Subsidy and Other Preoccupations 17

Medicine is full of aphorisms.

Aphorisms like: "The cornerstone to diabetes control is diet", "Abstinence is the only sure way of avoiding HIV infection", and "Breast milk is the best milk for babies".

Aphorisms may be true, but most of the time they are also irrelevant as reality oftens intervenes. That is why we have diabetes medication, condoms, and formula milk.

The aphorism angry doc would like to look at today (prompted by the comments on this previous post) is: "Home care is the best care."

One of the cited causes of bed shortage in acute hospitals is the difficulty in convincing the families of elderly patients who do not need to stay in an acute hospital to discharge to either their own homes, or to a step-down facility or nursing home. Any junior doctor who has worked in an inpatient setting is familar with the 'placement problem'.

There are many valid reasons for application to a nursing home (surveyed in this study), including:

• needs medical and nursing care
• needs assistance in activities of daily living
• care person willing but unable to cope with physical care/behavioural problems
• care person working or has other commitments
• the elderly person does not want to burden care person(s)

Even when the family agrees to transfer a patient to a nursing home, discharge from the nursing home with access to day-care or home care services may again meet with resistance.

The problem is recognised and indeed anticipated by nursing homes, which actively plan for discharge.

But if we look at the profile of nursing home residents and the reasons for why they are admitted to nursing homes (surveyed in this study), most do indeed have valid medical or social reasons for admission, and many both.

Traditionally, our society has viewed the placement of the elderly in nursing homes negatively, and the medical community has advocated home care as 'best care'. But given the profile of the modern-day family, is this still a viable option? Will we not be better off, in the medium- and long-term, if we start looking at nursing home placement as a necessity for a large part of our elderly population (including our own family or perhaps ourselves eventually) and be financially and psychologically planned for it; or should we still hang on to the idea that "Home care is the best care"?