Medical Social Integration from a Family Doctors Perspective

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Medical Social Integration from a Family Doctors
Perspective
2

• What are the differences between caring for a
  sick elder and a sick young adult?
• Why family doctors are in the best position to
  deliver community elderly care?
• Case example to demonstrate why medical and
  social integration is necessary for the delivery
  of optimal community elderly care.
• What are the obstacles of providing elderly cares
  by family doctors?

3
What are the differences between caring for a
sick elder and a sick young adult?

• Elderly patients commonly have multiple problems,
  including medical, mental and social conditions.
  Chronic illnesses also are more common in the old
  population.
• The elders have decreased reserve capability.
• The presentation of a sick elder is commonly
  atypical.

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What are the differences between caring for a
sick elder and a sick young adult?

• When people get old, changes in body composition
  make older people more vulnerable to adverse drug
  reactions.
• The intellectual decline, together with multiple
  physical deficits will cause problems in
  communication.
• Caring for frail elders requires both
  multidimensional and multidisciplinary management.

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What are the differences between caring for a
sick elder and a sick young adult?

• The elderly population is heterogeneous. That is
  to say, for the same age group of elders, their
  health status is not uniform and there is
  tremendous variation.
• As people age they become more individual and
  differentiated. There is increasing variability
  with age - among individual and among levels of
  functioning from day to day.

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What are the differences between caring for a
sick elder and a sick young adult?

• Because of this variability, chronological age
  per se has lost its meaning as a marker of
  personal capacity.
• As a general rule while managing sick elders,
  care becomes more important than cure and
  function more important than diagnosis.

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What are the differences between caring for a
sick elder and a sick young adult?
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What are the differences between caring for a
sick elder and a sick young adult?

• In the care of elderly patients, family members
  provide the majority of care necessary to keep
  their frail elders in the community.
• Therefore, a visit to the doctors office often
  includes the family caregiver accompanying the
  elderly person. Thus the doctor-patient
  encounter, which is commonly dyadic becomes
  triadic.

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What are the differences between caring for a
sick elder and a sick young adult?

• The role of the caregiver during these visits may
  not always be predictable it may be facilitative
  , supportive or neutral. It can also be
  antagonistic, such as the co-opting of an agenda
  to meet the caregivers own needs. Therefore,
  doctors need to have good communication skill in
  triadic encounter.
• Furthermore, in the care of their elderly
  patients, doctors may find themselves not only
  assisting caregivers in problem-solving and
  referral to community resources but also
  assessing the caregivers health and coping
  skills.

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What are the differences between caring for a
sick elder and a sick young adult?

• Caring for elders is stressful the caregiver is
  encompassed with the physical, social,
  psychological, and financial toll of providing
  care. The caregivers become the hidden victims.
  
• Recent finding has shown that family caregiving
  is an independent risk factor for mortality among
  elderly spousal caregivers.

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What are the differences between caring for a
sick elder and a sick young adult?

• Informal caregivers have a higher level of
  depression, more likely to experience physical
  pain, and more likely to experience financial
  stress.
• Failure by doctors to recognize the burden on
  informal caregivers may result in long term
  adverse outcome on this group that may outweigh
  the benefits of managing people with disability
  and chronic illness in the community.

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What are the differences between caring for a
sick elder and a sick young adult?

• Caring for the caregiver, thereby reducing
  caregiver burden and helping with care-recipient
  problems, could result in great benefit for the
  patient, informal caregiver and for the larger
  community.
• Doctors who look after the family and know the
  family function well, they are most suitable in
  the healthcare systems to assist both the frail
  elderly and their family informal caregivers.

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Why family doctors are in the best position to
deliver community elderly care?

• Are readily available and affordable.
• Are accustomed to provide holistic and family
  care.
• The family doctor seeks to understand the context
  of the illness. Many illnesses cannot be fully
  understood unless they are seen in their personal
  , family and social context. When a patient is
  admitted to the hospital, much of the context of
  the illness is removed or obscured. Therefore, it
  is not unreasonable for hospitalized elders
  request their family doctors to pay visits to
  them.

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Why family doctors are in the best position to
deliver community elderly care?

• Family doctors provide continuity of care and
  there is evidence that continuity of care is
  associated with patient satisfaction, decreased
  hospitalizations and emergency department visits
  and improved receipt of preventive services.
• The family doctor views his or her practice as a
  population at risk. Always think patients in
  terms of both as single and population groups.
  This concept is important for the delivery of
  anticipatory care.

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Why family doctors are in the best position to
deliver community elderly care?

• They have earned trust from the family long
  before seeing the patient.
• They have owned comprehensive knowledge of their
  patients.
• They practice patient-centered communication in
  such a way that it is correlated with the
  patients and caregivers perception of finding
  common ground.

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Why family doctors are in the best position to
deliver community elderly care?

