The current challenge

All European countries are experiencing rapid demographic transitions, with an increase in the proportion of over 65-year-olds and the most rapid increase in people over 80 years of age (Reference CreightonCreighton, 2014). This means that, increasingly, the business of acute hospitals is the care of older people, often with frailty, dementia or multiple long-term conditions complicating their acute illness. Without a radical shift in care models, at scale and surpassing anything we have yet seen, this will continue to be the case for the foreseeable future. There has been a general reduction in hospital beds and increases in ambulatory and community treatment but there remain gaps in services that fail to meet the needs of frail older people, which often result in hospital attendances (NHS Benchmarking, 2013; Reference CowlingCowling et al., 2014; Reference RadvanskyRadvansky, 2014; Reference MelzerMelzer et al., 2015). Particular challenges arise for those with frailty, chronic multiple conditions, and those with dementia, adding to the complexity of treatment and care needs of older people (Reference MelzerMelzer etv al., 2015).

Some of the key challenges facing hospitals caring for older people with frailty include unmet care needs, health inequalities, and a lack of quality service models and integration between services (European Institute, 2012). There is wide variation in the nature and scope of services addressing the needs of frail older people, with some countries such as Austria having recognized geriatric medicine as a subspecialty of internal medicine only from 2011 (Reference EkdahlEkdahl et al., 2012). While countries are acknowledging the need for better integration of services, implementation of more integrated care models has been slow (Reference Curry and HamCurry & Ham, 2010; Reference ShahShah et al., 2010).

The challenge of frailty

Frailty is defined as a state of increased vulnerability and a disturbance in homoeostasis where a stressor event can lead to dramatic changes to the health status of an individual, which result in increased dependency levels, mobility problems, a change in cognition, such as delirium, and marked levels of functional decline (Reference CleggClegg et al., 2013) (Figure 4.1; Box 4.1). Frailty is also associated with increased mortality and morbidity, and it is a strong predictor of care home utilization and death (Reference CesariClegg et al., 2016). There are two common models for defining frailty as a clinical entity and these are increasingly important as ways of segmenting and addressing the needs of hospital patients (Reference OliverOliver, 2016c). These rest on an identifiable “frailty phenotype” (Fried model) based on the presence of three or more characteristics or a “frailty index” (Reference Rockwood and MitnitskiRockwood & Mitnitski, 2011; Reference CesariClegg et al., 2016) based on an accumulation of deficits. There is an overlap between frailty, multiple co-morbidity and age-related disability (World Health Organization, 2015; National Institute for Health and Care Excellence, 2016), although it is now possible to identify people with frailty in community settings using existing primary care data (Reference CleggClegg et al., 2016) (Table 4.1), at the hospital emergency front door or on the inpatient wards, where simple pragmatic case-finding tools are often employed (Royal College of Physicians, 2013; British Geriatrics Society, 2014a; Health Improvement Scotland, 2015).

Figure 4.1

Vulnerability of frail older people to a sudden change in health status following a minor illness

Note: The top line represents a fit older person who, following a minor stress such as a urinary tract infection, experiences a relatively small deterioration in function and then returns to homoeostasis. The lower line represents a frail older person who, following a similar stress, experiences a larger deterioration which may manifest as functional dependency and who does not return to baseline homoeostasis.

Source: Clegg et al., 2013

Adequate assessments and interventions for frailty are important. Survival plots using primary care data in England suggest that those with severe frailty are at higher risk of dying by a factor of five (Reference BatesBates et al., 2014). A ten-year prospective cohort study involving community-dwelling older people identified frailty to be the leading cause of death, accounting for 28% of deaths compared to organ failure (21%), cancer (19%), dementia (14%) and other causes (15%) (Reference CleggClegg et al., 2013).

Falls are a common reason for admission to hospital and have come to the attention of policy-makers and payers. Frailty is known to be an independent predictor of falls, and figures over the last five years show that Ireland had spent an estimated €520 million on falls, while in the Netherlands fractures were estimated to have led to 80% of fall-related costs, amounting to approximately €540 million between 2007 and 2009. In England alone, falls in older people have been estimated to cost the National Health Service £2 billion annually (Reference FentonFenton, 2014). Across Europe and other high income countries, the estimated costs of falls to health care services are significant.

