geriatrics in Austria

Situation of Geriatrics in Austria

Austria - some socio-demographic data

  • 9 federal provinces (“Bundesland”, Vienna = capital+province)
  • 84 000 km2
  • 8.11 million inhabitants (Vienna: 1.5 million), projection for 2030: 8.4 million (+3.4%)
  • Average birthrate per woman: 1.5 …

Structure of the population according to age groups
 

  0 - 14 15 - 59 60+
2000 16.7% 62.6% 20.7%
2015 14.1% 61.0% 24.9%
2030 13.9% 53.9% 32.2%


Population trends 1970-2030
 

  Births Deaths Life expect. at birth (m/w) Life expect. at 60 (m/w)
1970 112,404 98,819 66.5/73.4 14.9/18.8
2000 78,268 76,780 75.4/81.2 19.5/23.7
2030 71,200 90,530 80.0/85.5 23.1/27.3


Public Health in Austria - Some “players”

  • Federal Ministry of Health: general health policy, public health matters, health education, federal hospital plan: regulates public general and specialized hospitals + private non-profit hospitals (regional distribution, number of beds, specialisation structure etc.)
  • Provincial departments of health: responsible for health administration
  • Social security institutions (incl. health insurance) - compulsory insurance (self-administered public corporations, regulated and overseen by the Federal Ministry of Social Affairs), responsible also for attributing a care allowance (“Pflegegeld”, 7 levels according to care needs)
  • Federal Ministry of Education: university education of medical professions
  • Austrian Medical Association:
    • independent, self governed body, compulsory membership for every practicing physician, social insurance for its members (additional for employed physicians)
    • professional lobbying institution
    • regulates and oversees professional standards, responsible for specialty training curricula (together with specialty associations and ministry of health), CME
    • specialty sections
    • has a decisive influence in establishing new specialties (together with ministry of health)
    • organized in 9 provincial medical associations
  • Specialty associations: scientific societies of the various medical specialties, f.e. the Austrian Society of Geriatrics and Gerontology

The Austrian Society of Geriatrics and Gerontology

  • 50 years old…
  • Still lobbying for the specialty of geriatrics…and for the establishment of a chair in geriatrics at the medical universities (Vienna, Graz, Innsbruck, 1 private university in Salzburg started a program in geriatrics)
  • Together with the Austrian Medical Association provides a postgraduate diploma course in geriatrics for physicians (8 weekends ofer the period of 14 months, almost 1000 participants since 1984, 400 on a waiting list for the next course
  • Bi-annual congress in Bad Hofgastein (years pair), emphasizing the medical-geriatric topics, in close cooperation with the German and Swiss societies
  • Bi-annual International Geriatric Congress in Vienna (years inpair), multidisciplinary character
  • European Journal of Geriatrics: the scientific organ of the German and Austrian geriatric societies

Teaching and training geriatrics in Austria
Teaching Austrian medical students in geriatrics exists only as isolated lectures within the individual clinical subjects. The establishment of a chair in gerontology and geriatrics has been the topic of discussion for many years.
 
The existing clinical chairs have so far successfully opposed such a chair. The absence of gerontology and geriatrics in the academic spheres makes the development of adequate, modern geriatric structures difficult. It results also in a lack of academic quality standards in the care of the elderly. The missing implantation of gerontology and geriatrics in pre-clinical and clinical training at Austria’s three public Medical Universities is partly responsible for the negative  attitude of many of the responsible political and professional representatives towards the conceptualization of a specialty, or at least a sub-specialty training in geriatrics.   The opinion predominates that geriatrics cannot be clearly defined and specified. Most recent developments: The Ministry of Health (after much lobbying by the Austrian Geriatric Society) started the process of establishing  geriatrics as a sub-specialty of internal medicine, neurology , psychiatry and rehabilitation medicine. There are less formal and political obstacles than for an independent specialty.   The Geriatric Society is submitting proposals for a curriculum and for a transitional solution.   Time perspective: fall 2005