• They practice learnt communication skills
  (triadic encounter, poor historians).
• They are used to deliver coordinated care.
• They are frontline doctors therefore they are in
  the best position to offer preventive care and
  functional geriatric assessment.
• They are keen to establish good patient-doctor
  relationship since it has always been their first
  priority.
• They advocate the practice of evidence-based
  medicine

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Case example to demonstrate the importance of
medical and social integration

• Mrs. Lau a 72-year-old, type II diabetic.
• Caregiver for her husband who is also one of my
  patients.
• Mr. Lau, in addition to coronary artery disease,
  has hypertension, osteoarthritis, cataract, gout,
  anxiety, and had a stroke three years ago.

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Case example to demonstrate the importance of
medical and social integration

• She complained to me during one of the regular
  follow ups that she was getting tired easily,
  losing weight, and lack interest in many things
  despite good blood glucose level control.
• I routinely enquired for caregiver stress, she
  suddenly bursted into tears and frankly admitted
  that she was disturbed by her husbands unusual
  behaviour.

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Case example to demonstrate the importance of
medical and social integration

• For the last few months, her husband had become
  very unreasonable, stubborn, irritable, and
  sometimes acting strangely. She began to has
  negative thoughts such as she was not wanted any
  more, she was not good enough for him, and they
  could no longer tolerate one another. Since she
  did not think that it was a medical problem,
  therefore she did not come for help. She became
  helpless and was trying hard to find the solution
  herself. She had decided that if the problem
  could not be solved, she would have to send him
  to an OAH.

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The analysis

• The longstanding doctor-patient relationship and
  knowledge of the medical and social background of
  the family helped me to spot the following
  problems.
• Mrs. Laus family, in addition to the underlying
  medical problems, there were undetected new
  medical problems and social problems.
• In this case, the new medical problems had
  emerged as a complication of her husbands
  underlying medical diseases.

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The analysis

• The new medical problems were
• Dementia and depression
• which are common in elders with multiple
  chronic diseases, especially those with a
  history of stroke.
• The social problems were
• Caregiver stress.
• Imminent family breakdown.
• Mr. Lau would have to be transferred to OAH
  against his will.

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The management

• I explained to her that the situation was not the
  same as what she thought instead it was the
  consequence of the new medical problems. I
  provided information about the management of the
  current situation. It was very effective in
  mitigating her emotional sufferings. I further
  offered non-drug, and drug treatment to Mr. Lau.
  Eventually the problem was solved. Additionally,
  Mrs. Lau was also screened for hidden
  psychological problem.

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The management

• In order to solve the social problems that came
  with the medical problem, namely dementia, I had
  also discussed with the family about referral to
  social services where supports for caregivers and
  dementia patients are being provided.

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The importance of medical and social integration

• Had I not enquired about the social situation
  (caregiver stress), I would have missed Mr.
  Laus medical problem.
• On the other hand, the social problems would not
  have been solved unless the medical problem was
  detected and managed.

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The importance of medical and social integration

• Doctors usually pay attention to medical problem
  and ignore social problem, but in the management
  of community elderly patients, holistic
  management is always necessary. Very often, in
  order to solve the elders problem, the doctor
  has to integrate the medical and social
  situations so as to find the solution to help the
  elderly patient and family.

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What are the obstacles of providing geriatric
cares by family doctors?

• The private family doctor do not have sufficient
  government support.
• By and large, continuity of care is not viewed
  important in the care of elderly patients both by
  the public and government.
• The one way referral system preposterously
  operating in Hong Kong , makes it extremely
  difficult for family doctor to manage and follow
  sick elders.

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What are the obstacles of providing geriatric
cares by family doctors?

• The family doctors do not have interdisciplinary
  team support which is often required for the care
  of elderly patients.
• There are few if any, private and public health
  care services integration.

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What are the obstacles of providing geriatric
cares by family doctors?

• Do not have adequate geriatric medicine training.
  Fortunately, there are courses like PDCG and
  PDCPM in Hong Kong that can help to supplement
  the family doctors knowledge.
• Ageism exists even among medical professionals.
  Comments such as old people are all similar and
  there is little value of doing anything for them
  are often heard.
• Communication problem resulting from cognitive
  impairment is one of the many reasons why doctors
  are reluctant to see elderly patients.

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What are the obstacles of providing geriatric
cares by family doctors?

• Family doctors role in OAH is made in such a way
  that it is replaceable and expandable. He is not
  sharing the leadership role in the management.
• Provision of preventive services by family doctor
  is difficult because of financial constraint.
• Time constraint.
• Reimbursement and remuneration.

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References

• 1. The dementia caregiver-a primary care
  approach. Stuti Dang et al, South Med J. 2008
  Dec 101(12)1246-51.
• 2. Family medicine attributes related to
  satisfaction, health and costs, Mireia
  Sans-Corrales et al., Fam Pract. 2006
  Jun23(3)308-16.
• 3. Physician Perspectives on the elderly
  patient-family caregiver-physician encounter.
  Mark J. Yaffe et al., IMAJ 20024785-789
• 4.The physicians role in nursing home care an
  overview. M E Williams, Geriatrics 1990
  Jan45(1)47-9.
• 5. A textbook of family medicine, 2nd edition,
  Ian R McWhinney.