Experiences of Healthcare Providers in Care Delivery to Older Persons

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suffer from one or more chronic problems above the age of 70 years according to a study by Ingle and Nath. Cardiovascular diseases account for about one third of mortality based on statistics from Government of India followed by 10% mortality from respiratory disorders in older people [2]. The prevalence of coronary artery disease for older persons greater than 60 years was 51.3 per 1000 population [6].
The status of Elderly report 2014 by Helpage India reported hypertension (42%), arthritis (36%), cataract (24%) and diabetes (23%) as the most prevalent diseases in older persons in the country [7]. The older persons are suffering from multiple chronic conditions mainly non-communicable diseases like cardiovascular disorders, cancers and have also seen a rise in mental disorders like depression, anxiety and dementia apart from vision loss and musculoskeletal problems [3]. 17.93% of the older men and 26.21% of older women experience either mild or severe disability with increasing life expectancy. The commonest cause of disabilities being arthritis, vision impairment, Parkinson's disease and stroke [5,8].
The magnitude of mental health problems in older persons in India is high. A study in 2012 stated that 17.13 million older persons out of a total population of 83.58 million older persons suffered from mental health problems in India [9]. Clinic based studies report a prevalence of depression from a range of 42.4 percent to 72 percent, while 18 percent of older persons have a definitive diagnosis of depression visiting a geriatric clinic [10,11]. Dementia prevalence for the older persons who are above 85 years in India ranges from 18% to 38% and, in those above 90 years ranges from 28 % to 44 % based on large-scale studies done [5].

Status of Geriatric Health Care Services in India
The Government of India introduced the National Program of Healthcare for the Elderly (NPHCE) in 2010-11 focusing on provisions for medical care for older persons [12]. The program envisages providing affordable, accessible and long-term high-quality, comprehensive and dedicated care services for older persons. It emphasizes on creating a framework for older persons and all age groups and promote healthy ageing. The noncommunicable disease program in the country supports the older persons through screening for diabetes and hypertension and providing medication for the same [13].
There is a dearth of geriatric care, which can be delivered through primary health care as 71% of older persons stay in rural India. Strengthening the traditional health practices such as Ayurveda, Unani and Homeopathy can help to promote health and prevent diseases in older persons. Geriatric mental health services, rehabilitation services, holistic primary care services catering to older persons, capacity building for mental health care for older persons are lacking in the country [14]. Professionals indicate the need to develop various specialties in geriatric care for example geriatric dental care [15], health problems of older women and promote active ageing [16]. Geriatric care lacks the support and push from healthcare administrative services to scale up [17]. A study mentioned a recreational day care center approach, which can be replicated for older persons to improve quality of life and nutritional status of those from the poor sections of the society. It stressed upon a program for caregivers, intersectoral coordination, advocacy for older persons and promoting social sciences research in geriatric care [18].

Training Programs on Geriatric Care in India
There is a shortage of geriatric training programs in in India. A study on education on geriatrics in the country identified 20 courses that focus on training in geriatric care which were reviewed for their duration, content and skills imparted. The study concluded that there was a need for short term and longterm training programs at the undergraduate, postgraduate and in-service learning level for all health care professionals. Only courses on family medicine in medical training have included the component of geriatric care. Educationists highlight the urgency to build competency in geriatric care in the country through blended learning and inter-disciplinary learning [19]. The healthcare providers need to be trained on geriatric pharmacotherapy at the undergraduate and postgraduate level to maximize benefits and minimize harm of adverse reactions to the older persons using multiple drugs [20].
Healthcare providers deliver care to all adult population including older people. Despite the rapidly increasing aging population, health care services for older people in India remain unorganized and care facilities inadequate as it caters mainly for young adult populations. The main objective of this research was to understand the experiences of health care providers providing care to older persons in a private hospital in Hyderabad city, India. Specifically, experiences in delivering care, infrastructure and resources involved, facilities needed, and skills required in care delivery were explored with the healthcare providers.