Minimizing harm in frail older people in hospital

Older people are at significant risk of “harm” often associated with their care and medicalization of their illnesses. Polypharmacy, falls, hospital-acquired infections, malnutrition and immobility are some of the common problems that arise, which can lead to increased morbidity and mortality of older patients admitted to hospital (Reference BarberBarber et al., 2009; Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014). Bed rest in itself has also been associated with a range of harms where 10 days of bed rest in healthy older adults can lead to a 14% reduction in leg and hip muscle strength, and a 12% reduction in aerobic capacity (Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014). Older people often already have decreased physical function which may be negatively affected by hospitalization. They also have poorer functional outcomes and are less likely to recover from their problems in hospital (Reference CovinskyCovinsky et al., 2003; Reference Kleinpell, Fletcher and JenningsKleinpell, Fletcher & Jennings, 2008; Reference Mudge, O’Rourke and DenaroMudge, O’Rourke & Denaro, 2010).

The role of primary care in care coordination and urgent access

Frail older people pose a challenge to primary care although family physicians are ideally posed to incorporate the identification and management of frailty in their practice (Reference Lacas and RockwoodLacas & Rockwood, 2012). Countries are increasingly implementing more proactive personalized care planning, care coordination and case management to enhance primary care services for (frail older) people with one or more long-term conditions (Reference CoulterCoulter et al., 2015). These care provisions are often provided by specialist nurses and therapists as well as volunteers in the care sector (Reference KringosKringos et al., 2013; Reference Bienkowska-GibbsBienkowska-Gibbs et al., 2015). At the same time, when the health or independence of older people rapidly deteriorates, it is important to ensure rapid access to urgent care, including effective alternatives to hospital (Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014; NHS Benchmarking, 2015). The following sections describe selected models that are being implemented in different settings to meet this need in particular.

Rapid community response teams

Older people with frailty are at a higher risk of unplanned hospital admissions (Reference BoutsioliBoutsioli, 2012; Reference SonaSona et al., 2012; Reference WittenbergWittenberg et al., 2014). In England alone, up to 42% of emergency admissions in 2011 came from care homes with older people who were within the last six months of their life; these patients also often had multiple admissions in the year leading up to death (Reference SmithSmith et al., 2015).

Rapid response teams can offer specialist advice and improve the care for frail older people with long-term conditions (Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014; Reference WittenbergWittenberg et al., 2014; NHS Benchmarking, 2015). These services may variously include geriatricians, GPs, specialist nurses, physiotherapists, occupational therapists, and sometimes others such as pharmacists, social workers, personal care assistants or generic rehabilitation assistants to address the complex medical needs of frail older people where time is of the essence, and without which the episode may result in hospital admission. These teams can also collaborate with ambulance organizations to divert patients to the community rapid response team and towards the community team. They are most likely to be effective when able to see patients within hours and when they have a range of skills within the team (NHS Benchmarking, 2016; Reference ShepperdShepperd et al., 2016).

Ambulatory care clinics

Ambulatory care clinics are defined as units that provide preventative intervention and chronic disease management services for frail older people who may be at risk of future hospital admission (Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014). Ambulatory care clinics can be located in hospital outpatient settings or in primary care, and led by GPs or specialist clinicians with a range of multidisciplinary staff that can include pharmacists and social workers to optimize care of the frail older patient. Ambulatory care clinics or ‘‘one-stop’’ frailty clinics are an emerging service in France that provides assessment, management and support for older people with the aim of preventing and minimizing disability among those who are fit enough to attend such services (Reference TavassoliTavassoli et al., 2014) and uses a collaborative approach with primary care and other allied professionals (Box 4.2). The overall evidence for impact of such service models remains weak, although a recent randomized controlled trial in Sweden demonstrated improved survival, and reduced length of stay in hospital without increasing cost up to three years after assessment (Reference Ekdahl, Alwin and EckerbladEkdahl, Alwin & Eckerblad, 2016). In the United Kingdom, rapid access ambulatory care clinics in community hospitals have shown that frail older patients who are referred from primary care, ambulance services and community teams can be seen more quickly and closer to home, with a MDT addressing complex care needs effectively, and figures show that only up to 20% of those referred are transferred on to the nearest acute centre, with 56% discharged home or to their previous care setting (Reference KoduahKoduah et al., 2014).

