By 2050 the number of Americans 65 and older is expected to double to nearly 90 million and the number 85 and older to more than triple to 19 million. Are hospitals ready for the influx of elderly patients these figures portend? Do they have the staff and protocols necessary to provide high-quality care for older, often medically complex patients? Do they have the processes and relationships in place to safely transition these patients to the appropriate post-acute setting and to provide a care continuum?
Unfortunately, the answer to these questions often is no, experts in geriatric care say. "Our health care system is misaligned with the chronic, degenerative and often complicated problems that aging bodies contend with," says Ken Dychtwald, a psychologist and gerontologist.
The aging population will be the biggest driver of health care cost increases as the baby boomers barrel toward cardiovascular disease, stroke, cancer, diabetes, blindness and dementia, says Dychtwald, the founding president and CEO of Age Wave, a consulting firm. Indeed, Medicare spending is expected to surge from $556 billion this year to $922 billion in 2020, according to the latest government projections.
If the health care system doesn't prepare, the nation will spend much more than necessary on care that isn't being provided well, Dychtwald says. To help prevent this scenario, hospital executives need to lead the way. "It starts from the top, from the administration's commitment that it is part of their mission, part of their vision to put things in place, [because] not everybody is a 35-year-old who comes in for a couple of days and then goes home and is in relatively good shape," says Liz Capezuti, R.N., co-director of the Hartford Institute for Geriatric Nursing.
The Affordable Care Act includes several provisions that could spur transformation in geriatric care. The law creates Medicare payment penalties for excessive 30-day readmissions and health care-acquired conditions. Because the elderly are particularly prone to both, hospitals will have to focus on this patient population to avoid reimbursement cuts. The act also authorizes accountable care organizations and the Community-Based Care Transitions Program, a demonstration project to test models for improving care transitions among high-risk Medicare beneficiaries.
The first step to improving care for the elderly is to evaluate the entire organization's approach to geriatrics — the hospital's mission statement, its policies and procedures, its equipment Capezuti says. Hospitals should delve into their quality and cost results to see where the problems lie. They should evaluate what services they have in place, who on staff is trained in geriatrics and what portion of the staff still needs training. Educating clinicians in geriatric care is not enough though, Capezuti says. Hospitals must develop care processes and provide the resources necessary to carry them out.
Attention to elderly patients' needs should begin on admission with risk assessments for the biggest complications, Capezuti says. These include falls, pressure ulcers and delirium.
Abington (Pa.) Memorial Hospital, which created its first geriatrics strategic plan in the mid-1980s, screens for all three risks, says Mary Hofmann, M.D., chief of the geriatric medicine division and medical director of Abington's Muller Center for Senior Health. The challenge, then, is implementing interventions to prevent a complication.
For example, Abington uses the symbol of a red blanket so staff can easily identify patients at risk for falls. It also has protocols in place to avoid them. One is a therapeutic walker program, which aims to preserve a patient's strength through assisted walking. Because bed rest was included in a standard physician order set, nurses were concerned that patients weren't allowed to get out of bed, which can rapidly result in a loss of mental and physical function.
"The nurses would say, 'We're not getting people out of bed because the doctors are writing bed rest orders,' and the doctors were saying, 'We didn't realize we put that order in,'" Hofmann explains. The hospital developed a get-out-of-bed protocol that authorizes RNs, who are trained by the physical therapy department, to decide when patients can get up.
Beyond individual protocols aimed at particular risks or conditions, some hospitals have established programs, care systems and even entire units to meet elderly patients' needs.
Abington's Muller Center offers a variety of services. Its Hospital Elder Life Program, a model developed at the Yale University School of Medicine, uses trained volunteers to engage older patients, specifically those who have medical conditions beyond their admitting diagnosis, to prevent their decline while in the hospital. "You can imagine that when people are confined to a hospital bed, their functional status and their cognitive status deteriorate oftentimes," says Rick Fullan, administrative director of the geriatrics service line and mental health services. Volunteers visit with patients daily and help them with meals, bedside exercises or walking, and hearing and vision equipment.
The hospital also has a geriatric medicine team — three geriatricians, three geriatric-trained RNs, and a clinical nurse specialist and social worker trained in geriatrics — on whom physicians can call for consultations. The team routinely consults on trauma patients because many of the hospital's emergency cases are elderly people who have fallen or been in automobile accidents. "We work hand in hand with the surgical trauma team to try to prevent delirium, falls, pressure ulcers, decreased nutrition — all the bad things that can happen to people in the hospital," Hofmann says.
In addition, 75 registered nurses with geriatric nursing certification are deployed throughout the hospital. They identify and address older patients' problems and train other nurses in their units. That allows the geriatrics team to focus on the more medically or socially vulnerable patients.
While it's important for hospitals to have an interdisciplinary team to handle elderly patients with complex needs, they also should make sure bedside nurses have enough basic knowledge to carry out important interventions themselves and to know when to call in the team.
Some hospitals have created Acute Care of the Elderly units, a model promoted by the Hartford Institute's Nurses Improving Care for Healthsystem Elders program. Wake Forest Baptist Health in Winston–Salem, N.C., was an early adopter of the ACE model, says Jeff Williamson, M.D., program director for Wake Forest's Sticht Center on Aging and chief of geriatrics and gerontology. The 16-bed unit is designed to help patients who were functioning in the community but are at high risk of losing their ability to live independently because of hospitalization.
"We take an aggressive approach to not just managing their needs but also managing their physical function," he says. "It's really to rescue people from having to go to the nursing home." Patients receive comprehensive treatment by a team of providers, including geriatricians, nurses, physical and occupational therapists, a social worker and a nutritionist.
