Senior Friendly Hospital Framework

[Flocka Bilodeau]

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Older adults are vulnerable to hospital-associated complications such as falls, pressure ulcers, functional decline, and delirium, which can contribute to prolonged hospital stay, readmission, and nursing home placement. These vulnerabilities are exacerbated when the hospital's practices, services, and physical environment are not sufficiently mindful of the complex, multidimensional needs of frail individuals. Several frameworks have emerged to help hospitals examine how organization-wide processes can be customized to avoid these complications. This article describes the application of one such framework-the Senior-Friendly Hospital (SFH) framework adopted in Ontario, Canada-which comprises five interrelated domains: organizational support, processes of care, emotional and behavioral environment, ethics in clinical care and research, and physical environment. This framework provided the blueprint for a self-assessment of all 155 adult hospitals across the province of Ontario. The system-wide analysis identified practice gaps and promising practices within each domain of the SFH framework. Taken together, these results informed 12 recommendations to support hospitals at all stages of development in becoming friendly to older adults. Priorities for system-wide action were identified, encouraging hospitals to implement or further develop their processes to better address hospital-acquired delirium and functional decline. These recommendations led to collaborative action across the province, including the development of an online toolkit and the identification of accountability indicators to support hospitals in quality improvement focusing on senior-friendly care.

Two guidelines on senior friendly hospital care were identified. A guideline from Ontario was developed to help hospitals perform as senior friendly organizations based on the five components of the Senior Friendly Hospital Framework, and to ensure that the recommendations were implemented. The identified Irish guideline provided detailed recommendations with respect to dementia-related design issues and the Universal Design of dementia-friendly hospitals for new-build projects or redevelopment and reconfiguration of existing hospitals.

A limited literature search was conducted on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No methodological filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2009 and January 29, 2019.

One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.

The quality of the evidence-based guidelines was assessed using AGREE II instrument.9 Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations were described narratively.

A total of 223 citations were identified in the literature search. Following screening of titles and abstracts, no potentially relevant reports from the electronic search were retrieved for full-text review. Two potentially relevant publications were retrieved from the grey literature search. After reviewing, two guidelines met the inclusion criteria and were included in this report. Appendix 1 presents the PRISMA flowchart of the study selection.

The objectives of the Ontario guideline11 were to provide recommendations for hospitals to perform as senior friendly organizations and to ensure best possible health outcomes for frail older adults. The objectives of the Irish guideline10 were to provide detail recommendations in relation to dementia related design issues and the Universal Design of dementia friendly hospitals.

The intended users of the Ontario guidelines were hospitals and Ontario Local Health Integration Networks (LHINs), while those of the Irish guidelines were acute hospitals and non-acute healthcare facilities.

The Ontario guideline11 was developed through reviewing the self-assessment reports of all adult hospitals across Ontario based on Senior Friendly Hospital Framework. The hospital self-assessment reports were reviewed by each RPG clinical review team and LHINs to analyze the quantitative and qualitative information. Expert opinion and evidence from healthcare literature contributed to the development of the guideline. The Irish guideline10 was developed through consultation with key documents, normative references, and stakeholder engagement. A research team worked in collaboration with people living with dementia, their families, caregivers, staff and management of a range of hospitals, as well as the heath service executive and the architectural profession.

Both guidelines10,11 were explicit in terms of scope and purpose, stakeholder involvement and clarity of presentation, but not completely clear for other components such as rigour of development, applicability and editorial independence. For rigor of development, both guidelines10,11 did not report the use of systematic methods to search for evidence (i.e., the strategy used to search for evidence should be provided with sufficient details to be replicated; otherwise, evidence could be selective, which has the potential to introduce bias), did not describe the strengths and limitations of the body of evidence, did not grade their recommendations, were not explicit in terms of external peer-review prior to publication, and did not provide a procedure for updating the guideline. In terms of applicability, it was unclear if costs were considered in the recommendations.10,11 For editorial independence, it was unclear if the view of the funding body had any influence in the content of the guidelines.10,11

The Ontario guideline11 contains recommendations for hospitals and for LHINs. Twelve recommendations for hospitals are intended to transform hospitals into senior friendly organizations and are focused on five domains: 1) organizational support; 2) process of care; 3) emotional and behavioral environment; 4) ethics in clinical care and research; an 5) physical environment. Five recommendations for LHINs are made to support hospitals, integrate the performance of hospitals with senior friendly health system, promote partnerships between health service providers, and optimize transition in care. These Senior Friendly Hospital Framework recommendations aim to support three clinical priority areas of 1) functional decline, 2) delirium, and 3) transitions in care.11

Only two guidelines were identified in this report, one from Ontario, Canada and one from Ireland. No national guidelines or other provincial guidelines on senior friendly care for hospitals across Canada were identified. The Ontario guideline had limitations from using self-assessment methodology, in which quantitative and qualitative responses were not consistent among hospitals due to differences in definitions for the metrics examined, and were based on subjective interpretations. The self-assessment template was not designed to seek information of all hospital services for seniors, but rather focused on five domains of the Senior Friendly Hospital framework. While the Irish guideline can be applicable to the Canadian context with respect to physical design of acute care hospital for senior patients and people with dementia, it was unclear if the Ontario guideline can be fully generalizable to all Canadian jurisdictions.

Two guidelines pertaining to senior friendly hospital care were identified. The Ontario guideline was developed to help hospitals transform into senior friendly organizations based on the five components of the Senior Friendly Hospital Framework, and to ensure that the recommendations are implemented. The Irish guideline provides detailed recommendations with respect to dementia-related design issues and the Universal Design of dementia friendly hospitals for existing settings or new-build projects.

Both guidelines were developed to support an acute hospital environment that is well-suited to the needs of elderly patients of all conditions including frailty and cognitive impairment. While the Ontario guideline provides a general approach for transforming existing adult hospitals into senior friendly care organizations, the Irish guideline focuses on physical design of a friendly hospital environment for the care of people with a range of disabilities or functional impairments including dementia. A national guideline with clear recommendations that is applicable to all Canadian jurisdictions should be developed to ensure a universal and standardized senior friendly care across Canada, not only focusing on the physical environment as in the Irish guideline, but also on other components as in the Ontario guideline.

A research team working in collaboration with people living with dementia, their families and staff and management of a range of hospitals, as well as the heath service executive and the architectural profession

8) Apply a senior friendly lens to patient-centred care and diversity practices, so that the hospital promotes maximal involvement of older patients and families/caregivers in their care consistent with their personal values (e.g. cultural, linguistic, spiritual)

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