4
Sites of Care for Older Adults
Kenneth S. Boockvar
Learning Objectives
Upon completion of the chapter, the student will be able to:
1. Weigh the likelihood of benefi t and harm when deciding whether to hospitalize an older adult.
2. Anticipate hazards of hospitalization for older adults and take measures to prevent them.
3. Discuss the advantages and disadvantages of different sites for post–
acute care with patients and families.
4. Understand the mechanisms for provision of long-term care in the United States and how they are fi nanced.
5. Optimize continuity of care during patient relocation.
General Considerations
Geriatric medicine is characterized by multiple levels or contexts of care.
The geriatrician and his/her team typically care for elderly patients along a continuum of these contexts, stretching from hospitalization for an acute problem, such as a stroke, to rehabilitation on a subacute ward, to conva- lescence in a nursing home, to continued care at home via a home care program, and fi nally to a return to primary care in the offi ce. Each of these contexts of care has its own scope of purpose, its own rationale, its own teams of care professionals, and its own fi nancial considerations and incen-
56
Material in this chapter is based on the following chapters in Cassel CK, Leipzig RM, Cohen HJ, Larson EB, Meier DE, eds. Geriatric Medicine: An Evidence- Based Approach, 4th ed. New York: Springer, 2003: Rubenstein LZ. Contexts of Care, pp. 93–97. Kane RL. The Long and the Short of Long-Term Care, pp. 99–
111. Levine SA, Barry PP. Home Care, pp. 121–131. Palmer RM. Acute Hospital Care, pp. 133–145. Selections edited by Kenneth S. Boockvar.
tives, all of which are actively evolving along with changes in the overall health care system and larger society. Proper geriatric care requires famil- iarity with all these contexts and an understanding of how best to manage patients within them.
Case (Part 1)
Ms. K. is an 87-year-old woman with mild cognitive impairment, occa- sional urge incontinence, and hypothyroidism whom you have cared for 3 years as an outpatient. Ms. K’s daughter brings her into the offi ce before her scheduled appointment because over 2 days ago she devel- oped a cough, low-grade fever, and dyspnea. Chest examination reveals inspiratory rhonchi and expiratory wheezes on the left side. You make the diagnosis of lower respiratory tract infection, order a chest x-ray, and are now considering whether to hospitalize Ms. K.
Epidemiology of Hospitalization
Although rates of hospitalization have declined in the past two decades for all age groups, the proportion of hospitalized patients who are age 65 years and older is increasing. In nonfederal acute hospitals, elderly patients account for 37% of all discharges and 47% of inpatient days of care (1).
Among noninstitutionalized adults, patients age 75 years and over have the highest rates of hospitalization, with nearly 15% being hospitalized yearly and 5.3% hospitalized two or more times per year (2). In addition, older patients have longer hospitalizations, higher mortality rates, and higher rates of nursing home placement after hospitalization (1). In-hospital mor- tality rates increase from 5% among those 65 to 74 years of age to 10% in those 85 years of age and older. Risk factors among older adults for 2-year mortality after hospitalization include weight loss, cognitive dysfunction, impaired functional status, greater chronic disease burden, and worse severity of acute disease (3).
Hazards of Hospitalization
For older patients, hospitalization is a two-edged sword. Although hospi- talization for acute illness offers older patients the hope of relief of symp- toms and cure of disease, it also exposes them to the adverse risks of hospitalization: functional decline, iatrogenic illness, and possible institu- tionalization (Table 4.1).