Institutions of geriatric care in Austria
Predominant institutions of geriatric care are institutions of geriatric long term care - nursing homes - they are institutions of public welfare, thus not part of the national health insurance and hospital financing plan even when medicalized… 2002: 68,033 places in residential and nursing homes…out of these 31,548 nursing home places with up to round the clock availability of medical staff… Numbers increasing by 3% per year since 2000… Until recently, institutional geriatrics in Austria have been associated only with structures of long-term or intermediate geriatric care. Geriatric care does happen in these institutions, but in quite an inhomogeneous way as far as quality of care is concerned.   Until recently, specific needs of geriatric patients have not been sufficiently met in the existing acute care hospital structures… Realizing this, the Austrian Federal Institute for Health Care (ÖBIG) (dealing with analyzing and planning structures of the health care system and advising the federal ministry and local health care providers) delegated this topic to a group of experts from the Austrian Geriatric Society (1999) The creation of a network of special units for the treatment of geriatric patients in the acute care sector of the health care system has been proposed. Admission criteria, obligatory standards for staffing, equipment, diagnostic (geriatric assessment) and therapeutic procedures have been defined.

Geriatric Acute Care in Austria
The Austrian federal agency regulating the health care system (ÖKAP) adopted this proposal in 2000 and decided to demand the provincial health planning authorities to create a network of geriatric acute care units in Austria. Until the end of 2005 there were to be 2079 beds dedicated to geriatric acute care integrated into existing hospitals in 50 locations, 460 in 14 hospitals alone in Vienna. Until end of 2004 only approximately 40% of the plan fulfilled… (in Vienna 60%)…Problems of financing and reallocation of resources… Revised plan (slower but more):
until 2010: 3,700 beds… (standards still the same)

Aims of geriatric acute care
(as defined in the Austrian concept)

  • Restoration or maintenance of the capacity to lead an autonomous and independent life and of the patients’ capacity for autonomy and participation
  • Prevention of further loss of function
  • Increase in quality of life
  • Reintegration of the patient into his usual social environment

Admissions criteria serve to:

  • define the group of patients to be treated
  • define a clear, common picture of what the geriatric structure does or should be expected to do
  • allow for a good patient selection and for a smooth transfer to the geriatric structure

Admission criteria for a geriatric acute care structure

  • Somatic and/or psychiatric morbidity requiring institutional (inpatient) care
  • Restricted or threatened independence through loss of physical and/or cognitive functional capacities or through psychosocial problems triggered by an illness
  • Need for rehabilitative measures aimed at improvement or  maintenance of functions and at reintegration to the patient‘s original social environment

Requirements of a geriatric acute care service

  • Multidimensional intervention
  • Interdisciplinary teamwork
  • Emphasis on the individual patient`s competence and resources
  • Ranking of problems, setting priorities in diagnosis, therapy and rehabilitation
  • Allocation of sufficient time


Phases of care in a geriatric acute care structure
 

1A Acute diagnosis and treatment
1 Geriatric assessment and treatment plan
2 Further diagnostic and therapeutic intervention, care and rehab by the interdisc. team
3 Outcome evaluation, preparation of discharge home or to another care structure
4 Outpatient care when indicated


Geriatric Assesment in Geriatric Acute Care
 

Dimension Index when done by
ADL Barthel, IADL admission, discharge nurse, OT
Cognition MMSE, CCT (Clock Completion Test) after admission psychologist, OT
Intensity of care nursing care index admission, discharge nurse
Mobility, balance Esslingen transfer scale, Tinetti Test admission, discharge (optional) PT
Nutrition MNA admission physician, nurse
Social situation structured interview admission, physician, nurse, social worker
Depression GDS (short version) admission, discharge(opt.) psychologist,
Incontinence questionnaire admission, discharge nurse
“Vitality” handgrip strength admission, discharge (optional) OT
Drug handling drug appli-cation test prior to discharge OT


Geriatric Acute Care - various service features 1 Prior to admission

  • Evaluation of the patients to be transferred to geriatric acute care

From admission to discharge

  • Geriatric diagnosis of acute/subacute conditions
  • Geriatric assessement
  • Weekly interdisciplinary conference
  • Therapy of the acute/subacute conditions in a hierarchical sequence
  • Reactivating nursing care

From admission to discharge (cont.)

