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DAY HOSPITALS

Geriatric day hospitals have been part of the health care of older adults for many years. The global increase in the number of older adults has combined with fiscal pressures to decrease lengths of stay in acute care facilities and resulted in shortages of long-term care space in most developed countries. Day hospitals are intended to serve as a midpoint between acute care and out-patient rehabilitation, and to not only delay institutionalization but also to improve quality of life and independence in the patients who attend.

First introduced in the United Kingdom in the early 1960s, when long-term care beds were even more limited than at present, day hospitals were designed to provide interdisciplinary assessment and management of chronic health problems for older persons. They were initially developed in association with geriatric inpatient services to allow access to diagnostic facilities, but many are now sited with ease of access for older persons in mind. There are day hospitals in community centers and in shopping malls in some parts of the world. Day hospitals are even known as community rehabilitation centers in some parts of Australia. Several programs in the United States use centralized day programs to provide integrated assessment and therapy for frail older persons (Program for the All-Inclusive Care of Elders, or PACE ). The key feature is the interdisciplinary assessment and management provided. Staffing usually consists of a geriatrician or physician with special training in the care of the elderly, nurses, nurse practitioners, physiotherapists, occupational therapists, social workers, and sometimes a speech pathologist or nutritionist. Often there is a recreational therapist. Case management models are usually used and day hospitals work in liaison with other community caregivers, such as home care services.

Patients who attend day hospitals benefit from both the therapy and the company of other peers. Most have individual therapy with specific treatment but will also participate in group activities such as exercise and usually some recreation. Some day hospitals provide more acute assessment and management. Persons usually attend for two days per week, although more often in some cases (PACE), and usually for about four hours each day. The geriatric program often arranges transportation.

Day hospitals should be distinguished from day centers, which do not provide specific therapy. Day centers are designed to maintain function and to provide not only activity and socialization but also respite for caregivers. They do not have the rich staffing of the geriatric day hospitals.

Reasons for attendance at a day hospital

The patients appreciate the interdisciplinary framework of a day hospital, which allows them to return to their own home the same day. The usual reason for admission is a complication of a chronic disease that has lead to a functional disability. A few persons are reluctant to come initially, preferring the security and comfort of their own home, but once they have become used to the staff and other patients, they are equally reluctant to leave! Older persons become deconditioned quickly after a serious illness or prolonged period of functional loss and as a result may have lost a considerable amount of muscle strength. They may be recovering from a stroke, an acute illness, a fractured hip, or have arthritis, or Parkinson's disease. For some reason they have become less independent and need physical therapy, adjustment of medications, and help in arranging their daily activities as efficiently as possible. Hypertension and diabetes are common conditions in day hospital patients. The staff of the day hospital spends much time educating the patients and families about the health problems and usually allows them a leading role in establishing the treatment goals. Once those goals have been met, the person is discharged from the day hospital.

Evidence of effectiveness

There is much controversy as to the effectiveness of day hospitals. A recent systematic review concluded day hospital care to be an effective service for elderly people who need rehabilitation, but it did not have any advantage over other comprehensive care, such as home therapy. It may be more expensive. There is little favorable published evidence from randomized controlled trials.

No difference was shown in the rate of hospitalization or degree of disability for patients who attend day hospitals compared to those who receive home care in either a Finnish or a British day hospital. An earlier Canadian study showed no difference in mortality between GDH and usual specialized geriatric care. Randomized controlled trials of geriatric day hospitals have generally failed to show any benefit in terms of either patient outcomes or cost savings, although those patients with the greater degree of disability have seemed to improve in some trials. These disappointing results may have been due to heterogeneity of physical and mental function in the patients who come to day hospitals or the wrong outcomes may have been measured. There may have been too much of a variation in the health status of the persons admitted to the day hospitals. The measurement instruments may not have been the best ones to measure important changes. Instruments that are designed to discriminate between persons who have a condition and those who do not may not be the best ones to measure change in that condition. If a woman has had a stroke, she may not improve the paralysis of the leg involved by attending the day hospital but after attending she may be able to walk a little further with an aid and feel much better about going out in a car or even public transport. She may also enjoy life more. Measuring her muscle power or the degree of weakness would not have shown much improvement.

On the other hand, it is possible that day hospitals are not effective ways of managing health problems in the frail older adult and other approaches, such as increased home care, need to be better evaluated. There is, however, a high acceptance of this approach from day hospital attendees and staff. Increasing evidence shows targeting patients most likely to benefit may improve outcomes in both physical function and reduction of caregiver stress. In several published studies, patients with the highest degree of physical disability seemed to benefit the most. Better selection of patients in the future may improve the effectiveness of these popular programs, but this would require evaluation in further rigorous research studies.

IRENE TURPIE

See also ASSESSMENT; FRAILTY; GERIATRIC MEDICINE; HEALTH AND LONG-TERM CARE PROGRAM INTEGRATION; MULTIDISCIPLINARY TEAM; OCCUPATIONAL THERAPY; SOCIAL WORK.

BIBLIOGRAPHY

BROCKLEHURST, J. C. "Geriatric Services and the Day Hospital." In Textbook of Geriatric Medicine and Gerontology. 2d ed. Edinburgh: Churchill-Livingstone, 1978.

ENG, C.; PEDULLA, J.; ELEANOR, G. P.; et al. "Program for All-Inclusive Care of Elders (PACE): An Innovative Model of Geriatric Care and Financing." Journal of American Geriatrics Society 45 (1997): 223–232.

FORSTER, A.; YOUNG, J.; and LANGHORNE, P. "Systematic Review of Day Hospital Care for Elderly People." British Medical Journal 318 (1999): 837–841.

TURPIEI. "The Geriatric Day Hospital." In The Oxford Textbook of Geriatric Medicine. Edited by J. Grimley Evans. Oxford, U.K. Oxford University Press, 2000. Pps. 1076–1086.