Prospective cohort studies found that 20% to 32% of patients admitted to general medical units lose independence in their ability to perform one or more basic activities of daily living (ADLs) by the time of discharge
Table 4.1. Iatrogenic problems in hospitalized older adults and keys to prevention Iatrogenic problemCommon reasons Keys to prevention Adverse drugPolypharmacy; drug–drug interactions;Rational drug prescribing: review all medications taken prior to effects altered drug disposition and tissueadmission; use lower than usual maintenance doses when geriatric sensitivity with aging dose is unknown; limit use of psycho-active drugs; avoid drugs that affect cytochrome P450 metabolism or are highly albumin-bound Falls/immobility Weakness of leg muscles; postural Assess falls risk at admission (chronic disease burden, cognitive hypotension; deconditioning due to dysfunction, neuromuscular dysfunction, sensory impairment); avoid prolonged bed rest; cognitive physical restraints; order physical therapy for transfer-dependent and impairment; sensory impairment gait-impaired patients; prescribe assistive devices (e.g., canes, walkers); modify environment (e.g., add handrails, grab bars to rooms); prescribe prophylactic subcutaneous heparin to immobile patients to prevent deep venous thrombosis Pressure ulcersImmobility; sustained point pressure Pressure ulcer risk assessment: paresis, cognitive dysfunction, over bones; excess moisture, frictionincontinence, malnutrition; turn patients at least every two hours; and shearing forces lubricate skin; optimize nutrition; order pressurized bed mattresses Dehydration/ Chronic disease predisposing to protein- Assess nutritional status at admission: body weight; muscle wasting; undernutritioncalorie malnutrition; poor oral intakeserum albumin, cholesterol, hemoglobin; monitor calorie and fl uid due to acute illness; anorexia; intake; obtain dietitian consult; give IV fl uids when oral intake is preparation for diagnostic studies inadequate or prohibited; consider enteral alimentation or peripheral hyperalimentation when oral intake is inadequate or contraindicated NosocomialTransmission of resistant/opportunisticHand-washing; sterilization of medical equipment; use narrow- infectionmicroorganisms by providers; use ofspectrum antibiotics when feasible; aspiration precautions in high broad-spectrum antibiotics; risk patients; disinfection of patient’s skin prior to insertion of instrumentation (e.g., urethral catheters);intravenous or intraarterial line; urethral catheterization pulmonary aspirationintermittently rather than continuously when indicated Contrast-associatedHypertonic contrast agents givenAvoid contrast studies, especially with renal diseases, dehydration, nephropathy intravenously for diagnostic studies;or multiple myeloma; substitute noncontrast studies; maintain dehydration; renal disease; myeloma adequate hydration before and after study Source: Palmer RM. Acute hospital care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003.
(4–6). The loss of independent functioning during hospitalization is associ- ated with serious sequelae, including prolonged hospital stay, nursing home placement, and mortality. Studies have also identifi ed risk factors for func- tional decline in hospitalized elderly patients which include age ≥75 years old; presence of disability in the performance of instrumental activities of daily living (IADLs) prior to admission; low mental status scores on admis- sion; presence of pressure ulcers; low social activity level; delirium; and presence of depressive symptoms (4,5,7).
Immobility
Immobility is associated with functional decline, increased risk of nursing home placement after discharge, medical complications (including deep venous thrombosis, urinary incontinence, pressure sores, joint contrac- tures, cardiac deconditioning and muscle weakness), and falls (8). Cardiac and muscular deconditioning occur within days of sustained bed rest.
When in the hospital, patients should be allowed free movement, and may need encouragement to sit up or to get out of bed even when they prefer bed rest (8).
Malnutrition
Undernutrition and protein-energy malnutrition are common in hospital- ized older patients and are linked to increased hospital and posthospital mortality (9). Acutely ill patients have greater nutritional requirements than well elderly patients. Nutritional consultation and appropriately pre- scribed nutritional supplements are warranted for patients at risk for mal- nutrition (10,11). Patients often have orders for nothing by mouth (NPO), and nutritional supplements are often not consumed. Therefore, in the hospital, food and fl uids should be prescribed and monitored daily (See Chapter 11: Nutrition, pages 177, 178, 180, 187).
Delirium
Delirium, an acute disorder of attention and cognition, occurs in 20% to 30% of elderly patients admitted with an acute medical diagnosis. Delir- ium may be precipitated by processes of hospital care, including immobi- lization of the patient, use of an indwelling bladder catheter, use of physical restraints, dehydration, malnutrition, iatrogenic complications, and psy- chosocial factors (12). Delirium prolongs hospital length of stay, increases costs of care, and increases the risk of nursing home placement or death (13). Delirium is best approached by preventive multicomponent interven- tions, since if it occurs, delirium can be diffi cult to treat (see Chapter 13:
Depression, Dementia, Delirium, pages 236, 237, 242).
Iatrogenesis
Iatrogenic illness is any illness that results from a diagnostic procedure or therapeutic intervention and that is not a natural consequence of the patient’s disease (14). Of iatrogenic events, adverse drug events are common in hospitalized patients and are associated with signifi cantly prolonged length of stay, higher costs of care, and increased risk of death. Virtually any class of medication can cause an adverse event, but anti biotics and cardiovascular drugs have been most commonly implicated in studies of hospitalized patients. The increased risk for adverse drug events in older adults is partly attributable to alterations in drug disposition and tissue sensitivity associated with usual aging and to drug–drug interactions.
Nosocomial (hospital-acquired) infection is another common iatrogenic complication of hospitalization, commonly involving the urinary tract, respiratory tract and blood stream (due to intravascular catheters). Colo- nization or infection with resistant or opportunistic infections may com- plicate hospitalization (15).
