A plea for the post-acute and rehabilitation care sector: the glaring oversight in the conversation on ageing

By Marie-Anne Fourrier, Hospital Director, Transformation and Development Director of the Korian group Health Division.

Start talking about old age and public debate tends to gravitate towards long-term care nursing homes. Such was the case with an opinion issued recently by the French National Consultative Ethics Committee, the CCNE. The opinion set out to encompass a much wider issue, as its title clearly shows: “Ethical issues in ageing: How useful is it to group elderly people among themselves in residential facilities? What means do we have for a society inclusive of elderly people?” Yet, in some cases, it was reduced to nothing more than an anti-nursing home rhetoric. However, did the CCNE not set out to break away from the default “elderly = nursing home” equation by pointing out that seniors should be able to choose where and how they live and that elderly care paradigms need to be shaken up and new forms of solidarity introduced? The CCNE has attempted to open up the debate and make the role of the very elderly population a key matter within society by inciting young and not-so-young populations to rethink their role and their duties in regard to old age.

To avoid grouping elderly people as if in a ghetto, what could be more important than finding ways for elderly people to return to their homes after the inevitable accidents that befall most seniors at some point, such as falls and acute illnesses? In this respect, post-acute and rehabilitation care (PARC) facilities will play a key role in ensuring that elderly people can return home, preventing unnecessary rehospitalisation, and even premature admission to nursing homes.

Post-acute and rehabilitation care services primarily cater for elderly people and patients with chronic diseases; their role is to help patients to recover their physical, cognitive and psychological abilities as best they can, but also to help them adjust to new-found limitations in their everyday life. Unlike a medical or surgical facility, a stay at a PARC unit is often relatively long - thirty days on average - which allows time to address different ways in which a loss of independence can be prevented: - Primary prevention by assessing how vulnerable the elderly subject is; - Secondary prevention including special training delivered by professionals (therapeutic education).

- Tertiary prevention as part of functional rehabilitation
Increasing the number of PARC day centres is a particularly promising way forward. It means that elderly patients can be treated as out-patients, which makes the return home smoother and improves their quality of life. On the whole, practitioners are ill-informed about PARC day centres, and private doctors are virtually unaware that it’s even an option; post-acute and rehabilitation day care involves a multidisciplinary team of healthcare professionals including doctors, caregivers, psychologists, physiotherapists and social workers, and the stimulating environment of group sessions secures two key aspects of prevention, both warding off a loss of independence and ensuring social engagement.  With a host of useful workshops covering fall prevention, exercise, therapeutic cooking and nutritional awareness, and cognitive and memory stimulation, day care centres help elderly people to regain their capacities and restore their self-confidence, two crucial factors for returning home after an acute episode. Successful PARC day care can help to avoid traditionally lengthy hospital stays in acute care units, returning to hospital for shorter stays (often preceded by a trip to A&E which is known for its detrimental effects), or even institutionalisation.

However, the post-acute and rehabilitation care sector in France is currently being squeezed and penalised.
On the one hand, the country’s health insurance system now routinely encourages patients to see their own doctor to the detriment of PARC units due to programmes such as the MSAP (Mise sous Accord Préalable des Hospitalisations en SSR) scheme which subjects PARC stays to a prior approval process, and PRADO, a programme for patients to return to their home. On the other hand, pricing strategies have clearly penalised post-acute and rehabilitation care over recent years, with the private sector being hit the hardest where daily rates have been dropping consistently since 2015.

While the French health system’s proactive policies to encourage GP, or non-hospitalised care may well have a legitimate basis in some instances, however, they cannot always be applied to an often isolated and dependent elderly population in areas poorly covered by medical and paramedical services. After being hospitalised, with or without surgery, being transferred to a PARC unit gives elderly and vulnerable patients a chance to catch their breath and serenely prepare their return home, whereas the average stay in standard hospital facilities rarely extends to more than a week. Furthermore, faltering medical and paramedical demographics should incite government authorities to increase the numbers of PARC units across the country. In isolated rural areas where medical and paramedical workers are particularly thin on the ground, PARC units are often the only way to ensure a safe health journey for elderly patients and avoid opting for premature institutionalisation. Without the support of a PARC unit, dwindling numbers of home care assistants make it even more complicated for elderly people to return home and stay there.

The policy rolled out over recent years by the Ministry of Social Affairs of lowering care tariffs at PARC units is now causing a real problem; the age, inevitable increased likelihood of illness and the dependency of the patients admitted are all steadily increasing, while the resources being made available to the post-acute and rehabilitation care sector are decreasing year after year. Regional health authorities’ parsimonious allocation of accreditations for PARC facilities for dependent elderly people with multiple pathologies has served to deplete this sector and done nothing to strengthen this link in the healthcare chain that plays such a key part in a move towards home-based care.

Thus, it would appear that rethinking elderly care policies as the CCNE would like to see can only be achieved by backing the post-acute and rehabilitation care sector in a bid to enable elderly patients to return to their homes and stay there. PARC facilities can pick up on early signs of an imminent loss of independence, prepare the person for returning home, promote therapeutic education and exercise, and help to close the gap in areas affected by a shortage of GPs. At a time when the number of natural caregivers is on the decline, PARC facilities provide a precious care solution where elderly people can find their bearings and recover their ability to live alone, reduce the risks of unnecessary and detrimental rehospitalisation, and stave off admission to a long-term care nursing home.

Here’s hoping that the role and the value of post-acute and rehabilitation care facilities doesn’t get overlooked in the roadmap announced by the French Health Minister Agnès Buzyn.