Community hospitals and intermediate care units

In Europe, community hospitals are increasingly being (re)considered as a means to address the care needs of older people in particular and are predominantly staffed by GPs and nurses, with some specialist input (Reference WinpennyWinpenny et al., 2016). These often provide pre- and post-hospital care and so bridge the gap between care received for an acute illness prior to discharge to home (Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014). One recent example is the introduction, in 2012, of municipal acute care beds in Norway, which are organized as part of the municipal health services together with GPs, local emergency services, long-term care services and other parts of social care (Reference Swanson and HagenSwanson & Hagen, 2016). They are targeted at stable patients who need monitoring or close follow-up from acute illnesses, often exacerbated by chronic medical conditions. Evidence from community hospital-type set-ups are mainly observational in nature, and evaluation of their effectiveness is still lacking (World Health Organization, 2015).

Comprehensive geriatric assessment for frail older inpatients

Comprehensive geriatric assessment (CGA) is a process of assessing an older person’s medical, psychological, physical and social functioning to inform the use of specific interventions and then develop and implement a plan for ongoing treatment and follow-up. There is good evidence from meta-analysis of numerous studies from several European countries that comprehensive interdisciplinary assessment of older people presenting to hospital delivers long-term benefits in terms of survival and the ability to remain in their own homes with less cognitive decline (Reference EllisEllis et al., 2011). Because this is an iterative process rather than a discrete event, a CGA initiated in hospital can be continued in a person’s own home to fully assess the need for support and so enable the frail older person to remain within their own environment (Reference EllisEllis et al., 2011).

CGA is multidisciplinary, although outcomes are best with a specialist geriatrician leadership or input team on admission of the patient (Reference EllisEllis et al., 2011; Reference Oliver, Foot and HumphriesOliver, Foot & Humphries, 2014). In the United Kingdom standards of care and assessment have been set out by national leadership bodies (British Geriatrics Society, 2014b; Health Improvement Scotland, 2015). Across Europe CGA is gaining momentum and is being used to assess and optimize frailty for a variety of medical and surgical conditions, and as a predictor of adverse outcomes. For examples, see Reference KristjanssonKristjansson et al. (2010) and Reference Molina-Garrido and Guillén-PonceMolina-Garrido & Guillén-Ponce (2011).

A recent review of the practice of CGA in high income countries in Europe, North America and Taiwan showed that only 32% of interdisciplinary geriatric consultation teams had used any formal CGA screening aid in intervention decisions. Also, while nurses formed key members of teams, their roles and responsibilities tended not to be clearly identified (Reference DeschodtDeschodt et al., 2016). There is a need to place implementation barriers of CGA into local contexts and so effectively address its effectiveness, culture change, educational needs of practitioners, research and evolving requirements of service provision (Reference GladmanGladman et al., 2016).

Specialist models of acute hospital care for people with frailty

Acute frailty services are specialist units that focus on specialized and tailored care for complex frail older people at, or close to, the hospital front door and with a focus on older people in the first phase of hospital admission. Where possible, they aim to assess and stabilize patients with a view to early discharge before they move to “deeper” wards within the hospital (Acute Frailty Clinical Network, 2015; Royal College of Physicians, 2015; Reference OliverOliver, 2016c). There are different models in various acute settings but the most common models include: emergency department-based models and acute frailty units (Reference Van CraenVan Craen et al., 2010; Reference DeschodtDeschodt et al., 2013; Reference ConroyConroy et al., 2014).

Emergency department-based geriatrics and frailty services provide specialist geriatric input in decision-making for frail older people who attend the emergency department; other objectives include providing a multidisciplinary assessment using CGA and initiatives to reduce admission rates (Reference BlakemoreBlakemore, 2012). Specialized nurses, who are experienced in falls, dementia, mental health and continence, are often available within these teams to provide support in hospital and coordinate better specialist care in the community at discharge. The overall evidence for emergency frailty units remains weak, with the majority of care models being trials of transitional care, which is a relatively novel concept of providing care for older people (Reference Conroy and ChikuraConroy & Chikura, 2015). Implementation of such care models in the emergency department remains challenging because of the complexity involved in identifying frailty, including the lack of standardized frailty instruments and poor understanding of frailty and the absence of clinical guidelines of frailty management in the emergency setting (Reference DentDent et al., 2016).

