Hospital care in Belgium

• 03-1945: first regulation for diagnostic and treatment centres.
• Many units filled with “older people staying for the winter”: no reimbursement after 6 weeks;
• 1959: expert commission (Dr.Cleerens, Dr. Verbeke….)
• New discipline is urgently needed: geriatric medicine and units “G”
• Discussion “geriatric hospitals” or “Geriatric departments in General Hospitals”

Min. Decision 03.10.1963

• Prof. De Schouwer and Dr. Simon
• Departments of Geriatrics and Rehabilitation “R”
  • “G” =/= “C”
• 0,5 beds “R” / 1.000 inhabitants (!!) = 5.000 beds
• Norm 24 beds per unit (instead of 30)
• 9.000 V-beds (long stay)

Min. Decision 03.10.1963
AND HOW EVERYTHING GOES WRONG……..

• Negative attitude against older persons..
• Planned 5.000 beds never reached…
• Rehabilitation of hip fractures….
• Rehabilitation after myocardial infarction..
• Reserve beds for amygdalectomie, polypectomie in children….

1976: advice from National Commission programmation of hospitals
Based on:

• Opportunity reasons
• Performance reasons
• Medical Manpower supply

“R-Departments” have to be reconverted in Departments for rehabilitation by Med.physiotherapists, orthopedics, etc.

1980 - Reaction of Minister D’Hoore
“The R-departments have a geriatric destination...”

1981

• R-departments: low profile of nursing, no social workers, no psychologists, no rehabilitation for the ADL, meals in bed, rarely back to home, 33% of patients younger than 60 years..
• V-departments: most younger patients, 33% stays less tha 30 days; a lot of activity of laboratory and X-ray; 40% needs no nursing care…
• No nursing homes, only residential houses, with very little staff, but many heavy patients

Memorandum BSGG 27-02-1982

• Full attention for the 80-85 ++
• With multiple pathology
• Central place of the GP in the care of the older persons (need for better education)
• Diagnostic nihilisme in the elder patients: too much care and not enough diagnosis and therapy and rehabilitation; too much unnecessary placements
• Specialised geriatric units: 40 to 50 % patients can go back to home (if admitted directly and acute in the unit)
• Multidisciplinairy working
• An unit integrated in the general hospital, with all possibilities of it;
• Internist with special competence in geriatric medicine
• Internist with special competence in geriatric medicine:
  • 1.knowledge of presentation of diseases in the leder persons and their therapy
  • 2.knowledge in the therapeutic possibilities of nurses and paramedics
  • 3.knowledge of psycho-social aspects
  • 4.knowledge in the organisation of a geriatric unit
  • 5.knowledge in the theoretical bases of gerontology
• Necessity to develop geriatric medicine at the universities
• Needs for special education of paramedics
• Financial improvement of this medical activity
• Necessity to create nursing homes

Evolution after this memorandum

• 1982: creation of nursing homes
• 1984: creation of G-Departments (suppression of R-depts)
• 1985: creation of the internist with special competence in Geriatrics

Geriatric Department
General:

• Unit in a general hospital for diagnosis, treatment and rehabilitation
• Direct admissions or sec. from other units (be aware of the possible invalidating effect)
• acute and subacute spec. care,
• Mean age > 75 years
• Active treatment for quick release with optimal restored physical, psychological and social potentialities;
• Mean length of stay less than 3 months;
• The Unit needs to dispose ON SITE of all what is needed to fulfil these goals

Architectonic requirements

• Fitted for wheelchairs,
• Possibilities for rest in the corridors
• Min. 24 beds per unit
• Restaurant, room for group exercises, living, etc.
• Home-like furnishment

Functional norms

• Nusing: high-low-beds, anti-decubitus, nightcommodities, wheelchairs, ambulators, etc.
• Kine: bicycle for exercise, exercise stairs, parallel bars,
• Ergo, logo,
• On the admission day: notation in the records of all relevant medical, social, paramedical and nursing figures
• Evaluation of chances going back to home or to a home-like situation
• Treatment scheme
• Correction of this plan according the evolution of the patient
• Weakly team conferences with notes in the patients record

Organisation requirements

• Head: an Internist with special competence in geriatrics
• Can ask in consultation the other specialists when needed
• One certified nurse has to assure the continuity of care
• Physiotherapist, OT, Speech therapist, social worker, etc
• A positive psychological climate
• Eating as much as possible in the restaurant of the unit,
• Physio and OT in group
• Socio-cultural activities

Actual situation

• Geriatric department in every general hospital (120)
• 260 internists with special competence in Geriatrics (5 + 1 year)
• 30 training places for geriatrics
• 50.000 places in Nursing homes
• Residential houses
• Service flats
• Short stay places
• Geriatric Day centres

Geriatric Care Program
Future

• Optional
• For a patient with geriatric profile
• Elements:
  • Geriatric unit
  • Geriatric outpatients
  • Geriatric day hospitals
  • Intern liaison
  • Extern liaison

Medical organisation

• At least 1 FTE internist-geriatrician
• Directed by internist-geriatrician

Nursing organisation

• At least 16 FTE / 24 beds
• GDH 2,10 FTE / 6 places
• Reference Nurse/hospital unit

Others

• Social worker
• Physiotherapy
• OT
• Speech therapy
• Psychology (gerontology)
• 5 functions - 4FTE / 24 beds

Internal Liaison:

• Has to be available: all functions, with 1 FTE for each geriatric admission, calculated with the formula: N = N70-74*0,45 + N75-79*0,65 + N80-84*0,75 + N>84*0,95

Intern liaison

• Reference nurse try to give a signal for every patient with geriatric profile
• Full attention to find the geriatric patients at the emergency departments.

Extern liaison:

• Integrated services for home care and with Circles of GP
• Nursing homes, residential houses, etc
• Day Care Centres

Quality norms

• Register of agreements
• Weekly multidisciplinary team
• Directed by a geriatrician
• Follow up of Quality: College of Geriatrics

Actual Situation

• 120 general hospitals (only a few exception without a geriatric department)
• 250 geriatricians in these hospitals

• In nursing homes: each patient keeps his own G.P.; one of these GP is a coordinator for the general policy.

In nursing homes: each patient keeps his own G.P.; one of these GP is a coordinator for the general policy.

Developments in Geriatric Medicine

• October 2003: agreement by the High Council for an independent speciality “Geriatric Medicine”: with training:
  • 3 years internal medicine
  • 3 years geriatric medicine

PUBLISHED IN THE OFFICIAL JOURNAL: on 19-08-2005.