nursing care. Along with that physiotherapy and occupation therapy is done to the patients as tolerated by them.
we were able to access a a large number of geriatric patients that are in need for the services :
1. we covered 1409 cases in the main hospital for acute care over 6 years, 4857 cases in psychiatry hospital over 5 years , and 1692cases in 2015 in primary care
2. we also have the mobile geriatric services which reach the geriatric population at home and provide for them services : in 2015 , 1443 case were visited and number of visits were around 19000.
3. We were part of national geriatric plan , as we put the medical part of the plan
4. A lot of educational services for health care workers : 22 workshops were 605 health care workers were trained
5. A lot of consultation services were given for patients and relatives : around 514 in health centers ,
6. We established educational materials in English and Arabic languages about the care of different geriatrics problems at home
7. Clinics that provide care for this population : number of visits for geriatric in health centers reached 300,000 in 2015.
8. To design a vaccination plan for the same population in different health facility , reaching 100% in inpatient an even the geriatric homes in 2015 , 1272 were vaccinated
9. A comprehensive preventive plan for females : for breast and cervical center
10. A medical assessment were done to even who resides in nursing home: 415 were assessed
11. Training sessions for nursing students :
12. Coordination with other NGOs : to increase level of awareness about geriatric care
13. Provide diet services specialized for geriatric population in all sectors : around 885 visits in the health centers
14. The plan for another post acute care facility , in process
15. Provide occupational therapy and physiotherapy services for who needed it .
| 9. What were the main obstacles encountered and how were they overcome?
Each step had its own challenge.
1. At first, it was getting the MOH agreement to approve the strategy which was later on eased by convincing them with real statistics about the problems being faced by the treating physicians and nursing staff.
2- No available database:
Challenge: The main obstacles we found at beginning of the strategy, that there was no available data of any kind that we can start with or to compare our results with.
The other major point that it was difficult for us as when we started there was a lot of paper work, and it was difficult to retrieve data.
- we created the booklet for the comprehensive geriatric assessment for data collection
- We established an electronic database.
- We analyze the data and give summary report to all stakeholders and to the decision making authority
- better and easier access for the data
- Facilitate data analysis, and daily updated data.
- Created a Database for future studies
2- Shortage of well trained staff in the best geriatric care
Another problem was a shortage of man power. As the geriatric population is considered huge and they constitute a significant percentage of the admission, to get enough staff to cover all the time could be a dilemma.
- shortage of well trained staff, including geriatricians , nurses , physiotherapists , social workers and dietitian who are trained to care of the geriatric population .
- A serial of educational lectures to all the health care workers and the stakeholders
- we started the program by limitation of the number of cases we can review
- more staff were recruited and trained mainly junior residents to ensure the sustainability of the project, more efficient data collection and analysis.
- more well trained health care workers are available to maintain the sustainability
3- No communication between all the stakeholders:
-there was no communication between the stakeholders who are taking care of the geriatric patients so the work was fragmented which makes it very difficult to deliver a quality service.
- Regular meetings between involved specialties with a high degree of transparency
- Availability of the forms with the recommendations inside the patients chart
- Availability of more geriatricians.
- More cooperation and collaboration between different specialties which improved the services we are delivering to this group of the population
4. Incorporating the family members and the patients actively in their plan of management
Challenge: we found that the patients and their family members or caregivers were not involved in any part of their management plan and they usually were surprised by the decision of discharge without any help form the staff in how to deal with their loved ones at home and that created a lot of problems.
The other main point was that many relatives belong to low socioeconomic status, so making them understand the needs of their elderly relatives and trying to help in their management was a bit of frustrating to them.
Solution : However, with the help of the social workers in particular who tried to provide them with basic supplies to ease the mission for them.
Outcome: the patients and their relatives are involved in their management plan from day one which was reflected clearly on the patients satisfaction and community satisfaction.