Hogeschool van Amsterdam

Urban Vitality

Transmural elderly care

Special professorship established by the AUMC

The Professorship in Transmural Elderly Care researches how hospitals, GPs, district nurses and nursing homes can work together optimally with the objective of giving elderly people better quality of life and helping them retain their autonomy.

Risk

For elderly people, acute admission to hospital comes with its share of risk. Three months after discharge, thirty percent are faced with permanent functional impairment (functional loss) and twenty per cent have died. In addition, twenty per cent of elderly people are readmitted to hospital within thirty days.

Solution

This problem can be addressed through several avenues. For one thing, better care for elderly people in their own neighbourhoods can prevent hospitalisations. This means higher levels of input from GPs and district nurses, but also hospitalisation in the neighbourhood. The ‘FIT’ and ‘WijkKliniek’ (‘DistrictClinic’) projects are working on these solutions.

If hospitalisation is unavoidable, the elderly person deserves the best-quality hospital care. Taking the transition to returning home into consideration is an essential part of this. It is important that vulnerable elderly people are given effective support following hospitalisation – support that isn’t just aimed at helping them undertake day-to-day activities, but that also factors in geriatric problems such as falls, memory problems and reduced mobility. The ‘Transmural Care Bridge’ and the ‘Cardiac Care Bridge’ are examples of solutions.

Palliative care pathway

Acute hospitalisation combined with multiple medical conditions and a decline in everyday activities can also be a sign of the patient entering the final stage of their life. The professorship is researching how effective care can be provided in this stage. With the ‘Pallisupport’ project, for example, the professorship is exploring ways that doctors and nurses can support elderly people in the final stage of their lives so that their deaths can be as comfortable as possible and in a place of their choosing.

Epidemiology of hospital-related functional loss

In order to develop interventions that prevent functional loss, the Professorship in Transmural Elderly Care is also doing long-term research into the mechanisms by which functional loss comes about. In the ‘Hospital-ADL’ study, elderly people are monitored closely from the moment they are admitted to hospital to three months post-discharge.  

The researchers monitor factors such as health issues, muscle mass, muscle strength, inflammatory substances in the blood and the amount of exercise the patients get while in hospital. In addition, special attention is paid to those issues that elderly people themselves consider important.

Published by  Faculty of Health 4 April 2019