The Era of the Elderly and a new kind of health care worker

Release the 5 Billion euro Health Prisoners

Surprise: We have too much health care staff in Community Hospitals

By Maria Klemetz

An interesting research publication by Aalto University on comparison of healthcare costs was released today (julkaisutiedote). It concludes, that in comparison to similar countries, Finland has too much healthcare staff in Community Hospitals (Terveyskeskusvuodeosasto), and that the differences within the country are so great, that equal care for inhabitants in different parts of Finland is not achieved.

The government wants to reduce the expenses in the municipalities in Finland by 1 Milliard (US Billion). A big part of this is set to come from reducing institutional care of the elderly. But do they know how to do create the system substituting this?

living environment of elders in terveyskeskus

Picture from a community hospital (Terveyskeskusvuodeosasto) used as elderly housing in central Finland 2013.

The two elders in the picture above will not get up from the hospital bed ever more. A rescue operation would include heavy rehabilitation, and suitable living arrangements, and that happening is unlikely in the current system. This hospital room is set to be their home for the last years of their lives. These two are not alone in their situation. Around Finland, tens of thousands of elders are housed in municipal health centres. In Europe, Finland ranks in its own league in hospitalization, and not in the good way (graph 1 below).

The elderly do not have a choice because they lack any other solution. Old homes are unfit for elderly special needs. Apartment houses lack elevators, and housing is placed so that an eldely peron with lower mobility cannot take care of their daily needs by themselves. This is a result of scattered urban structure and sprawl, and a favouring of space for large technical infra like roads and parking before human needs. Elderly people can in general only walk about 150-200 m with the aid of a rollator, so we are talking not only about the normal suburban- sub centre places like Nurmijärvi, but also about unwalkable urban areas. A big traffic junction will easily take up more than 150-200 m, and make distances too long for elders to cross.

The elderly as collateral damage

Small municipalities are in trouble. Because of the drastic demographic change, they lack traditional young health care customers. There are no more kids with easily healing broken bones, ear infections or other simply solved symptoms to treat. The customers are chronic. Patients are often old, and they have a wide set of different physiological, psychological and social ills, that need a totally new and different approach for treatment, than what the system health centre system was built for, mainly in the 1960´s -1970´s on.  To deal with the lack of traditional health customers, the communal health centre hospital beds are filled with chronics. These chronics get worse in this hospital environment. The elderly are collateral damage for up keeping an old health system.

In a hospital bed, and a hospital environment, without any reason to get up, muscles deteriorate and moving capacity can disappear. Without daily activities, especially elderly patients can turn into high maintenance patients incapable of moving, even as quickly as within 10 days. In the picture above, note the bed railings and the high bed that cages you to your bed. Cage beds are said to be needed, because worker resources are scarce and it is *safe* to keep patients not moving. The workers are very busy, because they have so many patients that cannot move.

Institutionalization of the Elderly in Finland

The governmental decision to reduce institutionalization in Finland comes at a late stage: other European countries have gone from institutions to lighter forms of serviced apartments, decades ago. Communal living for the elderly is one form of these serviced living arrangements. Our neighbour Sweden started the demounting of institutional care already 30 years ago, in the 1980´s.

Living at home with the assistance of home care, is one solution. But living at home, in a Finnish urban setting, with quite diluted city densities (resembling the US or northern Sweden), the question will arise: where will this home be situated? Should the home that is now a single-family house or apartment far away from all service, be moved closer to other people and necessary daily services? Basic services focus on first and foremost food: be restaurants, grocery stores, markets, communal kitchens. Also things to do that will drive you out from your lone apartment: cultural activities and any place for social gatherings. This same urban question of making functioning places for the elderly is posed by many sparsely populated areas around the world. To leave this question unsolved would be expensive.

Dementia hoito Suomi FIN

Graph 1: Institutional care of people with dementia in Europe. Finland is in a separate league from the rest of Europe. We put people with memory disabilities into institutions, institutions often placed outside the centres and always locked down. This is a form of out-of-sight-out of mind-approach that we need to change.

