Hospitals have primary responsibility for one of the biggest public health challenges: the explosion in the number of older adults living with complex, serious illnesses. Most Americans expect to live to a ripe old age thanks to modern medicine and public health standards. As we age, most of us acquire common chronic conditions like arthritis, memory loss and frailty, and one or more serious illnesses, like cancer or heart disease. By age 75, 78 percent of Americans are living with two or more chronic conditions. Health care spending is concentrated on this group.
The top 5 percent of spenders account for nearly 60 percent of total health costs, and people with multiple chronic conditions account for 93 percent of total Medicare spending. When the burden of serious illness exceeds a person’s or family’s capacity, the recourse is usually a visit to the hospital emergency department.
Here are five recommendations for how hospitals and health systems can address this challenge:
- Identify the high-need group. To match services to needs, identify the high-need group through systemwide screening. Patients with one or more serious illnesses plus a hospitalization or skilled nursing facility admission in the prior 12 months plus functional dependency have a 50 percent likelihood to be hospitalized in the next 12 months. These data points, except functional dependency, are available to hospital leadership. Requiring documentation of function in your electronic health record using a drop-down menu will address this gap.
- Assess and risk-stratify the high-need group. The most common reason for after-hours 911 calls is symptoms, e.g., out-of-control pain, shortness of breath, agitation or exhaustion. Use EHR data to identify these precipitants. If the dominant root cause of revolving-door ED visits and hospitalization is recurrent pain or shortness of breath, bring in clinicians with palliative care expertise.
- Match services to needs. Social work support is the right intervention for homeless individuals who return frequently to the ED. But in most cases of serious medical illness, frequent reliance on acute care is due to disease progression, increased suffering and worsening functional decline. The best approach in these cases is palliative care, available in more than 65 percent of U.S. hospitals with more than 50 beds. Ensuring adequate staffing and capacity to serve this growing, complex patient population is critical.
- Train your workforce. Most physicians and nurses lack training in the core knowledge and skills of palliative care, including communicating prognoses, establishing care priorities, conducting family meetings, coordinating care across settings, and safely and effectively managing pain and other symptoms. High-quality, online training on these skills is widely available and affordable.
- Track outcomes. To determine if initiatives are improving care, track outcomes like 30-day readmissions, hospital mortality and root causes of ED use. Place responsibility for these outcomes on leadership dashboards.
With these strategies, hospitals will be providing quality, high-value value care that results in less suffering for patients.
Diane E. Meier, M.D., is director of the Center to Advance Palliative Care in New York City and vice chair for public policy and professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, also in New York City.