In January 1994 a national centre for geriatric incontinence was established in Israel. It had previously been found that 20% of the elderly and 53-100% of the institutionalised geriatric patients suffer from urinary incontinence. Only 2% had received proper evaluation and treatment.
Structure of the Centre. A small team of professionals (two urologists, two geriatricians, two skilled nurses in geriatrics and in home care, a social worker, a coordinator and a secretary) were brought together from different institutions. This allowed promotion of interdisciplinary exchange as well as maximum co-operation between the medical centres and the community health services. After 6 months of training, the team was ready to address the goals of the Centre (see table).
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Goals Education and training of primary
healthcare professionals |
Education and training primary healthcare professionals. After experiencing and restructuring various training programs a system optimal for the healthcare system has been developed. A clinic is pre-selected to be trained according to certain criteria; it must be a large clinic with at least 3 general practitioners and a population of over 20% elderly patients. A leading team composed of a physician and a nurse are also pre- selected and they are committed to be in charge of promotion, detection and treatment of incontinence at the clinic.
The head of the clinic commits himself to the training programme, allowing the staff and the leading team to dedicate specified hours to incontinent patients. Use of the questionnaires and evaluation sheets developed by the Centre is demanded. The education program includes training the whole staff of the clinic, beginning with regular lectures and seminars, continued by 10 sessions of instruction and practice at the community clinic. In order to offer ongoing support and supervision, the leading team receives supplementary training. A new position of regional continence advisor was also created. The best physician and nurse from all leading teams of the clinics in a certain region received additional training to be in charge of incontinence in the whole region. This provides a professional hierarchy, and enables professionals to approach local or regional advisors as well as to contact directly with the Centre if they choose, and gives the Centre feedback on the activity and success of individual clinics. For continuous contact and dialogue with the clinics, the Centre's staff make constant visits to the clinics and ensure contact via telephone and by a quarterly newsletter. There is also an update program every 6 months for all professionals.
The Centre has developed a training program in nursing homes, allowing for differences in this setting in that not every incontinent patient receives treatment, detection is not a problem, and treatment is mostly provided by nursing staff and aides.
Outcome of this activity is constantly examined. Data on patients are collected each month from the clinics and from the nursing homes and we constantly update epidemiology, detection rates, and success rates of treatment at each clinic. Continuing data collection assures constant re-evaluation and improvement. Results have shown that this model of training combined with consultancy back up is beneficial. Detection rates are high and there is an average 70% success rate for patients treated at the clinics. The staff quickly become very much involved and devoted. In the nursing homes, we found that in addition to a surprisingly high success rate, treatment of incontinence made family members more involved with the patients' progress, saved costs on diapers and added to the prestige of the nursing home.
The Centre has also set up two central clinics. a referral Centre, equipped with advanced diagnostic tools (i.e. urodynamics), and capable of offering a vast selection of treatment, with hospital facilities including operating rooms and an incontinence clinic at a Geriatric Rehabilitation Centre, where continence care becomes part of the rehabilitation programme.
Other activities include the development and production of effective tools intended for professional staff, telephone advisory services to healthcare providers as well as to the public, production of information brochures and audio-cassettes, and promotion of incontinence awareness by lectures in the community. The Centre organised the first national meeting on geriatric incontinence held in Jerusalem in 1996 and conducts clinical and epidemiological trials along with basic science research.
Most recently faecal incontinence management has been included in the Centre's training program and a catalogue of all products available in Israel is being completed. The community service for housebound incontinent patients is being improved and guidelines for management of indwelling catheters in the community have been developed.
A countrywide program for establishing satellite Centres is currently in progress. Plans for the near future are to establish a Hotline for the public, to promote education programs in nursing and medical schools, hospitals and nursing homes and to develop guidelines for diagnosis and management of incontinence by primary healthcare staff.
Dr.Y. Vardi and Dr. I Gruenwald