HAD Hospital Acquired Disability

The main reasons for elderly to be put into an institution are dementia and inability to cope at home. By not answering to the needs of the elderly, we have created a hugely expensive care system that houses old people in our small community hospital beds. Changing the name of the hospital department to “Service Home” (quite common) does not erase the problem, nor does building bad service homes without addressing the core problem they have, do.  The elderly need holistic and preventive care: physical, psychological and social rehabilitation, elderly friendly walkable communities, housing combined with dense service structure. A life where help is not something you have to fight for (cheers, our friend Bureaucracy).  The elderlies´ actual need of help fluctuates much with times, and by individual. If acquiring help is difficult, as it is at the moment, one will hold on to it for security, once you manage to get it. Needed or not.

When an elderly person is put into an institution like ours, with tiny rooms designed to house only a bed, with little to do, and little of interest, the constant laying down deteriorates the muscles quickly. In as short of a time as 10 days the mobility of a previously walking elder, can disappear in a hospital environment. Medical professionals call this deterioration that occurs in institutions Hospital Acquired Disability HAD. By putting some elderly into institutions for longer time, we are creating vegetables. This is one of the most inhumane ways to create patients for, and keep a small communal hospital running, writes professor Erkki Vauramo of Aalto University in Talouselämä.

 SL702753
A hospital (and at times also the elderly service homes) lack the incentive to get up – why would you get up, to walk in the corridor? Hospitals create their own patients by being built and located so, that they passivate long-term patients. These health care hospitals were built for short-term care, when that was demographically needed. But now the majority of their resources go to long-term care that they are not suited for.

We have big possibilities for better choices

The European Directorate General for Health and Consumers DG SANCO has listed recommendations for maximum times that a patient should be placed in hospital institutions. This is in part in order to avoid HAD Disability, that is both costly, and a system created disability. HAD disability is caused by having to succumb your life 24/7 to the institution, that is not built for long-term care, nor fit for it. The recommendations for communal hospitals (Terveyskeskus-vuodeosasto) are max. 30 days, and for lighter more home like service institutions (Palvelutalo) max. 2 years. I created a few graphs to show the division of costs in regards to the recommendations in the Finnish institutions for the elderly. The green in the graph below is care as recommended; the red is not recommended care. Red care might make the patient worse. A good question is, if red is a malpractice of system (järjestelmällinen hoitovirhe). This is how the money resources in the Finnish system are used:

Division of cost of care periods in different institutions from hospital to serviced apartment

oikea vŠŠrŠ.xlsx

Graph 2. The overall cost of the not recommended care in red, is 5 Billion. The care, that is too long for institutions, and NOT recommended, makes up 83% of all care periods. The care shown in green, that follows recommendations, consists of only 17% of the overall cost (1 Billion). Our resources are used to house elderly who cannot cope at home, in hospital beds. This is because alternative housing and a support system is lacking.
 
oikea vŠŠrŠ.xlsx
Graph 3. The use of resources according to length of stay and type of institution.  In community hospitals (Terveyskeskusvuodeosasto) 99,15% of resources (1,32 Billion) are used for care that is against recommendations and is in cases inhumane. In community hospital beds, only 0,85% of resources goes to care that is within recommendations of suitable length for a hospital environment.
 

010_vaenn_tau_1012013123324930.xlsx

Graph 4. Graph shows that if Finland continues “Business as Usual”, the costs for elderly care will go from 2 Billion to almost 5 Billion years 2010-2060. I.e. the costs will more than double. Care that is against the health care recommendations (in red) will go up from 1,3 Billion today, to 3 Billion/year. Base data used is from SOTERA.