If creating a separate unit for elderly patients is impractical, a hospital can export the ACE interventions and multidisciplinary approach across the facility, Capezuti says.
What Happens After They Leave?
The focus on elderly patients' needs cannot center only on their inpatient stay, Capezuti says. Hospitals should have discharge and transitional care strategies designed to get older patients, especially those who are frail or have multiple conditions, safely to the next care setting. Discharge planning should begin at admission and make sure that elderly patients have the medical services they'll need in place, that their caregivers understand and can handle the patients' care needs, and, for patients able to handle their own care, that they understand what they need to do.
Too often, hospitals discharge elderly patients as if they were middle-aged, Williamson says. "The discharge instructions are almost identical whether you're 45, 55 or 85. That needs updating."
When an elderly patient has a medical episode — be it joint replacement, heart attack or cancer treatment — the care they get afterward is critical to their long-term health. So discharge planners have one of the most important roles in a hospital. "In their hands lies the progress or lack of progress the patient is going to make," Dychtwald says. "In their hands lies an enormous amount of cost control because if the person has the right process and care going forward, they're more likely to get better sooner. In their hands lies the possibility that that patient is going to be right back in the hospital or not. We don't think of our discharge planners or community care coordinators as being as important as that, but they are."
Because of the ACA's Medicare penalties for readmissions, hospitals must pay more attention to discharge planning and transitions to other settings. "Our government is saying, 'This can't be a revolving door,'" Capezuti says.
Wake Forest created the ACE Transitional Program about five years ago. Under the direction of a multidisciplinary care team, a geriatric fellow, medical resident and medical student visit older people in their homes or nursing homes during the first 10 days after discharge. The three make sure the patient is receiving the care the hospital ordered, taking the right medications in the proper fashion, and has the social and family support that was discussed in the hospital. They serve as a link for home health nurses. The program also is a way to pilot new transitional care strategies.
In another effort, Wake Forest is evaluating its partnerships with post-acute care institutions. The goal is to avoid unnecessary emergency visits or rehospitalizations.
Some hospitals are creating a full care continuum for older patients. Abington has an outpatient geriatric assessment center for elderly people who have memory problems, a complex array of physical problems, social situations complicating their health status, or problems with depression or incontinence. The hospital offers Operation Reassurance, a free service for people 60 and older who live alone. Every morning participants call a staff member who asks how the person is doing. If participant fail to call, the staff member calls them. If there is no response or an emergency, the staff member calls for help.
Last year Abington started a congestive heart failure transition program. "We follow patients into the community, whether they go home or to a nursing home, to make sure they have their medications, they're taking them the way they should, they're being monitored properly," Fullan says.
In Winston–Salem, Wake Forest is partnering with social-service organizations, payers and health care providers, including the other local hospital, Forsyth Medical Center, to better integrate the medical and social models of care for older patients, says Pamela Duncan, Wake Forest's director of transitional outcomes and professor of neurology. The community is in the middle of a root-cause analysis to see what contributes to readmissions.
Most hospitals realize they have to begin the transition from an inpatient, procedure-oriented focus to a more community-based approach for older adults so they don't need to be hospitalized or rehospitalized, Fullan says, but notes that "the problem that all hospitals are facing right now is that funding is still on the inpatient side."
Although the financial incentives are starting to change, he says, "the question is whether funding is going to be there during the transition or do we have to wait until later to get the funding for those kinds of services?"
Geri Aston is a contributing editor at H&HN.
A Five-Point Prescription for Change
The way Ken Dychtwald sees it, the health system is heading for a train wreck when it comes to the way it handles care for older Americans, whose population is burgeoning. Nothing short of a complete transformation is in order, says the psychologist and gerontologist. He offers a five-point prescription for change.
1 | The nation has to invest in beating many of the diseases of the elderly in the laboratory. Dychtwald points to polio. In the 1940s, many experts were trying to figure out how to make more and better iron lungs. Fortunately, Jonas Edward Salk had a different point of view and created the polio vaccine. The same approach is needed for chronic, debilitating conditions such as Alzheimer's, he says. Hospital leaders must have a stronger voice in guiding the scientific agenda so that patients with these conditions are cured instead of winding up in hospitals.
2 | The nation needs to establish standards of geriatric excellence. Practitioners of all types must become expert at dealing with and have a greater level of sensitivity to the medical, physical and social complexities of older adults.
3 | The health system needs to make greater strides in disease prevention and self-care. For example, one-third of elderly people fall each year. Falls result in 20,000 deaths and $30 billion in costs annually, Centers for Disease Control and Prevention figures show. "Why don't we teach 65-year-olds how to have better balance; neuromuscular control; and hip, leg and back strength to prevent falls in the first place?" The health system pays attention to heart disease and diabetes self-care, but hardly anything else, he says.
4 | The health system must provide a continuum of care for older patients. "When the conditions that prevailed were infectious or acute, the hospital was the perfect environment for the delivery of care," Dychtwald says. "But that is not the problem anymore. We are more likely to be grappling in the years to come with pandemics of chronic degenerative disease."
5 | The health system has to do a better job with end-of-life care. Discomfort with dying has resulted in a failure to embrace palliative and hospice care to the necessary level. "More often than not, we deal with death with extreme technology. We spend a fortune on the final weeks and months of life, and we don't necessarily leave the patient feeling any kind of spiritual comfort or dignity."
Dychtwald envisions the hospital's role in this transformed health system as an educator on geriatric issues; a resource through which a diversity of services are integrated and coordinated; a place where older patients come not just when they have acute conditions, but to prevent those conditions; a place that supports caregivers; and a place that has strong connections with outside services so there is a community care continuum.
