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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.

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acute and post acute care of the elderly models for improving outcomes

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
Objectives
  • Review the impact of hospitalization and SNF placement on outcomes in the elderly.
  • Review significance of and risk factors for functional decline in the hospitalized geriatric patient.
  • Review interventions to prevent functional decline and improve outcomes.
objectives3
Objectives
  • Review interventions designed to prevent readmission.
  • Review needs for improving discharge planning and transitional care for the hospitalized geriatric patient.
  • Emphasize importance of teamwork in the care of the geriatric patient!
hospitalization in the elderly background
Hospitalization in the ElderlyBackground
  • Patients >65  40% acute hospitalizations
  • Current reimbursement demands “quicker and sicker” discharges
  • Poor outcomes
    • High 1 year mortality
    • 30% functional decline
    • High readmission rates
    • High rates of home health use
    • High rates of SNF placement
prognostic index for 1 year mortality in older adults after hospitalization walter et al jama 2001
Prognostic Index for 1-year Mortality in Older Adults after Hospitalization Walter et al. JAMA 2001
  • Data
    • age >70, medical admission
    • Derivation 1600 pts, university hospital
    • Validation 1500 pts, community hospital
    • Demographic, functional, medical factors
    • Outcome- mortality at 1 year after d/c
prognostic index for 1 year mortality in older adults after hospitalization walter et al jama 20016
Prognostic Index for 1-year Mortality in Older Adults after Hospitalization Walter et al. JAMA 2001
  • Independent RF’s for 1 yr mortality
    • Male
    • CHF, CA as comorbidities
    • Functional decline in any ADL at d/c
    • Cr >3, alb< 3.4
prognostic index for 1 year mortality in older adults after hospitalization walter et al jama 20017
Prognostic Index for 1-year Mortality in Older Adults after Hospitalization Walter et al. JAMA 2001
snf outcomes
SNF Outcomes
  • 20-40% elderly in SNF at some point
  • 25% annual mortality rate
  •  50% admitted for short term post-acute care
  • Outcomes highly dependent on function at admission
outcomes of nursing home care lewis et al gerontologist 1985 ajph 1985
Outcomes of Nursing Home CareLewis et al. Gerontologist 1985, AJPH 1985.
  • 563 pts discharged from 24 NHs Southern CA
  • 80% admitted from hospital
  • Cognitive status, functional status, continence predictive of outcome
case 1
Case #1
  • Mrs. Dee Cline is an 80 y/o woman with a history of asthma admitted to the medical service with community acquired pneumonia and an asthma exacerbation. She is treated with antibiotics, bronchodilators and prednisone with improvement in her respiratory status over the next 4 days.
case 111
Case #1
  • Prior to admission the patient lived alone and used a cane for ambulating. She was independent in all ADL’s but required help with some IADl’s including shopping, laundry, cooking and cleaning. Mrs. C has some close friends but no family nearby.
case 112
Case #1

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.

functional decline
Functional Decline
  • Decreased ability to perform ADL’s
  • Deteriorization in self care skills
functional decline questions
Functional DeclineQuestions
  • What percentage of geriatric patients suffers functional decline during hospitalization?
    • 30%
  • What percentage of these patients returns to their prior baseline function?
    • 50%
slide16
Functional Outcomes in Medical Illness and Hospitalization in Older PersonsSager et al. Arch Int Med. 1996.
  • Prospective analysis of 1300 pts HOPE trial
    • medical diagnoses
  • Independence in 6 ADLs and 7 IADLs
    • 2 weeks PTA
    • discharge
    • 3 months post discharge
slide17
Functional Outcomes in Medical Illness and Hospitalization in Older PersonsSager et al. Arch Int Med. 1996.
slide18
Functional Outcomes in Medical Illness and Hospitalization in Older PersonsSager et al. Arch Int Med. 1996.
functional decline questions19
Functional DeclineQuestions
  • Does functional decline effect patient outcomes and prognosis?
    •  Mortality (increases with # of ADL deficits)
    •  SNF placement
    •  LOS
    •  Readmission
  • Impact on independence, quality of life
  • Costly
questions
Questions
  • What is the etiology of functional decline in the hospitalized geriatric patient?
cascade to dependency
“Cascade to Dependency”