  • Geriatric rehabilitation
  • Social work
  • Psycholgical and psychotherapeutic care
  • Inclusion of the relatives
  • Discharge planning, “diagnostic home visit”
  • Interdisciplinary documentation
  • Geriatric assessment at discharge

After discharge

  • Geriatric outpatient clinic
  • Transitional nursing cae

Further services

  • Geriatric consultation
  • Geriatric clinic

The interdisciplinary team in geriatric acute care - core team

  • Physicians, led by  a senior physician, specialist in internal medicine or neurology
  • Nursing personnel (qualified RB`s + nurse`s aids)
  • Physiotherapists
  • Occupational therapists
  • Speech therapists
  • Social worker
  • Clinical psychologist / psychotherapist

Availability of other disciplines in geriatric acute care

  • Neurologist or specialist in internal medicine complementing the core team`s medical orientation
  • Psychiatrist with gerontopsychiatric expertise
  • Other specialists: urology, physical medicine and rehab, orthopedic surgery, gynecology
  • Speech therapist (when not already in the core team)
  • Nutritional therapist

Patient / staff ratio in geriatric acute care
(as defined in the Austrian concept)
 

Professional disciplines Staff (full time) / Beds
Physicians (excl. chief) 1:10 to 1:8
Nurses (excl. chief) 1:1.6 to 1:1.1
Therapists (PT, OT) 1:8.4 to 1:5.2
Social worker 1:50 to 1:40
Psychologist / psychotherapist 1:100 to 1:80


Staff for a 24 bed geriatric acute care ward
 

Professional disciplines Staff (full time equivalents)
Physicians (excl. chief) 2.5 to 3.1
Nurses (excl. chief) 15.6 to 22.7
Therapists (PT, OT) 3 to 4.8
Social worker 0.5 to 0.6
Psychologist / psychotherapist 0.25 to 0.3
Total 21.85 to 31.5


Infrastructural requirements for a geriatric acute care unit - architecture

  • Room layout adapted to needs of handicapped people
  • Large rooms
  • Space for wheel chair mobilization, wide corridors, hand rails etc.
  • Short walking distances for patients
  • Communication space integrated into halls, corridors, lobbies etc.

Infrastructural requirements for a geriatric acute care unit – various room functions

  • ... Balanced provision of 1-, 2-, 4-bed patient rooms
  • Rooms for social activities (dining room, lobby...)
  • Rooms for various forms of individual or group rehabilitation (PT, OT), possibility of multifunctional use
  • Examining- and medical treatment rooms
  • „Training“ bathroom and kitchen to exercise toiletting, household chores

Technical equipent of geriatric acute care units Equipement in the unit:

  • EKG, EKG-Monitors, Holter EKG
  • Defibrillator
  • Pulse Oxymetry
  • 24-h blood pressure monitoring
  • Diagnostic ultrasound, echocardiography, ultrasound

Available round the clock:

  • Standard clinical laboratory
  • X-ray, CT
  • Endoscopy: GI, bronchoscopy

Outcome evaluation in geriatric acute care
 

Goals Evaluation criteria Evalutaion tools Parameters
Restoration  or maintenance of the capacity for an autonomous and indepenedent life Prevention of further loss of function Increase in quality of life Improved independence and autonomy, diminished dependency on assistance Geriatric assessment at admission and at discharge Barthel index
Transfer scale
MMSE
Intensity of care
Necessary aids
Nutritional status
Incontinence
Reintegration of the patient into his habitual social environment Rate of discharge of the patients to the previous social environment Comparison of place of residence before admission and after discharge Assessing the rate of readmission or NH admission Place of residence before admission and after discharge Death 30-day readmission, NH-admission

contacts in Austria

Dr.

Georg Pinter

georg.pinter@kabeg.at
+43 463538226667
Prof. (adj.) Dr.

Thomas Frühwald

thomas.fruehwald@wienkav.at
+431 80110 3340