Development of healthcare and social care services for the elderly population

The dynamics of clinical and demographic processes in the northeastern administrative district of Moscow are characterized by population aging and a significant number of seniors with disabilities. The proportion of elderly and senile people increased from 15.3% in 2011 to 18.6% in 2020. The number of primary disability cases among elderly and senile people increased from 43.4% in 2015 to 54.8% in 2020, with group 2 disabilities being the most prevalent (64.12%). In 2020, a total of 2678 elderly and senile individuals received healthcare and social care services in the outpatient care setting. Of 600 respondents receiving healthcare and social care services in the outpatient care setting, 53.8% were aged 60–70 years, 42.3% were aged 70–89 years and 3.9% were aged 90 years and older. In addition, 39.8% were men and 60.2% were women. The average age was 71.2 ± 3.4 years for men and 74.4 ± 4.2 years for women.

With regard to education, 14.4% of respondents had a primary education, 33.2% had a secondary education, 24.2% had a secondary vocational education and 28.2% had a higher education. Thus, the majority (71.8%) of respondents did not have a higher education. Among interviewed individuals over the age of 60 years, 68.4% were found to be disabled.

With 86.3% of respondents living separately, there was a high correlation between estimate of living conditions and age. Persons aged 60–74 years assessed their living conditions as good in 62% of cases, whereas persons aged 75–89 years assessed their living conditions as good in only 45% of cases. Living conditions were rated as satisfactory by 34 and 22.7% of respondents aged 60–74 and 75–89 years, respectively. With regard to marital status, widowed persons accounted for 48.4% of respondents. The authors noted 34.8% legally married respondents, of whom 70.2% were in their first marriage. A total of 8.4% of respondents lived in a common law marriage, 6.2% were never married or single and 2.4% were divorced.

One-third (34.2%) of elderly and senile individuals lived alone. Among seniors living alone, more women than men (60.3 and 39.7%, respectively) were observed. It should be noted that living alone was not always associated with having no children. Only 10.2% of respondents did not have children, whereas 41.7% had two children, 36.3% had one child, 9.5% had three children, 2.1% had four children and 0.2% had more than four children. The authors found that the percentage of people living alone increased with age, from 22.5% in respondents aged 65–69 years to 62.1% in respondents older than 80 years. An inverse relationship was seen for respondents living with a spouse.

According to the survey results, only 33.5% of respondents socialized with their relatives often, whereas 26.6% contacted their relatives from time to time, 19.5% contacted their relatives rarely and 18.3% were not able to communicate with their relatives. The authors recorded that 2.1% of respondents were unwilling to communicate with their family members. A total of 38.4% of respondents assessed their relationships with relatives, neighbors and close friends as good, with 30.2% assessing their relationships as very good. A quarter (25.4%) of respondents indicated that their relationships with relatives, neighbors and close friends could be better, and 6.0% assessed their relationships as poor

Finally, the authors noted that 28.6% of respondents lived below the subsistence level. Food, healthcare and pharmaceutical products predominated in the spending patterns of 84.6% of respondents (Table 1). The majority (68.9%) of respondents estimated their diet quality as medium. Diet quality was assessed as high by 10.8% of respondents and as low by one-fifth (20.3%). A total of 62% of elderly and senile individuals indicated they ate a diet rich in vegetables and meat, whereas 38% of respondents indicated they ate a diet rich in dairy products and baked goods.

The main concerns for elderly and senile individuals were health (85.0%), social care services (13.0%) and material welfare (3.0%). The authors assessed social integration of persons aged 65 years and older as extremely low. Only 3.0% of respondents were members of public organizations, and less than 1.0% were members of political parties. A total of 16.2% of elderly persons engaged in leisure activities, including amateur performances and art or sports clubs, and the majority (88.6%) of these were women (average age: 72 years).