Setting and respondents
The study was conducted in a private hospital in the city of Hyderabad, India which lies in the southern State of Telangana. The location was selected as the city is a major healthcare hub with a wide range of private and public healthcare providers in India. The private hospital was chosen as it is one of the major hospitals in the city and runs a center for older persons.
Using purposive sampling, 18 healthcare providers delivering care to older people at the Outpatient center and Inpatient department of the hospital were interviewed in English.
The purposive sampling was done based on their availability and consent to participate in the study. Informed consent was taken from the respondents before the interviews. The respondents were largely specialist physicians such as cardiologists, neurologists, Orthopedicians, health check physicians in the Geriatric Care Outpatient department as well as administrators who handled matters related to the geriatric patients in the hospital. They were in the age group of 35-70 years and were majority male with postgraduation in medical sciences. The respondents who were not ready to allocate time for interviews were excluded from the study.

Data Collection
Semi-structured interviews were conducted using an interview guide. The topics covered during the interviews of the health care providers explored their experiences in delivering care to the older persons in relation to the infrastructure, facilities, skills and resources required to cater to the older persons. The interviews were recorded using a recorder. The interviews lasted around 20 to 30 minutes each. The interviews were conducted between November 2017 to April 2018. No further interviews were conducted as soon as data saturation was reached.

Data analysis
The data was analyzed using content analysis with inductive approach where the data was coded, categorized and abstraction was done [21]. The interviews were conducted in English language and transcribed verbatim. The transcripts were maintained in a repository, read thoroughly, and parts or sentences of the transcripts were extracted for which codes were assigned. Similar codes were grouped under 22 sub-categories, which were then grouped under 9 generic categories. The generic categories were further grouped together to form 3 main categories.

Results
The analysis of the data resulted in three main categories: Preventive programs for older persons, Training for older persons' care and Facilities for older persons. These categories were derived from 9 generic categories as shown in Table 1.  Table 1: Categories and sub categories derived from the interviews.

Preventive programs for older persons
The health care providers discussed the need to reduce complications and risk for older persons as a vulnerable population through preventive care programs. The healthcare providers spoke about preventive plans for the elderly. The preventive care programs can pre-empt diseases and also prevent the secondary complications of diseases already present.

Preventive services for the older persons
The healthcare providers stressed on the need for preventing fractures and getting vaccinated as a part of preventive care for the older persons. Preventive care would reduce readmissions and morbidity of the older persons during subsequent admissions.
Fix the fracture and prevent the next fracture. A person who had one fracture, the possibility of having the other fracture is high, mortality is 50% in first one year. (Respondent No 1)

We should have vaccinations available for the older persons so that the complications and infections are prevented. (Respondent No 2)
The respondents highlighted the need of preventive services for older persons to reduce risk or morbidity and adverse outcomes. It would reduce the morbidity suffered due to vaccine preventable diseases like pneumonia and prevent repeat fractures in the older persons.
A respondent who running the blood pressure clinic said that the geriatric care OPD called elder care is helping in preventing care for the elderly through its services.
Geriatric clinic has started and they are giving wheel chair services, physiotherapy modalities, osteoarthritis patients are also giving care. Home care is also being given such as catheterization, injection, infusion for elderly. (Respondent 3)

Healthcare plans
Older persons are a vulnerable population and the home health plans reach out to the older persons at their homes and provide pre-emptive and proactive care.
We have patients who are enrolled for 3 to 6 months' plans and some who are on an annual basis. We have an annual plan for the elderly. We can record their blood pressure, blood sugar and how is their activity of daily living. Also, we can see digital records and reduce frequency of hospitalization for congestive cardiac failure, COPD, CHF. Good home care can reduce hospitalization per year. (Respondent No 4) A plan, for example, helps in recording patients' vital parameters such as blood pressure, monitor co-morbid conditions like diabetes and also digitize their data for continuous monitoring. This would reduce readmissions for chronic conditions due to a relapse of symptoms and minor complications, and help older persons maintain good health in the comfort of their homes ( Figure 1).

Training for older persons' care
This main category focused on training healthcare providers for older person's care. The respondents focused on the necessity to train a wide range of health and general personnel to address older persons' care due to the large older population in the country. The healthcare providers should start addressing older persons health problems by equipping themselves with skills and competencies to deliver care.