Acute frailty units, also referred to as “acute geriatric evaluation and management units”, are inpatient wards at or close to the hospital “front door” that admit frail older people for assessments, treatment, review and rehabilitation through the use of CGA (Reference Van CraenVan Craen et al., 2010). A meta-analysis by Reference Van CraenVan Craen et al. (2010) of American, Austrian, German and Norwegian studies found that acute frailty units showed a significant positive impact on functional decline at discharge and institutionalization at one year. It also demonstrated that multidisciplinary CGA added value to those who were admitted to hospital by meeting the specific needs of frail older people and resulting in higher satisfaction of care provided to the patient.

European countries are at different stages in the development of acute frailty or acute geriatric units, which tend to be concentrated in larger cities, mainly because of the uneven distribution of geriatricians (Reference Kolb, Topinkova and MichelKolb, Topinkova & Michel, 2011; Reference EkdahlEkdahl et al., 2012) and poor availability outside major centres. Whereas geriatric medicine is the largest internal medical speciality in the United Kingdom (Royal College of Physicians of London, 2015) and acute frailty units are found in small and medium-sized hospitals (Acute Frailty Clinical Network, 2015; NHS Benchmarking, 2016), it is not as well established in many European countries (EUGMS Survey, in press). For example, in Denmark and Sweden specialist geriatric units tend to be based at tertiary hospitals where frail older people undergo assessments that aid further planning of care. In smaller hospitals, geriatric care is embedded within general internal medicine departments on the whole (Reference Kolb, Topinkova and MichelKolb, Topinkova & Michel, 2011; Reference EkdahlEkdahl et al., 2012).

Delirium units and teams

Delirium units often coexist with dementia wards because of the common coexistence of the two conditions and similar management strategies that are employed to support patients (Reference LamLam et al., 2014). Delirium is so widely prevalent among older hospital inpatients that it is unlikely that specialist delirium units could ever look after all patients or that it is possible or desirable to cohort them all in one clinical area (National Institute for Health and Care Excellence, 2010; Reference OliverOliver, 2016a). And so, it is equally important to ensure that all staff caring for frail older people are able to recognize, prevent and manage delirium and that specialist teams are able to provide support and training of other staff.

One example is the Hospital Elder Life Programme (HELP), which was developed in the USA in 1993; it involves the use of a “multicomponent strategy” with multidisciplinary specialist teams who provide structured support to older people with delirium (Reference Young and InouyeYoung & Inouye, 2007). HELP has been implemented in more than 11 countries across more than 100 sites (Reference SteelfisherSteelfisher et al., 2013). It has been shown to be cost- and clinically effective, with reduced rates of delirium and functional decline, including the prevention and exacerbation of chronic medical conditions, with improved satisfaction among providers, patients and family (National Institute for Health and Care Excellence, 2010). Health Improvement Scotland is driving a national programme to prevent, recognize and improve outcomes in people with delirium and to share best practice (Health Improvement Scotland, 2016). The European Delirium Association now also has a network to share best practice and research across Europe.

Geriatric–surgical collaboration and liaison for frail older people

Not all frail older people are admitted under geriatric medicine and therefore it is crucial to provide CGAs where possible to optimize the care and health of older people admitted under different specialties. The more familiar and most widely developed liaison service across Europe is orthogeriatric collaboration with available evidence demonstrating cost-effectiveness and significant associations with reduced mortality rates in frail older people with fragility fractures (Reference Sabharwal and WilsonSabharwal & Wilson, 2015; Reference Knobe and PapeKnobe & Pape, 2016; Reference Ozalp and AsprayOzalp & Aspray, 2016). In Germany and Austria the explicit implementation of geriatric trauma centres has been developed where hip fracture patients are co-managed with common ward rounds between geriatricians, orthopaedic surgeons and specialized nurses (Reference KammerlanderKammerlander et al., 2011; Reference PapePape et al., 2014). In the United Kingdom the development of a fracture liaison service has been promoted as a “model of best practice” to provide optimum care to frail older people with hip fractures; a recent analysis of data from 11 hospitals in England points to significant improvements in mortality post surgery (British Orthopaedic Association, 2007; Reference HawleyHawley et al., 2016).

General surgical liaison is now a growing field in the United Kingdom, after its initial liaison model was developed specifically to address the needs of older people undergoing surgery, known as the proactive geriatric liaison with older people undergoing surgery (POPS) model (Reference HarariHarari et al., 2007). A survey of 161 hospitals in the United Kingdom showed that there are varying levels of geriatric-led perioperative services being provided across the country, with a combination of preoperative and postoperative services being offered that covers both acute and elective surgery, although barriers include funding, workforce issues, and a lack of inter-specialty collaboration (Reference PartridgePartridge et al., 2014).