Table 2 illustrates the quality of life of elderly and senile individuals living in the northeastern administrative district of Moscow. The authors documented that general quality of life in persons aged 65 years and older was characterized by a low level of physical and social functioning (49.8 and 64.8 points, respectively, on a 100-point scale), with high pain scale scores. The results of the study showed that all respondents had experienced pain over the past 4 weeks, with 72.3% describing it as severe. The indicators of quality of life were significantly different for men and women. Differences were most obvious in individuals aged 65–70 years and gradually disappeared by the age of 81 years. In the 65–70 years age group, the indicators of physical functioning were significantly lower among women compared with men (58.5 and 77.4 points, respectively, on a 100-point scale). Similarly, the pain scores for women aged 65–70 years were higher than those observed for men (58.0 and 29.5 points, respectively, on a 100-point scale), with differences disappearing by the age of 81 years (64.5 and 63.7 points, respectively, on a 100-point scale). Quality of life indicators reflected a general tendency toward age-related decline in quality of life. Thus, older persons (aged over 70 years) indicated a steady decline in their quality of life on most scales and reported loss of not only physical but also psychological functioning (Figure 1).

The majority (87.6%) of respondents assessed their health as poor. The main difficulties experienced by older individuals in their daily life were impaired vision (65.3%), memory loss (27.6%), hearing loss or deafness (14.3%) and speech disorders (5.4%). Among the elderly, pain level was almost 1.5 times higher than that observed in other population groups. In addition, 94.5% of respondents reported deteriorating health over the past 12 months. Self-care capacity was reduced in 86.1% of older persons. Moving around the home was difficult for 45.4% of respondents. The health status of interviewed patients was characterized by multiple pathologies. A total of 62.5% of elderly and senile individuals indicated the presence of four to five chronic diseases and frequent exacerbations (more than five times a year).

The following diseases were prevalent in the morbidity pattern: cardiovascular diseases (74%), nervous system diseases (71%), gastrointestinal diseases (62%), musculoskeletal diseases (53%), respiratory diseases (51%) and excretory system diseases (43%). The incidence of disease was 2.3 times higher (p < 0.01) among men than women. Considering the overall morbidity rate, both men (72.3%) and women (73.7%) visited physicians to manage their previously known chronic diseases rather than to find the new ones. The frequency of exacerbations in patients with chronic diseases was not associated with hospitalizations, as only 16.5% of respondents were hospitalized two or more times a year. An unmet need for vision correction was revealed in 62.5% of interviewed patients, 35% of whom were diagnosed with cataracts in one or both eyes. The authors estimated the need for ophthalmological care among elderly and senile persons to be 928.2 ± 6.45 per 1000 people. The need for dental care was reported by 74.3% of respondents, and the need for dental care in elderly and senile individuals was estimated to be 734.6 ± 7.27 per 1000 people.

Only 12.3% of respondents followed a personalized rehabilitation program. Respondents were not interested in applying for such programs since – after confirming their disability status and engaging in a personalized rehabilitation program – 98% did not see any improvement in the healthcare and social care they received. It should be mentioned that personalized rehabilitation programs are available in one standard form for both the disabled and the elderly requiring healthcare and social care, which does not promote healthcare and social care system quality. Elderly and senile patients visited local polyclinics for the following reasons: treatment and diagnostics (63.2%), consultations with healthcare professionals (26.2%) and rehabilitation (10.6%).

Based on the survey regarding healthcare and social care organization, access and quality, the majority (82%) of elderly and senile persons attended state-funded healthcare facilities (local polyclinics). Alternatively, 8% visited private medical centers, and 10% were registered in the newly established specialized healthcare and social care geriatric center. If offered a range of specialized healthcare services (geriatricians, cardiologists, neurologists and psychotherapists) and social assistance (psychologists, social workers and lawyers).

