Caring for the elderly or over servicing? While we debate, Frank and Clara quietly starve

In the midst of the very vocal campaign against the freeze in Medicare rebates, you might have missed another pre-election advocacy drive that was launched this week: Aged and Community Services Australia (ACSA)’s Old, frail and invisible campaign will use the election run-up period to highlight the significant issues impacting on older people who require residential or community care.

The campaign is particularly in response to recent budget cuts affecting residential aged care but is also calling for finalisation and funding of a National Aged Services Workforce Strategy.

Helping older people access services and care that respond to their needs can be a time consuming and expensive business. Sometimes things can reach crisis point with multiple health and social problems compounding so that people require hospital admission for testing, treatment and stabilisation, before they can return home or move to supported accommodation.

In the post below, rehabilitation physician Steven Faux tackles some of these issues in the context of the push for health professionals to avoid waste, free-up the hospital system and eschew over servicing. When it comes to doing all this, while providing the best possible care, it seems sometimes doctors are between the devil and the deep blue sea…

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Steven Faux writes:

Once in a while I see things that remind me how alone we really are, no matter where we live what our bank balance is, or how well connected we might be. And it is in those moments when we can thank your lucky stars that we have some privileges that are universal, like healthcare.

Meeting Frank and Clara

I did a locum once in a fairly prosperous mining centre when I was asked to see a couple bought into the rehab hospital from a town about 45 min away. The referral letter read:

Dear doctor, I think Frank and Clara might need a nursing home

 Yours….

Right, typical I thought. Rather than doing his job this GP was flicking a case to the specialist just because he had to make a couple of phone calls and it would have all been a bit too difficult. I was haughty, I took an immediate dislike to the politely prescriptive tone of the letter –here we go again, GP telling me what to do, no real assessment because if it takes longer than 6 minutes you are losing money, and there’s the school fees you know….

When I saw the pair of them, I thought I was looking at one of those photos of the rural poor during the 1920’s depression.  All they needed was a pitchfork. Frank was deaf as a post and his hearing aids were in his pocket. He was covered with what can only be described as a barnacled coat of skin cancers, including all over his bald head and ears. He had a rattling cough and his toenails hung over the edge of his deformed toes like a rooster’s talons. He was a quiet, passive toothpick of a man, who seemed a little confused about where he was and whether his son was due to come around, but every question was answered with “don’t ask me, ask the wife, she’ll tell ya!”.

“The Wife” was marginally less coated in barnacles, held herself with poise and, if she was the gasbag of the two, then they lived in a world where language was in recession.  Eventually, she denied that they were unwell in any way; just had a bit of trouble getting to the shops and would probably need to live in a “retirement village or some such.”

Her knees were both swollen and deformed, her lips were chaffed and fissured at the edges and she looked like she would flutter away in a breath of wind. Both of them had delirium of differing severities and both appeared severely neglected. They both needed a grease and oil and a bit of fattening up.

Frank had been a train driver for the mine, and they lived in a little fibro across the road from the company’s station – avoid the traffic right. At the age of 65 he had retired and continued to live in his house with his wife. His children visited when they could. He had a simple life of fishing and helping “the wife” – she had raised 3 children in that house, and supported the whole family. When he retired she continued to live a quiet life, visiting locals and keeping an eye on Frank who, over the years, had become a bit more forgetful.

Things fall apart

It got to a point where Frank couldn’t go to the shops without Clara. He would forget why he was there and would end up chatting to one of his old mates at the bus stop and then come home after the shops shut. So Clara had to accompany him all the time and she was getting a little stiff from the arthritis in her knees. Getting about at home was just manageable but walking to the post office or local shop started to be quite a trial.

Too proud to admit any discomfort she was always cheerful when she visited the GP and told him not to bother, they were managing well. He offered to get her knees x-rayed and she refused; said it wasn’t worth it. He offered to send her to the hospital to see an orthopaedic surgeon but she couldn’t get there and wouldn’t bother her children. She just accepted it all as part of aging.

One of the sons phoned the GP and said he had visited with some food and noticed that there wasn’t much in the fridge. The GP did a home visit because they rarely came to the practice. He suggested that he organise a shopping service and told them all about home delivery – gave them the phone numbers. Frank listened quietly and Clara thanked the doctor but said they were managing fine. The daughter arranged meals on wheels but another son later found all the frozen meals stacked in the freezer as Frank was suspicious of the freshness of the and the possibility of food poisoning.

Meanwhile Clara started to get weaker and decided not to leave the house at all. A daughter called and Frank told her all was well but she nevertheless dropped over a casserole.  She lived over 3 hours away by car and couldn’t get there often – so quietly and without bothering anyone Frank and Clara slowly starved and by the time one of the sons drove them to the hospital it was clear that they were markedly undernourished.

Accessing care

So as not to bother the GP they had made an inquiry at a retirement village that Clara thought might be suitable, and when her son took them “for a drive” it was on the premise that they were going to look at this place. But the GP and the son were in cahoots, and had made a plan to take them to the private hospital where I was locuming, for admission under the specialist, and from there to arrange permanent transfer to the “retirement village”.

The public hospital was not an option for Frank and Clara because even if they were admitted they might be discharged once it was established that Clara had capacity to make decisions, which she likely would have had after a couple of days with food, water and medical care. Then it would be in the hospital’s interest to discharge them both and ask the GP to do all the social stuff like finding them supported accommodation and so forth, unless the hospital had a geriatrician with a bit of fight in him/her who at least could refer them to rehabilitation if they had a public unit, or to a private rehab unit.

