geriatricians in canada have long looked to our colleagues in the united kingdom for inspiration and guidance . a recent report by david oliver , catherine foot , and richard humphries on behalf of the king s fund
raises many issues regarding current problems with the care for older adults in existing health - care systems and also suggests ways forward . given our long association and shared history ( the debt that we owe includes many of our pioneering clinicians ) , there is reason to read making our health and care systems fit for an ageing population with care . here
we hope not to summarize a lengthy and comprehensive review of many aspects of the health - care system , which are either problematic or promising in the care of frail older adults , but rather to highlight a few key issues which may help guide our thinking about the future of geriatric medicine in canada .
one key shift in mindset argued for by oliver and colleagues is an increased focus on community - based and intermediate care as alternatives to acute - care hospitalization .
hospital - centred care has such a strong culture that sometimes avoiding it can be more effective than trying to reform it .
the framework of  discharge to assess  versus  decide to admit  presents a useful alternative to our current 
discharge to assess  model , acute health needs are the focus of acute care encounters . patients are then discharged home , as soon as their condition has stabilized , for rapid follow - up of ongoing care and support needs by community - based clinicians .
alternatively , clinicians can actively decide to admit patients who require admission for specific medical therapies , rather than having admission be the default path of least resistance .
much stands to be gained from designing our systems of care to focus on care in the community and in the least acute setting possible , rather than subjecting older adults to the harms that are well - known in acute care and that typically have defied reform .
solid systems of care in communities can also potentially streamline assessment processes and avoid duplication of efforts .
some jurisdictions in the uk have even recognized that the assessment and therapy needs of older people living in their own homes do not take weekends off , leading to implementation of  seven day  care at home .
( as wayne gretzky famously said ) and get out in front of the move to community - based care .
the important role remains for clinical specialists working in tandem with primary care systems and clinicians and ( in an ideal world ) an organized form of so - called  intermediate care  .
such facilities aim to offer an environment in which rehabilitation and recuperation can be the primary focus , rather than settling onto the treadmill of yet more investigations which may add less benefit to frail patients then do solid clinical acumen , and a focus on improving function and meeting goals that are truly patient centered .
it also means making routine care less hazardous  for example , by avoiding the twin evils of over sedation and inadequate pain treatment  and promoting early mobilization , proper nutrition , interprofessional collaborative practice , and early involvement of patients and families in setting goals of care .
when it was introduced , intermediate care was quite controversial , as it appeared to harken back to the regrettable era in which geriatric medicine was viewed as an undertaking of care for second - rate patients in second - rate facilities by second - rate doctors . in a sharply worded 2001 bmj commentary
, raymond tallis and grimley evans argued that in the operationalization of the uk national service framework for older people , the good intentions of clinical experts were sidetracked by the political agenda to 
keep old people out of hospital  by reducing their  inappropriate  use of hospital beds , an agenda largely driven by cost savings but which had undertones of value judgments on the patient population , as well . in any event , renewed focus on good intentions and the evidence base ( of reducing harmful interventions and environments which thrive in acute care hospitals ) allows the benefits of intermediate care , with its focus on sensible medical care , rehabilitation , and re - enablement , to be realized .
the idea of  intermediate care  might sound pejorative still , but it should be recognized that it can be either a
( from care at home ) or a  step down  ( from acute care hospital ) . here , less is more : ideally , intermediate care is provided close enough to acute care that clinicians have an easy commute , but far enough away to allow them to avoid the temptation to over - investigate and treat what need not be investigated or treated . for many frail older people ,
the trap of access to invasive investigations that are too easy and too often - used , again by default , is a deep one . still , in an era in which patients labelled as 
social admissions  have a high risk of death , we need to be alert that words matter , especially when they are meant to designate whole areas of activity ; they re not called  brands  for no reason .
in recent years there has been an increasing focus on efforts to keep frail older adults out of emergency departments . while these efforts may be well intentioned , emergency health systems , including paramedics , ambulance services , and emergency departments , remain an important point of access to care when need is greatest . in consequence
, we should seek not to turn people away who need help , but rather to create better pathways of care once they have reached out for assistance .
for example , once a 911 call is made , if paramedics are trained and equipped to provide assessment and care on - site , a transfer to hospital may be avoided .
even so , this can only work sustainably if care in the home does not end when the ambulance pulls away from the curb .
clinical care programs focusing on rapid follow - up of older patients discharged from emergency departments ( e.g. , home visits by specialized clinicians trained in the principles of home - based comprehensive geriatric assessment [ cga ] ) show great promise in canadian settings and should be a focus for implementation and , importantly , evaluation and research .
our current models of care for frail older adults have been heavily hospital - based . given that hospitals can do more harm than good for frail older adults , this is not un - problematic .
alternatives include : 
 keeping them out of hospital in the first place ( geriatricians will have a pivotal role here , with familiar principles of cga and optimizing function , to which we would add a key role for advance care planning);making care less hazardous in the hospital ( here we see a great role for intermediate care and attention to cultures of care which minimize iatrogenic and environmental harms ) ; andattention to the interface between acute and long - term care  this will have both clinical and administrative aspects  with an emphasis on home supports that are flexible enough to meet the needs of users . keeping them out of hospital in the first place
( geriatricians will have a pivotal role here , with familiar principles of cga and optimizing function , to which we would add a key role for advance care planning ) ; making care less hazardous in the hospital ( here we see a great role for intermediate care and attention to cultures of care which minimize iatrogenic and environmental harms ) ; and attention to the interface between acute and long - term care  this will have both clinical and administrative aspects  with an emphasis on home supports that are flexible enough to meet the needs of users .
the king s fund report challenges us to  identify early priorities for change and quick wins  .
we also need to focus on what our brand will be , if we are to prosper , and not just compete , as canadian health care comes to grips with population ageing . what would be our quick win in a canadian context ?
community - based care , while perhaps not entirely quick , could be that win .
 a report from the united kingdom on making health and care systems fit for an ageing population proposes a range of interventions to make care better for older adults , especially those who are frail . here 
 , we discuss the proposed shift for the acute care hospital to other models of care . 
 the key for these models of care requires a fundamental shift to care that addresses the full range of an individual s needs , rather than being based around single diseases . how this might apply in the canadian context 
 is considered . 
 we emphasize strategies to keep people out of hospital but still receive needed care , make acute hospital care less hazardous , and improve the interface between acute and long - term care . 
INTRODUCTION
COMMUNITY-BASED CARE
INTERMEDIATE CARE: LESS IS MORE
ALTERNATIVES TO ACUTE-CARE HOSPITALS
EARLY PRIORITIES AND QUICK WINS