In 2020, the healthcare network offering services to the urban adult population included 12 healthcare facilities, comprising 36 outpatient departments and 24 day hospitals. With regard to healthcare network staffing, there were 5474 healthcare professionals in 2011 and 5678 healthcare professionals in 2020 (an increase of 3.7%). The number of healthcare workers per a population of 10,000 varied slightly during the examined period and averaged 112.4 (the average for the Russian Federation in 2020 was 44.0 per a population of 10,000). During the examined period, the number of nursing staff members did not change significantly, amounting to 9363 nurses in 2011 and 9256 nurses in 2020. At the same time, the number of nurses per a population of 10,000 decreased by 6.6%, from 171.2 to 160.6 (the average for the Russian Federation was 92.4 per a population of 10,000). The number of outpatient visits was 14,548 in 2011 and 15,933 in 2020 (an increase of 8.7%). The number of outpatient visits per a population of 10,000 was 271.8 in 2011 and 279.4 in 2020 (an increase of 2.8%). This variable exceeded the average for the Russian Federation by 22.3%.

Home health services were provided by SWCs. As of 2020, a total of 6297 individuals were receiving home care. The total number of SWC employees directly engaged in home care for older people was 654. The number of in-home services provided per person increased from 345 in 2011 to 467 in 2020 (an increase of 35%). Healthcare and social care services were often delivered to elderly and senile people without regard to age, concomitant disease or self-care capacity. Patients were normally selected without a physician's involvement, and 33.7% of respondents had not had their indications for outpatient care revised for 5 or more years. Moreover, more than 20% of patients had their mobility and self-care levels preserved. Low-quality healthcare and social care were explained by the following: insufficient population density (46.4%), long queues at polyclinics to see a primary care physician and other specialists (86.3%), poor time management of social workers (76.7%) and lack of differentiated standards for social care (72.4%). The typical portrait of a social worker was described as follows: female aged 40–59 years (81.1%) who obtained higher education, had more than 5 years of work experience in the system and underwent special training in social work (62%). For 98% of social workers, employment at SWCs was full-time. Social workers were found to be highly motivated. A total of 95.4% considered their work important to the social environment, and more than half (54.6%) of respondents were completely satisfied with it. The majority (53.4%) of social workers prioritized life experience, compassion and personal qualities over professional knowledge, and such a philosophy affected their work performance. Consequently, 57% of respondents indicated a lack of legal, social and psychological knowledge.

The survey exploring satisfaction of patients aged 60 years and older with outpatient and inpatient care and various social welfare services demonstrated that 10.4% of patients visited their primary care physician only once a year and 11.4% visited their primary care physician twice a year. Almost half (48.4%) of patients saw their primary care physician every month, 22.3% saw their primary care physician twice a month, 7.2% saw their primary care physician once a week and 0.3% saw their primary care physician more than once a week. Importantly, 86.4% of patients indicated that they faced various problems at the stage of contacting a polyclinic (no healthcare professionals available, remote polyclinic, long waiting lists, inconvenient appointment time, etc.). Respondents noted that the situation with home visit physicians was more favorable. Only 21.2% of patients found themselves unable to get through to the polyclinic. The majority (72.3%) of respondents assessed the volume of diagnostic procedures they received in the inpatient setting as sufficient, whereas 23.6% of patients considered the volume insufficient and 4.1% felt it was excessive. The volume of healthcare interventions was characterized as sufficient by only 39.9% of respondents. Notably, 59.7% of patients assessed healthcare interventions as insufficient, and only 0.4% considered them excessive. Dissatisfaction with the volume of healthcare interventions was associated with drug shortages in hospitals (reported by 68.4% of respondents). Drug supply was described as satisfactory and sufficient by 31.2 and 0.4% of respondents, respectively. None of the respondents assessed drug supply as abundant.

The survey revealed that the satisfaction of elderly and senile individuals with quality of outpatient care was generally low (not exceeding 14.8%). At the same time, satisfaction with inpatient care was slightly higher (23.4%). The following gaps were identified in outpatient care: unsuccessful attempts to contact polyclinic (72.2%), long wait time for an appointment with a primary care physician (64.7%), lack of information regarding diagnostic and therapeutic procedures performed (39.2%) and insufficient volume of healthcare interventions (21.7%). With regard to inpatient care, respondents indicated the following gaps: long waiting lists for planned hospital care (73.2%), limited drug supply (68.4%) and lack of information concerning diagnostic and therapeutic procedures performed (63.2%).