Other European countries are at different stages of developing medical liaison services as there is clear recognition of the value of geriatric input into the management of complex medical issues. Belgium introduced the “Geriatric Health Care Programme” in 2007 by adopting the development of a geriatric unit that also provides internal and external liaison services to frail older people on non-geriatric wards through similar tenets of CGA and MDT working (Reference Van Den Noortgate and PetrovicVan Den Noortgate & Petrovic, 2009; Reference BaitarBaitar et al., 2015). In Ireland the older person assessment and liaison service (OPAL) showed that the service model provided timely CGA, and facilitated effective discharges from hospital, which may be further enhanced by efficient referrals and assessment processes through the use of clinical nurse managers (Reference HayesHayes et al., 2016).

The role of outpatient clinics

Outpatient clinics in secondary care serve to bridge the gap between hospital care and the community once a patient has been discharged from hospital. They may also assume the role of “specialist” clinics that assess and treat specific conditions such as Parkinson’s disease, respiratory or cardiology conditions, as well as falls and syncope clinics. Falls (prevention) clinics have been shown to reduce the incidence of injurious falls among older people by providing specific interventions around falls prevention with the support of physiotherapists and occupational therapists (Reference MooreMoore et al., 2010; Reference PalvanenPalvanen et al., 2014). Outpatient falls and syncope clinics are sometimes defined as day clinics, where assessments involve addressing underlying medical conditions to be treated, which are followed by further assessments by the physiotherapist and occupational therapists before an intervention is put into place (Reference Lamb, Gates and FisherLamb, Gates & Fisher, 2007). Outpatient clinics may also provide day services such as blood transfusion and chemotherapy where appropriate to enable patients to return home without needing inpatient admissions for such procedures. However, the provision of such assessment and follow-up does not necessarily have to happen on hospital sites, especially when travel and repeat attendances could be disruptive and distressing to older people with frailty. In some cases, hospital specialists and skilled MDTs can provide outpatient services in community and primary care settings closer to patients’ homes, often in collaboration with primary care teams (British Geriatrics Society et al., 2012; King’s Fund, 2014; Reference GordonGordon, 2015).

End of life care

A study examining the place of death in older people with dementia-related diseases across 14 countries showed that in Europe the proportion of deaths in hospital ranged from 1.6% in the Netherlands to 62.3% in Hungary (31.7% in England, 35.9% in France, 32% in Italy, 33.6% in Spain, 21.6% in Belgium) (Reference ReyniersReyniers et al., 2015). A qualitative systematic review of integrated palliative care in Europe found that a palliative care framework is necessary to improve symptom control, lessen care-giver burden, improve continuity and coordination of care, reduce admissions, increase cost-effectiveness and enable patients to die in their preferred place of care (Reference SioutaSiouta et al., 2016). In 2010 the National Gold Standards Framework in End of Life Care Centre, a volunteer sector organization in the United Kingdom, was formed to provide support, training, and innovation in delivering better end of life care through advance care planning, with the goal of improving the quality and coordination of care, reducing hospitalization, and enabling more people to live and die at home (Gold Standards Framework, 2012). A 2015 audit on death and dying by the Royal College of Physicians of London (2016) found that of the 93% of patients whose death was predictable and documented, only 54% of case records showed that the needs of the person were asked about, with only 24% of patients having clinically assisted (artificial) hydration; 34% of cases had documented evidence about the need for clinically assisted (artificial) nutrition. Only 67% of hospitals reported that they implemented change to their service by taking into account bereaved family and friends’ requests about patient care in their final days (Royal College of Physicians of London, 2016). Between 2005 and 2012 improvements in coverage of palliative care services had been made mostly in western European countries compared to central and eastern European countries, with still significant gaps across services (Reference Centeno-CortesCenteno-Cortes et al., 2016). There is only one chance to get end of life care right and often this is unfortunately not the case. With a limited number of hospice beds and palliative care specialists available, advance care planning and addressing end of life issues earlier is pivotal, and if the patient does end up in hospital in their final days, then every effort should be made to get it right from the start (Reference OliverOliver, 2016d; Royal College of Physicians of London, 2016).