This is not a weird or unusual story in the world of geriatric care, it happens in cities just as often as in country areas and is a product of retained dignity in the presence of failing capacity. There are fancy medical terms like hypokinetic delirium or acute on chronic dementia but they make no sense outside a hospital so I won’t be using them.

An admission, and stability

So they stayed for 3 weeks while we treated a urinary tract infection for Clara, and the arthritis she had in both knees, cleaned Frank’s hearing aids, replaced the batteries and got him to use them; established that Frank had dementia (Alzheimer’s disease), a chest infection and clapped out lungs (emphysema).

Both of them saw a dermatologist in town and had their skins cancers burnt off. They were both seen by the Aged Care Assessment Team who approved them for nursing home placement, the family were counselled on the costs and went to see a financial adviser in aged care costings, then they took Clara to see a local facility which she liked, and they moved in.

Costs, competencies and opportunities

A conservative estimate would put the cost of their admission and care to the health funds and Medicare at about $48,000. Accommodation including nursing rehab consumables, food etc ($42,000), medical care specialist appointments 3 times a week at approx. $75 each ($1350), dermatologists ($1000), radiology (2 chest x-rays, 2 knee x-rays, 1 brain scan) and pathology (urine, sputum tests, blood tests, kidney and liver function tests, sugar tests, vitamin levels) (approximately $3000), case conferences and family conferences ($780). Drug costs would be in addition.

Another approach would have been to get them seen by the GP, and have all their chronic diseases treated one at a time. This would have taken about  11 – 22 GP visits over 12 months (2 for the infections, 4 for the arthritis and emphysema diagnosis and treatment, and throw in  a couple of x-rays, some microbiology tests and a couple of knee injections, 6-8 for the skin cancers (you cannot burn them all of off at once), 2-4 to counsel them about nutrition and shopping and getting access to the town (I’d throw in some blood tests and scripts for certain vitamins), 2-4 with their children to discuss nursing home placements and get them to understand Frank’s dementia (thrown in a CT scan), Clara’s position as his decision maker and ”person responsible” (new name for next of kin),  the process of Aged care Assessment and the associated costs.

That cost over 12 months would have been between $2800 – $3200 (20 min GP attendances are $37 each on Medicare so $407-$814, a couple of treatment plans $240, the pathology and radiology tests would be about $2000 on Medicare, the ACAT teams are paid by the federal government and would be 2-4 hours of a nurse or an allied health therapists time $60-$120 with on costs). It would have required an exceptionally skilled GP with good technical skills (for example to do the knee injections), amazing communication skills as there are so many players, a practice nurse to assist in the coordination of the ACAT and the family and impressive management and team coordination.

And the GP has to be into it, so if you have a GP in the area that has more of an interest in paediatrics and obstetrics they may not have the skills or drive to do the geriatric stuff, or they might be overwhelmed with other work. And this is all predicated on a patient or couple of patients who are keen to be cooperative and do not have other ideas about health like – “stay away from doctors they make you sick”, “all you need is acupuncture for pain and vitamins for feeling poorly” or as in this case “you only bother the doctor about serious things, they are far too busy to chat about how to get to the shops!”

Valuing good GPs

Now some of my colleagues will say that a good GP will be able to use all the resources in their area to help, such as clinics at the local hospital and outpatient rehabilitation which would be true of the city but not always true in the country where GP’s have to operate more autonomously. The bean counters would say that the GPs have to get better at handling the chronically ill in the community and stop sending them into the hospitals – but would also say that seeing a patient once or twice a month for a year is over servicing and yet clearly that would have been what was required in this case.

Very experienced and highly trained GPs could do all this without a problem but not at every point in their careers. Some GP’s only get there for part of their career, because in the first 5 – 10 years they are well trained but not experienced. Most GPs become more skilled as they practice, and certainly for me when I was a GP, it was only from my mid career  that I could easily handle complexity in general practice. Moreover, the pricing structure of general practice encourages superficiality as GPs are paid more if they can see a patient every 6 minutes rather than seeing fewer patients in a day for 20 minutes each — and let’s face it, it takes an older person around 6 minutes to undress in winter, so responsible GP’s will have to arrange to address one health issue per consultation, and call the patient back a number of times.

So do GPs over service by calling older patients back to the surgery for a number of consults or are they simply working within the structure of fee for service? That structure still rewards shorter consultations (6 patients an hour, 10 min consults, GP makes $138/hr before expenses; 3 patients an hour, 20 min consults, GP makes $108/hr).  Even if you think they are over servicing, it is still much cheaper than referring the patients to a hospital and admitting them to do the year’s work in three weeks.

I take my hat off to those GPs who risk the charge of over servicing to help deliver care to complex patients and in so doing minimise costs in our healthcare system. They continue to make it one of the most efficient and affordable systems, that delivers some of the best health outcomes in the world.

Steven Faux is Director of the Rehabilitation Unit at St Vincent’s Public Hospital in Sydney, specialising in pain management and rehabilitation medicine.

He is also a senior lecturer at the University of New South Wales.

Read his previous post on medical complexity and “over servicing,” Madge’s Waltz: the delicate dance of medical decision-making, here