Medical and general skills to deliver geriatric training
A team-based approach will assist to address needs of older persons as care of older persons is multi-dimensional.
Geriatric care is a multi-disciplinary approach. Not physicians alone, we need to have trained nurses, physiotherapists, dieticians, psychologists. It should be a team approach. All of them require having a special training in geriatrics, which we do. (Respondent 5) General physicians, specialists, nurses and allied health teams need to come together to provide care to the older persons. These professionals need to be equipped with skills which can help them address the health issues of older persons. The hospital is trying to train the healthcare teams in delivering care to the older persons.
I would want to empower doctors with a sense of responsibility to treat mind and soul and the physical body later.
We are giving tablets to take care of the aches, pain but we are not addressing the mental disturbances. I would empower MBBS doctors and also empower BAMS/ ayurvedic, BUMS/ Unani and alternative medicine. We see RMP as competitors but they are

Home care training
The respondents focused on the necessity for specific skill sets which will enhance older person's care delivery at home.
The biggest challenge is that we don't have trained home health aides as a cadre. We need to create program for all categories of health professionals. (Respondent No 8) Physicians, nurses, paramedical staff need to be trained with skills for giving care during home visits. This would ensure access to care at home for older persons with mobility limitation or who are unable to reach a healthcare facility.

Family medicine led geriatric care
Family medicine specialists are trained in the basic skills of various specialties.
Family medicine is the best branch and are exposed to all kind of subjects and are exposed to medicine, surgery, dermatology, TB Chest and all departments. I suggest family medicine people should take care of geriatric people. (Respondent No 9) Older persons suffer from a wide range of problems and instead of visiting a different specialist every time for their medical problems, respondents suggested that family medicine specialists would be able to review them at one place and then plan a treatment course accordingly.

Mental health support skills
A good understanding of geriatric medicine, drug interactions, treatment with minimal medications, a need to involve whole family in the treatment, a thorough understanding of the psychological problems associated with geriatrics patients. Need for a thorough understanding into conducting a medical interview to elicit those unique geriatric problems. Need to have knowledge of counselling techniques to address common issue in geriatric patience. Compassion and Empathy.

Training for older persons Facilities for older persons
This main category focused on providing facilities to the older persons such as transportation to health care facilities, assisted living homes and technology, which can help them, access healthcare better.

Easing access
Older persons can access health services better if they can avail good transportation services, which takes them to the healthcare facility.
User friendly rest rooms need to be provided. They cannot walk up the stairs so a lift service needs to be there. Even in the wheel chair you have to put the belt and you need to take care. They also need help to get on the couch and off the couch as they have Orthopedics problems also. Special care for elderly is important. I believe people above 70 years should be treated as elderly as people at 60 years of age are relatively healthy. They need attention but they don't want to disturb their family members. They find a problem to travel in distance and somebody to accompany them makes a lot of difference Pick up and drop service could be of great help to them. Older persons face challenges reaching the hospital in terms of logistics, modes of transportation and convenience. A transportation service, which can pick up and drop them back home will provide mental peace for an older person already suffering due to medical problems.

Infrastructure for geriatric care
The respondents mentioned the need for assisted living and temporary stay homes for the older persons, facilities and step up homes for older persons. These homes provide short term stay for older persons who are recovering from an illness or a procedure. It can be a facility where older persons can recuperate after being discharged from a hospital and before going home. The advantage of such a facility is access to staff trained with skills to handle minor to moderate medical problems which may arise during the stay or the transition to recovery.

Technology to facilitate older person's care
Consultations after the initial face-to-face meeting can be done through technology using online consultation and video chatting.

Online consultations and video conferencing have come in big way.
We can do a video chat and solve people's problems. I feel in interiors GP can play a good role and speak to a neurologist for medication changes. For minor things, they can take care themselves and for major problems, they can speak to a neurologist. Population is ageing and we see elder people. There are challenges of mobility and communication in elderly. Mobility issues are there. They are not able to come for follow up. (Respondent No 17) A respondent said that digital medical records which help in documentation help in continuity of care for the elderly. There is a need to create awareness about geriatric care facilities and geriatricians for the elderly.

