Proposed System of Integrated Geriatric and Disability Care Services in Sri Lanka (A Concept Note)

: The global landscape is witnessing a significant transformation marked by a rapid increase in the aging population, driven by epidemiological and demographic transitions. Sri Lanka, like many other countries, is experiencing a significant demographic shift with an increase of older population. Notably, Sri Lanka stands out in South Asia, with 12.3% of its population aged 60 or older, the highest proportion in the region. Similar to other countries Sri Lanka also experiencing the increasing of elderly population. Sri Lanka is not geared to cater the elderly population and their needs as well as related health conditions, hence; it is the need in the current context. Objective of this paper is to propose a service delivery framework for elderly and related health care to the Sri Lankan health system based on the current findings. Methodology used are a desk reviews and key informant interviews to gather current data on elderly care and develop the model based on these findings. The development of geriatric health services in Sri Lanka is crucial to ensure that the growing elderly population receives the care and support they need to age healthily and maintain their quality of life. By addressing the unique healthcare challenges faced by the elderly, we can enhance the overall health and well-being of the elderly population in the nation.


INTRODUCTION
The global landscape is witnessing a significant transformation marked by a rapid increase in the aging population, driven by epidemiological and demographic transitions (Jarzebski et al., 2021).Sri Lanka, like many other countries, is experiencing a significant demographic shift with an increase of older population.Notably, Sri Lanka stands out in South Asia, with 12.3% of its population aged 60 or older, the highest proportion in the region (UNFPA, 2017; Solano, 2021).The proportion of elderly citizens (aged 60 and above) is steadily increasing due to improved healthcare, better living conditions, and decreasing birth rates.With this demographic transition, it has been noticed high need for comprehensive and responsive healthcare services tailored to the unique healthcare requirements of the elderly (Roser, 2023).Common issues of older persons include chronic non-communicable diseases, cognitive impairments, frailty, higher susceptibility to disabilities, multi-morbidity, polypharmacy etc. (World Health Organization, 2022).It is essential to offer optimum management to their ailments timely to prevent death, preserve the quality of life, prevent disability, promote active aging, and reduce healthcare costs.Hence, identifying this as a priority and reorganizing health service in order to cater such needs has become a need of the day.

BACKGROUND & JUSTIFICATION
Similar to other countries Sri Lanka also experiencing the increasing of elderly population.Sri Lanka is not geared to cater the elderly population, and it is the need in the current context (Dissanayake,  Health care needs of older people Since aging is believed as a process in which the occurrence of disease is frequent and normal, less emphasis is usually paid to symptoms, hence underreporting is common.Manifestation of symptoms and syndromes also tend to differ in young adults due to aging, impaired physiological reserve, multimorbidity, and polypharmacy.These lead to late detection of diseases leading to bad outcomes.On the other perspective, single pathology can be hardly used to explain all symptoms and signs in older persons, compared to young adults.Treatment targets also may differ in elderly compared to the young, where some abnormal finding in young, can be considered as a state where treatment is not required.Hence, this complexity and multi-morbidity, leads to long term follow up as well as acute many emergencies such as CVA (Cardio Vascular Accidents) / Strokes, MI (Myocardial Infarction) / Heart Attacks and orthopedic issues as well.

Current service provision
These elderly patients strait away attend for Secondary and Tertiary care for all ailments in most of time which could be managed Primary Care level.Such referred patients from Secondary and Tertiary care are currently attending for highly congested diseased based follow up clinics in such higher institutions without proper reviewing due to heavy overcrowding though those could be followed up easily and properly at the PHC.Similarly, for acute emergencies, PHC centres close to their homes are bypassed most of the time to Secondary and Tertiary care where specialist services are available avoiding the platinum minutes of golden hour.It is clear that current health services are not in a position to cater the complexities of elderly patients' needs in both acute and follow up care hence directing to seek any appropriate addition / s.

