Introduction

Elder Care Continuum is a terminology that is widely used but least practised in India.

During a recent conversation with my physician friend at Auckland, NZ, we discussed the case of an elderly patient being discharged from the hospital post his TKR procedure. The discharge process included the participation of the treating surgeon, supervising nurse, physician, the caseworker attached to the patient & the family member. Post discussions & inputs from all (included the field visit by the caseworker to the home of the elderly), it was decided & approved to move the patient to the transition facility for a time period before moving him to his own residence. The caseworker was assigned the responsibility to report progress to the group during the period. This instance clearly demonstrated the existence of a system that guided the patient into a type of health setting relevant to the patient to ensure successful outcome (in this case speedy recovery & reduced chances of readmission).

Care Continuum

By definition, elder Care Continuum is a concept involving a system that guides and tracks elder patients over time through a comprehensive array of health services spanning all levels and intensity of care. There are two important elements to this definition, (i) Different health settings & (ii) Care Supervision & documentation.

Different Health Settings: During the lifetime of the elderly, they may have to be exposed to various health settings covering both short & long stays which includes elder residence/senior living facility, hospital, nursing home, transition care facility, palliative & hospice, memory care centre & psychiatry unit. Each one of these facilities is designed to meet certain specific purposes. The attached image depicts these various settings.

Care Supervision: This is a critical piece of the care continuum process. Normally it is advised that the family doctor/physician plays this role who understands the individual, his health conditions & his family well.

Indian Scenario & Challenges

Health Settings: While we have fared better in terms of hospitals to manage acute & chronic ailments, we are still nascent when it comes to all the other specialized environments. It is sad to see the decline in the concept of family doctor (primary care physician) which is vital to care continuum. Many players who forayed into this in the urban markets have either shut down or not doing well.

Care Supervision: The concept of family physician which seemed to have been prevalent a few decades ago in India seem to be becoming extinct now. Traditionally this role has been played by the family members as well which of course is on the decline due to the change in the social fabric where we have seen a shift to the nuclear family concept. Technology has not played any role in achieving effective supervision as well. In fact, we have seen tech models, such as doctor discovery platforms or online consult models, being counterproductive in this situation wherein any person can directly choose a super-specialist as the first touchpoint which is against the recommended principles.

Human Resources: We have a handful of medical colleges in India producing less than a dozen of geriatricians annually many of whom relocate to countries outside India leaving a void in India. There are few fellowship & diploma programs that have been introduced but are insufficient. In addition, institutions to produce paramedics, counsellors etc. to deal with eldercare are also insufficient.

Cost & Financing: Ayushman Bharat launched under the National Health Protection Mission provides cover for the underprivileged but lack of different health setting environment is a dampener. While the population covered by formal insurance is very low in India, even for those covered by insurance they cannot access these specialized care facilities owing to the absence of coverage. Thus, most of these elders have to rely on out of pocket spend (OOP).

Government Policies: The Economic Survey of India, 2019 dealt extensively on the growing elder population in India & placed its recommendations. The finance budget which followed this submission seems to have totally ignored this important area. Geriatric population seem to be a neglected subject in the GoI agenda.

Opportunities

Many of these challenges pose an opportunity for entrepreneurs, care professionals, educationists, insurance companies & activists. These opportunities range from setting up & operating specialized health settings, establishing training curriculum, newer financing & insurance products and most importantly working with the local government institutions in PPP models.

Conclusion

Elder Care Continuum is a terminology that is widely used but least practised in India. With the elderly population to touch 24 crores by 2040, we do not have a road map as a country to deal with this and there is an urgent need for the GoI to take this seriously and work expeditiously. In addition, we have a responsibility to work with the governments, pursue these through various industry bodies/forum, use the opportunity to innovate and commercially benefit as well.

By Rajagopal G & Dr Reema Nadig, KITES Senior Care raj@kitesseniorcare.com, drreema@kitesseniorcare.com

[Presented at the Unmukt Knowledge Series “Solutions for Empowered Elder Living”, held on 21st August 2019 at the Hyatt Regency, Chennai]