The January 22 cover story of the Journal of the American Medical Association focused on the growing problem of unnecessary hospitalization. As our nation’s lawmakers wrangle over the topic of health care reform, this is one thing everyone can agree on: these unnecessary hospital trips cost money, and aren’t good for the health of seniors. Policymakers are looking at ways to protect the well-being of our vulnerable seniors and, in the process, saving money for Medicare and consumers.
For Seniors, Is This (Hospital) Trip Necessary?
Hospital care is expensive. Yet according to a recent report from the Medicare Payment Advisory Commission (MedPAC), 60 percent of all Medicare emergency room visits and 25 percent of hospital admissions are “potentially preventable.” And this is not just a matter of money. Hospitals, it turns out, are not always the best care setting for seniors. Researchers are looking at ways to keep older adults out of the hospital. This includes:
- Encouraging patients to be treated by their primary physician rather than at the emergency room.
- Better preventive care and management of diabetes, heart failure and other common health problems.
- Helping seniors manage their medications.
- Identifying and treating depression, which increases emergency room use.
- Improved healthcare education and information for consumers.
Avoiding the Hospital Revolving Door
Re-hospitalization is also an expensive and dangerous problem. According to the National Association of Area Agencies on Aging (n4a), nearly 20 percent of Medicare patients discharged from the hospital are readmitted within 30 days, costing over $26 billion every year. Why are seniors readmitted at such a high rate? Sometimes they have nowhere else to go—they can’t get an appointment with their primary care physician or don’t understand their care instructions. Studies show that in other cases, patients are released too soon: almost half of all surgical complications happen after discharge. And often, the reason for readmission is unrelated to the condition for which the patient was hospitalized. (See “Is Post-Hospital Syndrome Real?” below for more about this.)
For hospitals, there is a new emphasis on preventing unneeded readmissions. Medicare penalties are one reason for the concern: beginning in October, Medicare began reducing payments to hospitals which have high rates of preventable readmission.
Of course, not all readmissions can be prevented. But healthcare agencies are taking steps to help seniors, professionals and consumers address the problem. The Agency for Healthcare Research and Quality (AHRQ) calls for improvements in care transitions between the hospital and care facility or home:
- Education for patients about their diagnosis and treatment while they are in the hospital and upon discharge
- Making appointments for needed follow-up care
- Improved instructions on how to take medications
- Following up with patients within a few days of discharge
Improved communication within the system is also important. Said Dr. Elizabeth Rasch of the National Institutes of Health, “When a person has an emergency department visit, their primary care providers often don’t know or don’t get the results of that visit, and vice versa. The emergency department often doesn’t know about the complex medical history people bring with them. That’s where things tend to break down.”
The AHRQ also recognizes that patients may be unable to remember discharge instructions. Family caregivers play a valuable role at this time. Hospital discharge planners, geriatric care managers, home care professionals are also often called in to help.
Is “Post-Hospital Syndrome” Real?
Care received in a hospital saves the lives of millions of seniors each year, and helps many enjoy a higher level of independence and quality of life. Yet studies over the past few years have confirmed that a hospital stay can have a negative impact on seniors. In a January 2013 study appearing in the New England Journal of Medicine, Yale University’s Dr. Harlan Krumholz showed that many hospital readmissions are for a medical condition that is different from the initial cause of hospitalization—”post-hospital syndrome,” a 30-day period where patients are at risk.
A stay in the hospital can leave seniors vulnerable to medication problems, urinary tract and other infections, sleeplessness, bedsores, and even falls, which can even lead to a more serious problem than that for which the senior was admitted. Of special concern is hospitalization delirium—a sudden state of confusion that sometimes occurs after surgery or a serious illness. This temporary event is sometimes mistaken for dementia—and delirium has been found to raise the risk of or hasten the course of cognitive decline in some patients.
Hospitals are making changes to support better outcome for elders. Some have opened geriatric emergency departments to meet the special needs of frail older patients, with such features as specially trained personnel, a quieter setting and thicker mattresses for comfort and bedsore prevention. Experts are calling for more geriatric training in medical and nursing schools, as well as policies that make geriatrics a more attractive specialty for med students.
For More Information
The Agency for Healthcare Research and Quality recently released a consumer booklet: “Taking Care of Myself: a Guide for When I Leave the Hospital.”
The Joint Commission healthcare accreditation organization offers the “Speak Up” series of patient education brochures and videos.
The Eldercare Locator website has the online booklet “Hospital to Home: Plan for a Smooth Transition.”
Read more about the post-hospitalization syndrome study in the New England Journal of Medicine