Objective
To propose a service delivery framework for elderly and related health care to the Sri Lankan health system based on the facts on review of current situation

METHODOLOGY
Desk reviews and key informant interviews were done to gather information on current service provision and gaps on elderly and related health care then the model is proposed based on these findings.

FINDING AND DISCUSSION
With the identification of importance of arranging special care for elderly and elated health conditions, there are many initiatives are being implemented; mostly developing necessary human resources and system development.In response to the growing needs for specialized healthcare for older individuals, postgraduate training for elderly care has been initiated in 2014 in view of developing specialists on elderly care.Also, Ministry of Health in Sri Lanka has introduced a training course in elderly and disability care as well as palliative care for medical offices and nurses in primary healthcare settings This reflects a recognition of the urgency to equip healthcare providers with the necessary knowledge and skills.
However, the focus on elderly and disability care has been predominantly limited to secondary and tertiary care hospitals rather than Primary Health Care institutions where those identified problems and gaps could be easily attended.Recognizing the necessity to expand these services to primary care institutions, in parallel to human resource development, system developments have been proposed and some have been introduced such as establishing integrated care pathways for elderly and related health conditions (stroke, orthopedic cases that needs long term indoor care).This strategic move aims to bridge the gap between specialized care and primary healthcare, enabling a more comprehensive and accessible approach to elderly and related disability and palliative care as well as linking with home based care or community based rehabilitation care.

How does integrated care service cater the geriatric health requirements?
The practice of this integrated health services aims to maximize functions in spite of the disease, to compress the morbidity, and to delay onset of complications.Hence, it focuses on the prevention of functional decline, early detection and managing indoor care more effectively as well as integrating follow up care.Most of the time, it promotes cost-effective use of services.Breaking down of complex health issues of older persons into multiple simple problems, symptoms and syndromes and addressing them individually by various means are involved in the practice of geriatric medicine as strategies.It also takes a multifaceted approach to functional Development of an integrated care for elderly and disable persons has become a need of the day Responsibility of Ministry of Health is to ensure equitable access to quality healthcare services for the elderly population, regardless of their location and socioeconomic status.While establishing specialized services on geriatrics at higher levels of care, the quality of life can be improved and the burden on the healthcare system can be reduced.Hence, the development of integrated health services is essential to address the specific health challenges faced by the elderly and disable population in Sri Lanka with development of strategies at all levels of care for early detection, prevention, and effective management of chronic diseases prevalent among the elderly, such as diabetes, hypertension, and cardiovascular diseases.Healthy lifestyle choices should be promoted among the elderly through health education, physical activity, and nutrition programs.Specialized geriatric care units in healthcare facilities should have the capacity to provide comprehensive care, offering a range of services, including assessments, rehabilitation, and palliative care.Care services should always focus on low cost interventions enhancing efficiency of services and should pay emphasis to the concerns of families and caregivers as well.

Strategies proposed for establishment of integrated geriatric and disability care services in Sri Lanka
These strategies could be implemented through the partnerships of Ministry of Health and provincial governments, academia, government and non-governmental departments and agencies as well as private sector towards funding, technical guidance, consultancies and facilitation for implementation as well as monitoring.It is necessary to secure funding through government allocations, grants, and public-private partnerships to support the implementation and sustainability of the services.

A. System Improvements 1. Establishing early identification screening mechanism through Family Medical Clinics
Family Medical Clinics established in Out Patients Departments (PMCIs) including Divisional Hospitals and networked through a database will screen all empanelled families hence all elderly people will be screened and early detection could be done for preventable diseases.

Reforms in care pathway and introduction of step down centre concept
It is difficult to manage such patients for long time in a higher centre due to accommodation issue.Usual way is to discharge directly to their homes.But, here it is proposed to manage in a transit period at underutilized Primary Care institution as a step down hospital and then to discharge to their homes following a care giver training to their family member /s.Within the step down PHC centre, patients could be managed by trained MOs and NOs under the direct supervision of relevant specialists in the higher centres who are physically visiting and / or virtually through Telemedicine.Appropriate referral and back referral pathways between the higher tertiary and secondary care and primary care institutions should be established.