Facilities for Older Persons Discussion
The study aimed to describe the experiences of healthcare providers in delivering care to older persons. According to the healthcare providers, the important factors to consider in care of older people were preventive programs, training of multidisciplinary health care personnel on health care problems specific to older persons and facilities for older persons.
One of the main findings of the study was suggestion of preventive programs for the older persons. Preventive care can be integrated at various stages, such as symptom experience, selftreatment, assessment of symptoms so as to pre-empt and early detection of diseases and prevent complications [22]. A study by Irvine and others on the cost-effectiveness of fall prevention program and benefits assessed 3,320 British pounds were saved per fall averted. Prevention strategies also include minimizing high-risk medication which causes falls, gait training, treating vision problems and also customizing the home environment to prevent falls [23,24]. Previous studies have also identified the need for preventive programmes to maintain the health of older persons and promote active ageing [25]. The preventive health programs for older persons can be tailored based on gender needs [26].
The healthcare providers in the study stressed on the need of training programs to equip health care personnel including administrative staff with skills for helping older persons. They also spoke about the need for general and clinical skills, which are required for care of older persons. Well trained staff with geriatric care competencies also influence healthcare seeking during the selection of appropriateness of treatment, selection of treatment plan stage, treatment stage and recovery and rehabilitation stage [22]. A study focusing in successful aging stressed upon community based geriatric care across the country where kiosks for older persons can be created [27]. This will require strengthening of care workforce for older persons standardized geriatric care training [28,29]. NHS practical guidelines elaborate about providing safe and compassionate care to frail older persons using an integrated care pathway [30]. There is also a need to change the attitudes of the healthcare professionals for geriatric care and improve the healthcare delivery for the elderly [31]. Geriatric Boot camp trainings can be organized which will train healthcare professionals for the core concepts in elderly care [32]. A study discussed about challenges and chances in comprehensive geriatric care assessment for medical professionals and healthcare providers such as nurses and physiotherapists such as communication and technical skills in different clinical settings [33].
The health care providers in the current study emphasized the need to have facilities which are tailored to help the older persons to easily access care in the hospital. This included transportation, older person friendly facilities in the hospital and a system which can make it easier for the older persons to navigate within the hospital systems and processes. Easing access, better geriatric care facilities and online counselling can help providers give better care to the older persons across various stages of healthcare seeking. The study by Zlatinov and others discusses and explores the potential for transitional care models for the older persons and plugging the gap in older persons' care and creating more evidenced based mechanisms for the future. Transitional care involves movement of patient's care from one health setting to another and proper coordination can lead to reduction in costs, hospital readmissions and improve patient satisfaction for older persons [34]. This study looked at the comparison between residential facilities for older persons for long-term care in developed countries and Iran through a systematic review and deficiencies, which could be bridged. It stressed upon the need for the existing nursing homes in Iran to scale up to match the psychological, social and physical requirements of older persons and comply with international standards [35].
Research on long-term care of older people stressed upon to bring in innovative approaches in facilities for older persons for disease like Alzheimer's as the person cannot stay in the hospital for long. Long-term care centres, day care centres and alternative accommodations for older persons can be possible solutions. The care economy consisting of doctors, social workers, physiotherapists, counsellors can be a significant part of the labour force in addressing geriatric care [36,37].

Methodological consideration
The strength of the study lies in gathering in-depth qualitative experiences of the healthcare providers in the hospital across various specialties and its specialized geriatric care center. The specialists are associated with the new geriatric care center in the specific hospital where the study was conducted and are well equipped in terms of resources and experienced specialists who have treated older persons across the disease spectrum.
The study focused on one private hospital in the city. There are other government and semi-autonomous health care institutions in the city, which deliver care to older people. The results of the study hence may not be transferable to the experiences of health care providers of older persons in government hospitals or those in rural areas.

Conclusions
The healthcare providers in the study stressed upon the need for better training of health care staff, preventive programs and facilities customized to deliver health care to older persons. These areas can improve the delivery of care to the older patients in hospitals. Health care facilities can look at creating a unique experience for the geriatric population based on the feedback from the healthcare providers.

Ethical Considerations
Ethical approval for the study was granted by the Ethical Board, Tata Institute of Social Sciences, Mumbai, India and the hospital ethics committee of the private hospital where the study was conducted. Informed consent was obtained from the participants prior to each interview. Confidentiality and privacy of the data provided by them was ensured. The respondents were informed that their participation was voluntary and they could withdraw from the study at any point of time.