Care of older patients with dementia and mental health problems in general hospitals

Dementia encompasses a group of organic brain diseases and the most common forms are Alzheimer’s dementia, vascular dementia, mixed dementia (having Alzheimer’s and vascular components), Lewy bodies and fronto-temporal dementia (Reference HackmanHackman et al., 2013). The personal, social, and economic costs of dementia are substantial, often complicated by multiple co-morbidities or frailty. The global estimate of older people living with dementia is expected to increase to 81 million by 2040, of whom 30% will be living in Europe (Reference Kaplan and BerkmanKaplan & Berkman, 2011). Hospital patients with dementia are typically more frail, and at risk of significant complications of hospital-acquired infections, delirium, loss of function and unplanned readmissions (Reference Hermann, Muck and NehenHermann, Muck & Nehen, 2015). They can find hospital admission confusing, which can have a negative impact on their health and well-being both physically and mentally. Many who present with delirium are subsequently found to have dementia after discharge from hospital, with the two often coexisting (Reference JacksonJackson et al., 2016).

Countries across Europe have developed national strategies towards the diagnosis and management of dementia in hospitals and the community (Royal College of Psychiatrists et al., 2013). Specialized and appropriate care in hospital is vital for diagnosis and for supporting frail older people with dementia and their families towards a life that is disability-free and productive as far as possible. The main models of care delivered in acute hospital settings include specialist dementia wards, liaison psychiatry teams who provide diagnosis and support to patients, and dementia specialist nurses who work both in the hospital and in the community setting. The following discusses each approach in turn.

Specialist dementia wards

Specialist dementia wards have been in development across European hospitals to cater for the needs of older people with dementia (Reference Wilkinson and HendriksWilkinson & Hendriks, 2015; Reference O’ConnorO’Connor et al., 2016). Although such specialist units have not demonstrated measurable impact on hospital and primary care utilization, mainly because patients tend to be at the end of life, the experience of patients and their carers were reported to be significantly better compared to care received on general wards (Reference GoldbergGoldberg et al., 2013). Reference GoldbergGoldberg et al. (2013) also demonstrated, in a randomized controlled trial of specialist and mental health units, that patients had more positive interactions and engagement with the staff, families perceived the management of confused patients to be more empathetic, and discharge planning was seen to be more efficient. There is variability in terms of the number of beds available in these facilities and length of stay. Components of care include therapy involvement, spaces for patient interaction, a routine that meets the needs of patients with cognitive deficits, volunteer workers, and specialist staff who provide care and tailored plans for individual patients that take into account their social and cultural backgrounds (Reference Hermann, Muck and NehenHermann, Muck & Nehen, 2015).

Liaison psychiatry for older people

With so many older hospital patients having dementia or mental problems accompanying their other complaints, there is no prospect of all patients being admitted to specialist units, so other models of specialist input matter. Liaison psychiatry or liaison psychological medicine is defined as a specialty that manages people who present with mental and physical symptoms concerned with the interplay between physiological, psychological and social determinants that cause ill health. Liaison psychiatry teams often consist of a MDT which includes psychiatrists, nurses, support workers and therapists (Royal College of Psychiatrists et al., 2013), and liaison psychiatry for older adults is provided either by psychiatrists with an interest in old age psychiatry or by specialist nurses. Liaison psychiatry for older adults (LPOA) has become embedded in many European hospital settings as part of the routine assessment to improve the quality of life of older people (Reference Mukaetova-LadinskaMukaetova-Ladinska, 2006). For example, an LPOA service in a tertiary hospital in Portugal found that delirium and dementia accounted for more than 60% of the diagnoses and although the referring complaint was mostly “mood disturbances”, it was found that only 24% of these patients had depression, highlighting the poor diagnostic experience of referring clinicians (Reference NogueiraNogueira et al., 2013).

Evidence on liaison mental health services points to some benefits for people with dementia, for example increased referral rates for cognitive assessment, better detection and diagnosis, and greater staff confidence in caring for patients with dementia. However, a literature review of dementia care in general hospitals showed that, despite individual case studies demonstrating local benefit, trial evidence around mental health liaison is lacking. Quality of inpatient care improves as a result of these services, but the impact on cost-effectiveness and length of stay remains uncertain (Reference Dewing and DijkDewing & Dijk, 2014).