Possibilities

In Finland, we are at a crossroad of a 5 billion euro possibility. We have located the problem, which uses basically all resources. We also know why this happens – the elders cannot cope at home because of lack of motivational rehabilitation, lack of social contact, and because a part of the population has gradually developing lack of memory (dementia, Alzheimer). We have a system that due to demographic shift not dealt with, produces its own patients. Health care needs have without doubt changed with demography, but we have not yet changed the system. The system should aim at handling chronic disease: making it possible to live a good life with disability, instead of focusing on curing. In the same way, as industry has to re-evaluate its processes focused on machines and definable, tangible products, also health care is turning into partly non-tangible disease control. This widens the scope of health care and turns it into a cross-professional entity. The future of medicine will not any more be with the hero surgeon, who treats the instant fracture, but with the professional who can make chronic disease manageable. The hero surgeon-, fantastic in his own skill-, will surely keep his position, but from a national economic point of view, managing chronic disease will have bigger economic impact. The future doctor is a geriatric, a physiotherapist, psychologist and above all, a vocational therapist (toimintaterapeutti) … and well, a city planner. The future doctor is a team. These professions need the education and belief in their own knowledge, to make a difference. They also need to start looking for results in patient overall situation. A prescription cannot take away loneliness that can lead to depression, or make the patient´s home suitable for lower mobility.

End double service production

As it is now, our health centre hospitals and also the service homes for elderly cannot or do not systematically use the services existing in society. Service homes are often considered secondary, and built on bad spots, on cheap land (“saving”). There is also a notion of that the elderly need “peace and quiet”, when from a health perspective, the exact opposite could be better. By separating itself from society, the institution needs to produce its own society inside the facility -create a double system aside society. In institution, there is food production or food delivery, a spa, a gym, green rooms, common rooms, kiosks etc – all built and serviced separately by the institution. The staff trained for health care is stressed: on top of health care, they have to be entertainers, socialites and listeners. They are organizers of the double society inside the hospital. All things that a normal life needs. Creating a life in this way artificially is expensive. It also limits all the service produced to the “common middle” –  to be “cost effective” within an ultimately costly system. Elderly people are individuals and not all of the common middle. While this institutional life production is upkept, outside the service home in the urban city, there is an existing kiosk, grocery store, restaurant, library, swimming pool, funny people to look at, someone tripping over – the best life entertainment there is. By placing the service homes close enough to all this life, double production of normal life can be avoided, and health care staff can focus on their main task -health care.

Pay the doctor for health, not sickness

The government plans to give municipalities money counting how many sick they have. This would most likely be a mistake, as it increases the incentive to create sick people. The money should be better linked to results: how many people the municipality can heal, to cope in life. If health professionals´ salary or state funding for a municipality is dependent -not on how many sick people they treat-, but on how much they heal, the incentive is wiser. A municipality could get money based on how much change to the better they have managed to produce in the district. In such a system, follow-up will be better, care pre-emptive, cheaper, and primary care will work better. Comparisons of districts would have to be made based on similar socioeconomic age groups and take into account socioeconomic movement up in the lower groups, as a positive factor.

Also to finance the repair old health centre bed wards, as they were -spaces too small for daily rehabilitation and located far away from services -, is a similar counter productive money hole.

Strengthening belief in rehabilitation

Way too many doctors do not even themselves believe that rehabilitation of frail elders is possible. Yet, it is possible in other parts of Europe, for example in Sweden. The Finns are not too different a species to the rest of the humans to be rehabilitated, even if often claimed so.

There is a case, where a community hospital was in for closure. It was full of these vegetablized elders -the same we encounter around the country-, that lay unmoving in bed with mouths open. The hospital called in a team of rehabilitation specialists, and within weeks they had rehabilitated these elders so they walked, could take care of daily activities and could return to life for few years still before their final leave. This final time before death, when a person usually is bed-ridden, at best in Swedish elderly care homes it is only one week. In Finland on average it is from months to years. Are not our Finnish elders worth as short of a final death time, as the Swedes?