Creditor. Ann Int Med. 1993.

the dysfunctional syndrome
“The Dysfunctional Syndrome”

Functional Older Person

Acute Illness/Possible Dysfunction

Hospitalization

Hostile Environment

Depersonalization

Bedrest

Starvation

Medicines

Procedures

Depressed Mood

Physical Impairment

Dysfunctional Older Person

Palmer et al. Clin Ger Med 1998

functional decline questions23
Functional DeclineQuestions
  • At what point could the healthcare team have identified Mrs. C’s risk of functional decline?
    • On admission
  • What are her specific risk factors?
    • Age, IADL dependency on admission
hospital admission risk profile sager et al jags 1996
Hospital Admission Risk ProfileSager et al. JAGS 1996.
  • Prospective cohort study, subgroup of HOPE, age >70, medical admits
  • Scoring System
risk profile
Risk Profile
  • Practical and simple
    • No additional training
    • Little extra time
    • Can be performed by M.D., R.N., Case manager, Social Worker….
questions27
Questions
  • Are there effective models for the prevention of functional decline (and other poor outcomes) for the hospitalized geriatric patient?
functional decline interventions
Functional DeclineInterventions
  • Geriatric consultation
  • Acute Care of Elder units (ACE)
  • Hospital Elder Life Program (HELP)
  • Nurses Improving Care for Health System Elders (NICHE)
medical unit to improve functional outcomes ace landefeld et al nejm 1995
Medical Unit to Improve Functional Outcomes (ACE)Landefeld et al. NEJM. 1995.
  • Prepared environment
    • Carpets, handrails, large clocks
  • Patient centered care by a multidisciplinary team
    • Daily eval with protocols to address self care, nutrition, mobility, cognitive status, skin…
    • Daily rounds by team
medical unit to improve functional outcomes landefeld et al nejm 1995
Medical Unit to Improve Functional OutcomesLandefeld et al. NEJM. 1995.
  • Discharge planning
    • Started by SW on day of admission
  • Medical care review
    • Geriatrician and geriatric NP to review care, make recommendations, provide supervision
medical unit to improve functional outcomes landefeld et al nejm 199531

Much better

Better

Unchanged

Worse

Much worse

Usual care

13%

11%

54%

13%

8%

ACE

21%

13%

50%

7%

9%

Medical Unit to Improve Functional OutcomesLandefeld et al. NEJM. 1995.
  • Randomized trial, univ hospital 300 medical pts each to ACE unit vs. usual care

Functional Status Admit to Discharge

medical unit to improve functional outcomes landefeld et al nejm 1995 counsell et al jags 2000
Medical Unit to Improve Functional OutcomesLandefeld et al. NEJM. 1995. Counsell et al. JAGS. 2000.
  • No difference in functional outcomes at 3 months.
  • No difference in readmission rate.
  • ACE in a community hospital
    • No difference in functional outcomes
    • Improved process of care
    • Improved pt, family and provider satisfaction
ace units getting started
ACE Units- getting started
  •  100 in U.S.
  • Resources
    • Summa Foundation (Akron, OH)
  • Initial $$ with overall savings for hospital over time
the hospital elder life program inouye et al jags 2000
The Hospital Elder Life ProgramInouye et al. JAGS 2000.
  • Goals
    • Prevent cognitive and physical decline
    • Promote independence
    • Assist with transitions
    • Prevent readmission
  • Multidisciplinary intervention instituted hospital wide
  • Prior data for prevention of delirium
the hospital elder life program inouye et al jags 200035
The Hospital Elder Life ProgramInouye et al. JAGS 2000.
  • Patients age >70 and one RF for cognitive or functional decline
      • MMSE <24
      • Any mobility or ADL impairment
      • Dehydration (BUN/Cr >18)
      • Vision or hearing impairment
the hospital elder life program inouye et al jags 200036
Geriatric nurse specialist

Elder life specialist/director

Geriatrician

Volunteers

Rehab services

Chaplain

Pharmacy

Nutrition

Psychiatry nurse

Social Work

Care Coordination

The Hospital Elder Life ProgramInouye et al. JAGS 2000.
the hospital elder life program inouye et al jags 200037
Daily visits

Orientation

Sleep enhancement

Oral hydration

Feeding assistance

Therapeutic activities

Early mobilization

Vision, hearing protocols

Geriatric nursing assessment

Interdisciplinary rounds

Provider education

Community links and follow up

Geriatric consultation

Interdisciplinary Consults- pharmacy, nutrition, chaplain etc.