Specialist dementia nurses

The care delivered by specialist nurses has been identified to be of key importance in supporting people with dementia. There has been increasing interest in many settings in developing specialist nurse roles as one approach to improving the care of people with dementia in hospital (Reference Griffiths, Bridges and SheldonGriffiths, Bridges & Sheldon, 2013), and across European countries specialist nurses are being widely used to support frail older people with dementia in acute hospitals and the community (Reference Hermann, Muck and NehenHermann, Muck & Nehen, 2015). A scoping review of the role of the dementia specialist nurse in acute care working directly with people with dementia and their families for a significant period of time found this model to benefit older people with dementia in hospital and their families (Reference Griffiths, Bridges and SheldonGriffiths, Bridges & Sheldon, 2013).

Discharge-to-assess models and early supported discharge

In a discharge-to-assess model, a patient whose acute health needs have been stabilized is subsequently discharged home for rapid assessment of their needs in their own home environment and follow-up of ongoing care by community-based clinicians (Reference Andrew and RockwoodAndrew & Rockwood, 2014). An older person who is deemed medically stable for discharge from the emergency department or acute medical unit ward but still requires ongoing support is discharged home with a team of multidisciplinary therapy staff for assessment. A plan of support is put in place immediately; should the patient fail the assessment at home, they would then return to hospital (Reference SilvesterSilvester et al., 2014). In the United Kingdom a number of local quality improvement studies have shown the benefits of early senior review linked to these models in terms of reduced admission rates, reduced bed occupancy, and higher rates of discharge home within 24 hours of presentation (Reference FoxFox et al., 2013; Health Reference FoundationFoundation, 2013). However, the majority of studies are single case based and there is little robust evidence from controlled trials. Data from such quality studies suggest that effective discharge-to-assess models require timely expert assessment on initial acute presentation to hospital and adequate capacity for medical and nursing care, therapy support, and social care for providing assessment and support at home (Reference SilvesterSilvester et al., 2014).

Early supported discharge (ESD) enables patients to return home earlier and receive rehabilitation within their own homes. Unlike discharge-to-assess, it tends to rely on more traditional assessment of needs in the hospital setting as the basis for defining ongoing clinical and care needs after discharge. This service is more commonly provided for people who have physical disabilities such as post-acute stroke (Reference Fearon and LanghorneFearon & Langhorne, 2012). In contrast to discharge-to-assess models of care, ESD follows after completion of assessments in the hospital and the patient is found to have met the minimum criteria for transfer back to their own home (Reference KirkKirk, 2013). EDS is comparatively widely implemented across European countries, with much of the evidence originating from northern Europe and a 2012 Cochrane review concluded that among older patients following stroke, those who were discharged with an ESD service had improved physical outcomes, reduced lengths of stay in hospital, lower dependency rates and reported higher satisfaction with services compared to those receiving conventional services (Reference Fearon and LanghorneFearon & Langhorne, 2012; Reference Mas and InzitariMas & Inzitari, 2015).

Hospital at home schemes

A number of countries in Europe have developed innovative models of care in the community to bridge the gap between hospital and home, or to provide extra support at home without hospital admission (Reference Jones and CarrollJones & Carroll, 2014; Reference VilàVilà et al., 2015). Examples include the “hospital at home” model and the “virtual community ward”, which enable frail older people to continue to be treated within their familiar environments.

In a hospital at home setting, care is provided within a patient’s home, with services similar to those provided in hospital but delivered by a community-based team or hospital-resourced outreach staff through domiciliary visits (Reference ShepperdShepperd et al., 2010). There is mixed evidence about the effectiveness of hospital at home services. Systematic reviews of single chronic disease management, such as COPD and heart failure, suggest that patients seem to benefit from the service as the readmission rate is reduced and the system is proving to be more cost-effective. In contrast, frail older people with multiple co-morbidities seem to have an increased rate of readmission (Reference ShepperdShepperd et al., 2010; Reference Jeppesen and JaeJeppesen & Jae, 2012; Reference QaddouraQaddoura et al., 2015).

End life care seems to be better managed using hospital at home type models. For example, a programme in Barcelona, Spain, found such a service to improve end of life care in patients with terminal illnesses, with up to 72% choosing to remain at home in their final days with support from the community teams (Reference VilàVilà et al., 2015). A recent systematic review of home-based end of life care found this to significantly increase the likelihood of dying at home compared with usual care, with some evidence of improved patient satisfaction at one-month follow-up (Reference ShepperdShepperd et al., 2016).

