|Asia is aging fast, particularly eastern Asia, including Taiwan,
China, Korea, and followed by southern Asia . Health characteristics
of older people differ extensively from adults, which deserves some
specific designs in the healthcare system to ensure the quality of care.
Modern healthcare system emphasizes reducing acute hospital lengthof-
stay to improve the efficiency of the whole healthcare system, but it
may jeopardize the chances of frail older patients to receive sufficient
rehabilitation . It is generally agreed that older patients need a longer
period of time to recover from the acute illnesses and the process
of recovery requires multidisciplinary approach . A common
difference of healthcare system between Asian countries and western
countries include the lack of well-established general practitioner
system and post-acute service system . Moreover, the Geriatrics is
also a newly developed specialty in most Asian countries that currently
only Taiwan, Hong Kong, Singapore and Japan have developed some
specialty training programs [5-8]. Due to the health care needs of
older people, acute care system and long-term care system have been
developed in various forms across Asian countries, but not post-acute
care services. To date, only Taiwan and Singapore have formally started
post-acute services. However, due to the unavoidable needs, post-acute
care services did exist in the healthcare systems of individual country
with different names [9-11].
|In recent years, a series of researches regarding post-acute care
in Taiwan has been published internationally sharing important
information of post-acute care to the world. Taiwan is one of the
fastest aging countries in the world and the development of post-acute
care services was started based on the British system, i.e. intermediate
care. The concept of intermediate care was formally introduced in
2000 after the National Bed Enquiry in England, which has become a
national standard in the National Service Framework for Older People
of England afterwards . Intermediate care provides integrated
social and health care services close to home to promote functional
independence and prevent unnecessary hospital re-admissions for
older patients after acute illnesses. Several established models of
intermediate care have been developed in England, e.g. hospital-at
home, community hospital, rapid response team, hospital supported
discharge team, community rehabilitation team and so on. Amongst,
community hospital model has been considered the most cost-effective
model , and so was the post-acute care service system built in
Taiwan. Compared to intermediate care in England, post-acute care
developed in the United States was more skilled nursing facility-based
practice that aimed to shortened hospital length of stay in acute beds.
Therefore, post-acute care services in the United States may mix with
some acute care and sub-acute care, instead of the purely “post-acute”
stage. Currently, in the United States, four types of post-acute care
services have been developed, including skilled nursing facilities, home
health agency services, inpatient rehabilitation facilities and long-term
care hospitals .
|In England, patients referred to the intermediate care services were
evaluated by the primary care team and integrated with the discharge
planning by preparing community-based care package for patients in
need. Therefore, the determination of referrals for intermediate care was made according to the care needs for individual patients, instead
of disease entities. However, in the United States, the referral criteria
for post-acute care were firstly categorized by disease entities, including
stroke, traumatic brain injury, hip fractures and patients receiving
arthroplasty. For patients with multiple complex medical conditions,
e.g. chronic heart failure, chronic obstructive pulmonary disease, and
osteomyelitis, they would be admitted to the long-term care hospitals
in the United States. Nevertheless, main post-acute care services in
the United States were delivered through skilled nursing facilities
and home health agencies. Eventually, elderly patients may present
with different functional deficits on top of the acute illnesses, which
absolutely needs multidisciplinary team intervention after the success
of treatment for acute conditions. Therefore, screening post-acute care
needs for older patients should be based on the multiple complex care
needs instead of specific disease care needs. Based on this scenario, the
post-acute care services in Taiwan were screened and delivered by the
comprehensive geriatric assessment (CGA) and the clinical outcomes
were also evaluated by CGA . In American models, evaluation of
effectiveness and care problems identification of post-acute care were
done by different instruments in different settings, e.g. using minimum
data set in skilled nursing facilities. Nevertheless, these instruments
were similar to CGA in clinical Geriatrics. In England, no specific
instrument was implemented to evaluate care problems or clinical
effectiveness but using clinical judgement of multidisciplinary team.
|The development of post-acute care services for frail older
patients is of great importance because nearly a third of older patients
discharged from medical wards of acute hospitals may die within a
year if no post-acute care was provided . Moreover, every 3 months,
a quarter of these patients may re-admitted to acute wards . This
discovery strongly demonstrated the significance of post-acute care
for older patients, irrespective of disease entities. Taiwan started the
post-acute care services in 2006 and 3 tertiary medical centers with
5 community hospitals (150 beds in total) participated in the pilot
program. The patients were screened by CGA at tertiary medical
centers or acute wards of the community hospitals. The intermediate
care units of the community hospitals were refurbished and staffed
according to the principles of elder-friendly hospitals to provide a
home-like environment that equipped by a multidisciplinary care team.
A universal practice guideline was introduced by the Intermediate Care Program Management Office in Taipei Veterans General Hospital that
regulated the service model of all participating hospitals . Overall,
we found that nearly a quarter of elderly patients in the acute wards
may possess certain functional problems that were suitable for postacute
care referrals (unpublished data). Moreover, current program
significantly improved short-term physical and mental function in
4-week services , and this functional improvement was also beneficial
to long-term mortality risk reduction for older patients . Besides,
we found a significant dose-dependent relationship between physical
therapy and functional outcomes, which suggested the clinical benefits
of the intensive physical re-ablement program in post-acute care
settings. Meanwhile, less than 20% of patients admitted to intermediate
care units may be re-admitted to acute wards due to various reasons,
mainly infectious diseases, and some fall-related injuries (unpublished
data). Post-acute care is sometimes being mistaken as part of long-term
care services, which is not correct in many dimensions that post-acute
care is designed mainly to promote functional recovery for frail older
patients instead of maintaining function in long-term care settings.
Therefore, post-acute care should be delivered within certain time
limit. In England, intermediate care is usually no more than 6 weeks
and in the United States it may extend to 100 days in some occasions.
However, to draw a clear distinction of post-acute care between acute
and long-term care is challenging and is dependent on the healthcare
service systems in different countries.
|In conclusion, older patients usually need a longer period of
time to recover from acute illnesses but shortening acute hospital
length-of-stay is a common solution for every country to reduce
healthcare expenditure, which will definitely jeopardize the chances of
rehabilitation for frail older patients. Therefore, introducing the postacute
services in modern healthcare systems is of critical importance to
improve the efficiency of acute care system and to ensure the health of
older patients. Since Asia is aging very fast, the establishment of postacute
care system should be initiated as soon as possible to cope with
the healthcare challenges in the near future.
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