The Hospital Elder Life ProgramInouye et al. JAGS 2000.
help getting started
HELP- getting started
  • www.info.med.yale.edu/intmed/elp
  • HospitalElderLife@yale.edu
  • Training materials $4000, equipment $3500 to start and $2000/yr
    • Training manuals, tapes, business, management, clinical tools
  • $$ for elder life specialist, nurse specialist, volunteer coordinator, provider education
nurses improving care for healthsystem elders fulmer et al geriatric nursing 2002
Nurses Improving Care for Healthsystem EldersFulmer et al. Geriatric Nursing 2002.
  • Models for improving nursing care throughout the hospital
  • Geriatric Institutional Assessment Profile
    • Target needs, education, protocol development
  • Nursing practice protocols
    • cognitive assessment, eating/feeding, pain management, restraints, falls, pressure ulcers, sleep, incontinence
  • Geriatric resource nurse model
nurses improving care for healthsystem elders fulmer et al geriatric nursing 200241
Nurses Improving Care for Healthsystem EldersFulmer et al. Geriatric Nursing 2002.
  • SPICES screening tool
    • Skin impairment
    • Poor nutrition
    • Incontinence
    • Cognitive impairment
    • Evidence of falls, functional decline
    • Sleep disturbance
niche getting started
NICHE- getting started
  •  100 hospitals
  • NICHE package $7800
    • Leadership conference
    • GIAP data analysis
    • Practice protocols and models of care
  • Additional $$ for R.N. training, institutional leadership (geriatric CNS, NP), patient care items
  • www.hartfordign.org
case 2
Case #2

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.

case 245
Case #2

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.

case 246
Case #2

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.

case 247
Case #2

Discharge is delayed even though the patient is stable from a medical standpoint.

What went wrong?

questions48
Questions

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?

transitional care and discharge planning naylor ann rev nurs res 2002
Transitional Care and Discharge PlanningNaylor. Ann Rev Nurs Res. 2002.
  • Transitional Care
    • Bridge gaps between providers, services, sites of care
    • Promote safe and timely transfer of pts from one level of care to another
    • Provide accurate and complete communication between providers and sites of care
transitional care and discharge planning naylor ann rev nurs res 200250
Transitional Care and Discharge PlanningNaylor. Ann Rev Nurs Res. 2002.
  • Patients and families
    • 1/3 pts unmet needs after discharge
    • Lack of input into discharge decisions
    • Lack of knowledge, education
    • 1/3 with >1 component of d/c plan not implemented
  • ½-¾ recommended info not transmitted to SNFs and home health
quality discharge planning
Quality Discharge Planning
  • Involvement of patients and families
  • Effective communication
  • Multidisciplinary approach
risk factors for poor discharge outcomes naylor j cardiovasc nurs 2000
Age >80

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

Noncompliance

Risk Factors for Poor Discharge OutcomesNaylor. J Cardiovasc Nurs. 2000
intervention to prevent readmission in elderly patients with chf
Intervention to Prevent Readmission in Elderly Patients with CHF
  • Intervention
    • Intensive CHF and dietary education
    • Active SW consult
    • Analysis of meds by geriatric cardiologist
    • Home visits by team + home care
  • Results
    • 90 day readmission rates (29% vs. 42%),
    • cost
    • Better quality of life
    • No difference in survival

Rich et al. NEJM 1995

apn transitional care quality cost model
APN Transitional Care/Quality Cost Model
  • Intervention
    • Geriatric advanced practice nurse
    • early assessment, education, d/c planning
    • 4 weeks post-discharge home follow up
  • Results
    •  readmission rates (20% vs. 37% at 24 wks)
    • total hospital days
    • post-discharge medical costs
    • No difference in functional outcome

Naylor et al. JAMA 1999.

conclusions
Conclusions
  • Hospitalization and SNF placement have significant impact on outcomes in the elderly.
  • Models for improved outcomes require dedicated multidisciplinary approach.
  • Lots of room for improvement in area of transitional care/discharge planning