Virtual and community wards

Virtual wards also replicate a hospital ward. However, contrary to the hospital at home model, which provides acute clinical care, the virtual ward places emphasis on the integration of medical teams, nursing, therapists and social care to provide a proactive approach of care to people at risk of hospital admission (Reference Jones and CarrollJones & Carroll, 2014). They can be used to support discharge (“step down”) as well as preventing admission. The evidence of the effectiveness of virtual wards in frail older people with complex multimorbidity remains mixed (Reference BardsleyBardsley et al., 2013; National Institute for Health and Care Excellence, 2016). Recent evaluations of virtual wards in four parts of England were unable to demonstrate reductions in cost or hospital bed utilization, although there were some reductions in elective activity (Reference LewisLewis et al., 2013). Similarly, a randomized controlled trial of a virtual ward for high-risk adult hospital discharge patients in Toronto, Canada, did not find a statistically significant effect of a virtual ward model of care on readmissions or death at different points of time after hospital discharge (Reference DhallaDhalla et al., 2014). Reference LewisLewis et al. (2013) commented, based on the English experience, that where virtual or community wards are developed locally, this should be motivated by patients’ needs and the need to provide care closer to home for those at highest risk, rather than because they will deliver savings (Box 4.3).

The role of community geriatricians

We have discussed the role of geriatricians in hospital care but their role in the community is just as important in providing support to community services for frail older people. In some European countries this is the major part of their work, with acute hospital care being more the province of internal medicine physicians (Reference Kolb, Topinkova and MichelKolb, Topinkova & Michel, 2011; Reference EkdahlEkdahl et al., 2012; Reference GordonGordon, 2015). The role of community geriatricians includes support for people in nursing and residential facilities, support for community case management teams or virtual wards or discharge teams, and close work with primary care teams to support high-risk patients with frailty (Reference Oliver and BurnsOliver & Burns, 2016). For example, in the Netherlands and Norway community geriatricians provide specialist care to frail older people residing in nursing homes through CGA with a network of multidisciplinary professionals to optimize care (Verenso, 2015). Community geriatrician involvement in care homes has been linked to a reduction in medications prescribed and optimizing drug treatment, thereby reducing risks of readmission associated with adverse drug reactions (Reference Burns and McQuillanBurns & McQuillan, 2011). Evidence suggests that adverse drug reactions are common in the post-hospitalization period and this needs to be addressed effectively across transitions of care in order to prevent harm and inconvenience.

Intermediate care rehabilitation services

There are several definitions of intermediate care but the common thread underlying them is the provision of health care services to those who require support in the transitions between acute care, primary care and social care. They vary in their provision of support depending on the needs of the patient to optimize and achieve their baseline function where possible or to provide an environment for further assessments such as CGA to take place (Reference Woodford and GeorgeWoodford & George, 2010). The following section discusses each category in turn.

Crisis response teams can take the shape of rapid response teams (see above) that provide step up or step down services. Step up services are targeted at older people who require support in their home or in an intermediate care facility, with the aim of avoiding hospital admission where possible and appropriate. Step down services provide a bridge service for transitions from the emergency department or post discharge from hospital (NHS Benchmarking, 2015).

Home-based intermediate care services are provided within a person’s home by a multidisciplinary professional team. In Finland such services are provided by a nurse and home-care aid worker, depending on individualized plans devised by the case manager for a period of time until independence has been restored or regular home care has been put in place (Reference Hammar, Rissanen and PeräläHammar, Rissanen & Perälä, 2009).

Bed-based intermediate care services overlap with other community-based facilities that are situated within nursing homes or local community hospitals and more commonly accommodate frail older people who have been admitted to hospital and require a period of convalescence and rehabilitation prior to discharge to their home.

Rehabilitation services outside hospital focus on providing a suitable environment to promote functional recovery. Delivered by a MDT, these services aim to meet the rehabilitative goals of service users by concentrating on activities that are important to the individual but which may have been missed in a clinical environment (Reference PearsonPearson et al., 2015). Rehabilitation primarily includes physical therapy and occupational therapy to prevent admission to an acute hospital or facilitate a stepped pathway out of hospital.