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Acute and Post-Acute Care of the Elderly: Models for Improving Outcomes. Adrienne Green, M.D. Assistant Clinical Professor and Hospitalist University of California San Francisco. Objectives. Review the impact of hospitalization and SNF placement on outcomes in the elderly.
Adrienne Green, M.D.
Assistant Clinical Professor and Hospitalist
University of California San Francisco
On the planned day of discharge, Mrs. C tells the nurse that she is having difficulty getting up from the chair and that she feels “very shaky” while walking.
Discharge is delayed even though the patient is otherwise stable from a medical standpoint.
Creditor. Ann Int Med. 1993.
Functional Older Person
Acute Illness/Possible Dysfunction
Dysfunctional Older Person
Palmer et al. Clin Ger Med 1998
9%Medical Unit to Improve Functional OutcomesLandefeld et al. NEJM. 1995.
Functional Status Admit to Discharge
Elder life specialist/director
Care CoordinationThe Hospital Elder Life ProgramInouye et al. JAGS 2000.
Vision, hearing protocols
Geriatric nursing assessment
Community links and follow up
Interdisciplinary Consults- pharmacy, nutrition, chaplain etc.The Hospital Elder Life ProgramInouye et al. JAGS 2000.
Mr. F is a 75 y/o man with mild dementia, CAD, HTN, and recently diagnosed CHF. He was in good health until 6 weeks PTA when he was admitted with progressive DOE, orthopnea and edema. ECHO demonstrated severe diastolic dysfunction and hypokinesis from old MI. With aggressive diuresis and BP control, Mr. F’s symptoms resolved and he was discharged home on hospital day #3. His PCP was notified to assist with follow up.
Mr. F is now readmitted with recurrence of all his symptoms. Clinically he appears to have a CHF exacerbation that is felt to be due to medication and dietary non-compliance.
Mr. F lives alone but has 2 daughters nearby. He is able to perform his own ADLs but requires assistance with IADLs. He has been reluctant to accept help in the home.
Mr. F again responds to diuresis and BP management. On hospital day #4, he is told he can go home. Later that morning his physician receives an irate phone call from his daughter. She is surprised by the discharge plan, very anxious about potential for yet another rehospitalization and states that she doesn’t think her father can manage on his own any longer. She demands a meeting with the physician and social worker later in the day.
Discharge is delayed even though the patient is stable from a medical standpoint.
What went wrong?
What could have been done to prevent this uncomfortable confrontation?
Are there effective models for optimizing the transition of elderly patients from the acute to post-acute setting?
Poor support system
Multiple, active chronic health problems
Mod-sev functional impairment
Poor or fair self rating of health
Multiple hosp past 6 mo
Hosp past 30d
NoncomplianceRisk Factors for Poor Discharge OutcomesNaylor. J Cardiovasc Nurs. 2000
Rich et al. NEJM 1995
Naylor et al. JAMA 1999.