Lack of quick cash  – a political problem

The municipalities have at their hands old community hospitals and service homes for the elderly, that are not fit for long term care. These old spaces are built around the bed, and the whole organisatory and architectural flow, was back in the days (and still is) built to make it easy for a worker to give care to the bed.  This produces a care system, focused on the patient NOT getting out of bed. In short term care -fine, but now this system mainly treats chronics, the bed focus uses up all the resources and makes people sicker. Sick people need more hospital care, and the circular problem continues. To change this, a rehabilitation system is needed, together with new housing types more focused on making it possible to live your life. -Live it with needed support.

The city centres need to be densified, become walkable (rollator-able) and human-friendly. In this way city centres attract both local services and people, the two being dependent on each other. The municipality needs to generate money to do the investments to turn the old structure into something more focused on short distances and humanity. The investments would be regained quickly, in a few years, by the savings in health care costs.

Urbanism in the Era of the Elderly

The Era of the Elderly needs environments where the “weak people” feel at home, and where they want to spend time. Primarily the focus should not be on what the prime age adults think is cool or good. Prime age adults can cope and even thrive in bad environments, frail older people can not. They cannot live in disorienting large cityscapes, in cities with too long distances, they can not cross big areas dedicated for cars or unmaintained no-mans land that we have lots of in the suburbs and they need local services. To plan for the old, is the urban way to change the old system, and cut down on the expenses that the bad environments caused in the first place. Some resources can be found in stopping repair constructions of non-functioning spaces, bad for this purpose as they are. Communal politicians are the ones who decide how areas are built, state politicians how public infra subsidies are directed. This change needs good political communicators. Politicians face a challenge in communicating the change process to their voters. Before, non-communication and bulldozing projects by authority might have worked, but in today´s socially connected society,  it does not work that well. Who of our politicians will have the courage and the social skill to pull the change through the right way so it actually works?

It is easy to move costs into another place in the system by simple cuts, but no change to the actual system, much harder to actually create a system that is truly more efficent and even generative.

Written by Maria Klemetz, Architect and PhD candidate at Aalto University.

> More research and reports on the subject in Finnish.

In my next blog post I will write about the concept of integrated elderly living that we are developing at Aito Architecture – a part of the  solution to this Billion euro problem.

You can share your thoughts by commenting on this article below or by email, opinions are greatly appreciated.  If you are interested in the research for the Cities in the Era of the Elderly, or as a public institution want a closer analysis of the data, or want to discuss the possibilities of Elderly Friendly Urbanism in your municipality, you can contact our architecture office at toimisto@aitoark.fi . We do planning and consultation in the subject.

At the moment in Finland, within the old system, the costs for “wrong” elderly care  (=type of care that is against recommendations)  make up around 1,3 Mrd (Billion) €/year extra in Finland. In 2060, with the increase in old people, to continue the same kind of care system would cost an extra of 3 Mrd/year. Unless we change the system of care to focus on making life possible, instead of serving a life, the costs will keep growing. This system dictates how we have built care facilities in the past, and how we will build in the future. The buildings and environments set the limits for how care is, or can be carried out.

The PhD research “Cities in the Era of the Elderly” aims to show how we can change the elderly care system, by bringing the elderly into society as participating people.  By making it possible for the elderly to cope in daily life, the elders themselves, just by living, also create a more active economy. In the same time, Old Age is given the chance to be better than at the moment. The system savings for this are estimated to about one third to half of the current elderly care system costs.  This estimate does not yet take into account the positive value of the added amount of people in the urban economy. This research will give guidelines for the creation of Elderly Friendly, walkable communities.

Since research of public system change does not appear to be popular with funders, the research is self funded. These funds are by now depleted. If you want to see this research ready and published soon, you can help by becoming a Research Funder. All Funders will get lots of love, and of course be invited to the party. To donate you can use the link button to PayPal, or other codes below. For an invitation leave your contacts in the message field.

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