Social welfare services provided to elderly and senile persons were assessed as mainly satisfactory (76.4%). However, the volume of social welfare services was assessed as insufficient by 42.4% of respondents and as sufficient by 38.4%. With respect to satisfaction of elderly and senile individuals with social welfare organization, the results revealed that only 21.2% of respondents, of whom 42.4% were disabled, regularly used the services offered by social welfare institutions. The aforementioned services were sometimes used by 12.4% of respondents, of whom 24.6% were disabled, and 13.4% of respondents indicated that it was difficult to apply for social welfare programs, as it was necessary to prepare a large number of documents and wait. Men applied for social welfare programs less than women (15.2 and 24.8%, respectively). The number of candidates for social welfare programs increased with age (12.2% among citizens aged 65–70 years and 34.6% among citizens aged over 70 years). Elderly recipients of social welfare services were completely satisfied with the services they received in 12.4% of cases, partially satisfied in 31.0% of cases and dissatisfied in 56.6% of cases.

Using a knowledge-based approach, the authors created a scale for assessing health and social isolation risk in individuals receiving home-based social welfare services (Table 3). Each criterion was given a score. The experts involved were geriatricians, primary care physicians, social workers and psychologists who were members of the healthcare and social care expert commissions. The scale consisted of four sections covering the social and hygienic characteristics of respondents (5 criteria) as well as their health status (6 criteria), vital functioning (5 criteria) and risk factors (10 criteria). Depending on the score obtained, recipients of social welfare services fell into one of the following groups: low health and social isolation risk (score: 33–73), medium health and social isolation risk (score: 74–114) and high health and social isolation risk (score: 115–152).

Initially, the most significant factors characterizing the identified organizational weaknesses or strengths of the healthcare and social care system were entered into the strengths, weaknesses, opportunities and threats matrix. Based on the results of the analysis, the authors developed a new organizational model for healthcare and social care services designed to integrate the activities of SWCs and local polyclinics (Figure 2).

Because geriatric healthcare had been separated from social care by institutional barriers, these sectors were functionally integrated through creation of a coordinating council for pensioner healthcare and social care at the regional administration. The functions of the coordinating council included resolving common problems arising in geriatric healthcare and social care, assessing the need for healthcare and social care and monitoring the access to and quality of healthcare and social care services provided.

In addition to the organizational and functional model, a number of information technologies were developed, which made it possible to automate some routine functions and served as the basis for adaptation of the healthcare system to the needs of older people. Based on a single regional register, an algorithm for monitoring the health of elderly and senile people was developed and introduced into the activities of healthcare organizations (Figure 3). This algorithm describes the interdisciplinary and interinstitutional work of healthcare professionals. Automated screening of needs recorded by healthcare professionals makes it possible to develop a personalized program of health precautions and rehabilitation measures for senior individuals.

The personal data of assigned patients are sent to the healthcare organization that provides outpatient care (local polyclinic). The register of elderly and senile persons automatically selects a group of individuals. Primary care physicians have access to records of patients residing in the service area. In addition to the standard clinical information, physicians enter into the register information about limited mobility or reduced self-care capacity, eligibility for social care services, date of the patient's next examination, estimated length of hospital stay, eligibility for palliative care, etc.

One more program was developed and subsequently implemented at the reception desks. Known as Elderly Monitoring, it automatically reminds the patient of scheduled examinations or admissions. The registrar arranges the patient's appointment with the appropriate specialist, documents the required information and invites the patient for an office visit at the fixed time. The primary care physician monitors and regulates the procedure for planned hospitalization. Social workers store information regarding the care provided, the patient's identified needs and the time interval for the next expected visit. The relevant lists (which are generated automatically) are sent to the coordinating council for pensioner healthcare and social care at the beginning of each month.