Home Based Care / Community Based Rehabilitation
Discharged patients could be managed with the assistance of Care giver trained family members and will be supported by Public Health Nursing Officers who are supposed to visit their homes and monitor or even by MOs in the Family Medical clinics under the direction of Family Medical Specialist.Evan Telemedicine could be used to monitor and manage patients in Home Based Care.Implementing telemedicine solutions to facilitate remote consultations, particularly for elderly individuals with limited mobility, can be considered as a feasible option to reach more clients.

Follow up of elderly patients with chronic diseases
Such elderly patients could be followed up for all diseases collectively through a comprehensive holistic care at above described Family Medical Clinics equipped with necessary medicine and diagnostic facilities rather than visiting several clinics on disease based care.

Community Outreach & Telemedicine
Establish community-based programs, partnering with provincial health system to reach elderly citizens in rural areas, offering preventive care, health education, and regular health check-ups.Public Health Nursing Officers (PHNOs) can be utilized for this as an existing resource.

 Provision of information;
Information of the kinds of assistive devices available, information on care givers training program, information on linking to Social Services Department (SSOs and ERPOs) and to the NSE, information to link to Disability and Elder Support Organizations, database of persons to whom the services were provided and a database to identify the persons who need to be followed up to check on the persons who receive support via the Desk.

 Provision of Services;
Facilitating access to required assistive devices via the health sector, Social Services Dept, NSE, NGOs, Donors etc., Facilitating the link with area SSOs, ERPOs and Elders and vice versa, Help families of elders to undergo care giver training programs, Supporting families to find care providers for elders who require assistance, Facilitating with the NSE officers to access the many services provided for by the NSE, Facilitating the delivery of required medicines for housebound/ disabled Elders, Linking secondary care services eg.eye care, ENT care, stroke care etc. for required elders, Linking with Civil Society Organizations, Disability Service Organization and well-wishers interested in providing Elderly and Disability care services, Hotline telephone support services to care givers and elders who require additional information related to elder and disability care.

B2. Upgrade and equip healthcare facilities to friendly accommodate the elderly and disable ,
• Carryout a hospital facility assessment • Develop PMCUs, DHs, BHs and MOH offices to be able to provide elder and disability friendly health services including making them wheelchair accessible

C3. Redistribution and Mobilizing of Human Resources for Health
Relevant staff categories trained and developed as effective teams at various levels especially in PHC level according to availability of other resources as well.Mobilization and redistribution should be considered for existing resources.Cadre development may be an option for certain institutions.

D. Monitoring and Evaluation
Establish a comprehensive coordination, monitoring and evaluation mechanism with digitalized data flow to assess the effectiveness of geriatric health services in terms of healthcare access, coverage and availability, as well as affordability, health outcomes, patient satisfaction and cost-effectiveness etc.
Author: Dr. G.S.P. Ranasinghe Volume 07 Issue 05 May 2024 Available at: www.ijcsrr.orgPage No. 2570-2577 deficits, physical and psychological conditions and managing them according to set individual goals of care.Treatment goals are usually customized, often discussed and agreed with care givers or families.

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Summary of pictorial representation of integrated care pathway for elderly care described in the Annexure I.) establishing an 'Elders and Disabled Persons Service Desk: A special desk /counter at each of the Primary Care Units (PMCUs and DHs) as well as SC and TC institutions (BHs and above) for elders and other disabled persons and care givers of them who require assistance.It will be manned by a designated nursing officer who is able to provide all relevant information and services regarding below mentioned services to elders / disabled persons and their families at this desk such as;

Physical Infrastructure changes to make hospitals elder friendly Hospitals
need to have access to elder / disability friendly toilets, walkways with side rails, ramps at points with steps, smooth floors of walkways / corridors within the hospitals for easier mobility, Access to drinking water, Access to adequate seating, If services are available in higher floors-lifts, low angle ramps with support railings or wheelchair access facilities to staircases are needed, Appropriate infrastructure facilities for users of white canes, Adequate numbers of wheelchairs, trolleys for within hospital patient movement for investigations etc.If necessary, motorized vehicles, if wards and services are far apart.
• Renovate/ construct / modify the hospital environments to ensure that the facilities are elder friendly: this includes both physical infrastructure developments and process changes.Installing appropriate medical equipment B3.

