BOX 3–4 Rule 8: Anticipation of Needs

Current Approach: React to Needs

Pearl Clayton is 86 years old. She has been widowed for 5 years and lives alone. She has recently shown signs of forgetfulness and has had two recent falls, one of which resulted in a fractured wrist. Her adult daughter and son-in-law would like her to go to a doctor and get a thorough evaluation, particularly of her forgetfulness. They procrastinate and do not get around to taking her. It is difficult to get any advice over the telephone. Finally, Pearl falls, fractures her hip, and is hospitalized. Her fall is related to a combination of over-the-counter sleeping pills and the use of alcohol, begun during a prolonged period of grief after she became widowed.

During her hospitalization, she suffers hypertension and grand mal seizures during which she aspirates; she develops severe pneumonia and spends 2 weeks intubated in an intensive care unit. At the end of this time, her broken hip finally can be repaired, but she has become so frail and confused that she cannot be transferred home and must go to a nursing home. During her time at the nursing home, her family, caregivers, and those in the hospital where she has periodic acute admissions have no guidance about the use of life-sustaining measures.

New Rule: Anticipation of Needs

Under the new rule, anticipatory management results in a mental status evaluation and home visits that make it possible to identify Pearl’s problems in time to prevent the fall that would have led to her hip fracture. Even if the hip fracture had not been completely prevented, clinicians would have had available to them a complete and accurate medical history during Pearl’s hospitalization so that those caring for her would have known to anticipate withdrawal symptoms from her medication and alcohol use. She would have received appropriate medical management, avoided aspiration and intubation, and recovered sufficiently to return to her own home.

community services. Notable efforts to adopt this approach in the United States include the innovative On Lok Senior Health Services, first organized in San Francisco’s Chinatown, and its replications in the Program of All-Inclusive Care for the Elderly (PACE) (Eng et al., 1997; Rich, 1999). Such programs of care for frail elderly persons in the community have brought together resources likely to be needed by many elderly patients. Other countries, including the United Kingdom and Finland, have also focused on such linkages designed to anticipate patient needs (The Ministry of Social Affairs and Health and The Association of Finnish Local and Regional Authorities, 1999).

Rule 9: Waste Continuously Decreased

The current system tries to conserve resources through restrictions and budget limits, withholding services and creating queues to drive costs down. This is

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