changes needed to make hospitals elder friendly
a. Creating new counters for speedier services for elders and for disabled persons at existing clinics, in the OPD and at the Pharmacy, admission, discharge, laboratory test counters, imaging service counters, Where necessary provide seating facilities for elders queues, Train all staff categories (separately) to show empathy towards elders and disabled persons, Introduce mechanisms / processes to reduce the total time spent in hospital for outpatient and clinic services, Introduce day surgery, short stay service options prioritized for elders and disabled persons, Create a separate line / counter for the Elders with priority for disabled elders, Provide handouts / guidance notes/visuals for collecting samples for easier understanding, Develop mechanisms to collect samples form elders and especially disabled elders in the area.b.Strengthening the community based and in-hospital screening services for Elders for NCDs, cancers, mental health issues, and eye care, COPD, Asthma, musculoskeletal disorders etc. Establish facilities for walk-in screening of elders at HLCs or at OPD for BP, RBS, dietary advice, BMI measurements, selected cancer screening, etc.
 Establish Eye care clinics designated for elders International

Ranasinghe Volume 07 Issue 05 May 2024 Available at: www.ijcsrr.org Page No. 2570-2577 
Carryout outreach screening programs for NCDs and Eye care targeted for elders and for disabled persons living in hospital draining area or in cluster catchment areas  Develop protocols and arrange mechanisms for back referral of elders from secondary care level hospitals to nearest PHC (PMCUs or DHs) hospital for long term management of NCDs (Diabetes, Heart diseases, Hypertension, Chronic Kidney Diseases, Asthma, COPD, musculoskeletal disorders etc.)  Create a link with PMCU/DH Medical Officers and the Clinics / Specialists at relevant Secondary care hospital for advice, guidance and clarifications.Establish arrangements for annual and biannual up-referral for eye care, foot care, scans etc. Ensuring that the basic essential laboratory and other investigative services are conveniently accessible to elders. Strengthening the well women clinics to ensure that female elders are screened for early detection of NCDs and cancers. C.

Human Resource Management C1. Capacity Building of healthcare workforce
Ensure availability of trained human resources to provide a comprehensive Elderly Care service.It is essential to have a long-term plan to train the healthcare workforce (including doctors, nurses, and allied health workers), in geriatric and disable care, focusing on the specific needs of the elderly.It is essential to identify an appropriate centers as the center of excellence for geriatric care at National level and use for training of health care professionals. Provide training opportunities to the service providers (e.g.MOs, Nurses, Attendants, PHMs and PHIs etc) at hospitals and MOH Offices in project areas.Review the Human Resource availability in hospitals and MOH offices ensure that existing vacancies are filled. Review the new tasks that are included (under activity 2 and 3) and assess the required additional cadres for provision of elderly services in PMCUs and DHs and selected Secondary care hospitals. Appoint Medical Officers with Post Graduate training in Geriatric Medicine and Family Health to the Divisional Hospitals  Reactivate the Care giver Certificate program and the Diploma Level training program as vocational training programs  Development of specialists in geriatrics according to the developed appropriate doctoral programmes (MD in Geriatrics),  Postgraduate Diploma in Elderly Medicine, enrolling more medical officers to the study programmes  Geriatrics should be included in the undergraduate curriculum of Medicine and Nursing.Develop a certificate course on elder care, of at least 6 / 3 months for MOs and NOs,  Appropriate post basic courses must be introduced for nurses to get enrolled, the opportunities should be expanded and participation in these should be encouraged.Special emphasis must be paid to Primary Health Care and Rehabilitation Service providers( MOs and NOs) to get appropriate in-service training programmes at regular intervals.