Depression
Depression and depressive symptoms are present in 20% to 25% of medi- cally ill elderly patients in the hospital (7). Environmental changes (e.g., a brighter room), physical and occupational therapy, increased frequency of family visits, and psychological counseling may be of immediate benefi t to the depressed patient. (See Chapter 13: Depression, Dementia, Delirium, page 227.)
Improving Outcomes of Hospitalization
In light of the known hazards of hospitalization, the alternatives for an older patient should be considered, such as home care for patients with acute but non–life-threatening illnesses, hospice or palliative care for patients with terminal illness, or direct admissions to a skilled nursing facility. Prior to hospitalization, the personal values and priorities of patients and the wishes of their families should be addressed. The patient’s advance directive should be reviewed with the appropriate family member or power of attorney for health care. A review of the objectives of hospi- talization, the diagnostic evaluation, and probable outcome should be discussed before or early in hospitalization (see Chapter 7: Medicolegal Aspects of Older Adult Care, pages 94, 96, 98).
If the decision is to hospitalize, personal comfort should be addressed throughout hospitalization. Privacy and quiet at night are important.
Family members should be encouraged to visit patients. A normal bowel and bladder regimen is maintained with a toileting schedule, and a bedside commode or urinal for men. Fiber supplements or hyperosmolar laxatives
are helpful to prevent fecal impaction in immobilized patients or those taking opiates or anticholinergic agents.
In addition, models of care designed to enhance patient functioning during hospitalization or immediately postdischarge have emerged in the past decade, and include acute care of elders (ACE) units (5,16,17), the Geriatric Care Program (18), and the Elder Life Program (19). These models should be taken advantage of. The objectives of these interventions are to improve functional outcomes of hospitalization, reduce hospital lengths of stay, prevent nursing home admissions, or prevent rehospitaliza- tion. They offer hope that the adverse consequences of hospitalization can be attenuated through comprehensive assessment, special units, and com- prehensive discharge planning.
Case (Part 2)
Ms. K. is admitted to the hospital and is prescribed intravenous antibiot- ics. Her symptoms of infection and dyspnea improve, and she is medi- cally stable for discharge on hospital day 4. However, she has become deconditioned from lying in bed and nurses have observed her perform- ing unsafe maneuvers while ambulating in her room. She agrees to undertake rehabilitative treatment, and you need to help her decide on a post–acute care location.
Post-Acute Care
Post-acute care refers to medical, nursing, and rehabilitative care provided to patients following acute illness and hospitalization. Formerly, this phase of care took place in the hospital, during extended hospital stays. However, currently, because of fi nancial incentives to reduce hospital length of stay, almost all post-acute care occurs outside the hospital. Thirty eight percent of all Medicare-covered hospital discharges in 1995 received one or more forms of post-acute care. The dominant model was home health care, accounting for over half of all the post-acute care usage. Other sites of post-acute care are nursing home and hospital rehabilitation units. However, hospital-based rehabilitation is available only to a small number of indi- viduals who can adhere to a rigorous (at least 3 hours a day) regimen of rehabilitative therapy, leaving most patients and caregivers of older adults with a choice of home or nursing home-based care (see Chapter 10: Exer- cise and Rehabilitation, pages 168, 171, 172).
Medicare covers 100 days of post-acute care after hospitalization, and only fully covers the fi rst 20 days, with a substantial co-pay (20%) after that; thus, many courses of rehabilitation are less than 20 days. Medicare coverage can only be invoked for skilled services, for example, parenteral therapy (not including insulin), complex wound care, or daily physical,
occupational, or speech therapy. Daily compliance and consistent medical or functional improvement is necessary to retain the benefi t. If patients cannot meet these requirements, the Medicare benefi t is terminated (see Chapter 5: Medicare and Medicaid, pages 73–75).
Compared with other sites of post-acute care (e.g., home with home care, hospital rehabilitation units), nursing homes may be at a disadvantage in providing the necessary services (Table 4.2). Many nursing homes do not have the nursing staff, especially professional nurses, to meet the needs of patients just discharged from the hospital. In addition, doctors are less inclined to do rounds in the nursing home as frequently as they do in the hospital, in part because Medicare is less likely to pay for frequent visits.
Likewise, nursing homes may not be able to provide the rehabilitative ser- vices needed. Some homes have physical therapists on staff; others contract for such care. Nursing homes with subacute or rehabilitative units are more likely to have the full range of rehabilitation services and team members (Table 4.3).
Case (Part 3)
Ms. K. enters a subacute unit at a local nursing home and undergoes 15 days of gait training and strength exercise therapy. She recovers most of her strength and is discharged home with a walker. Her daughter arranges for 4 hours of home assistance daily and takes over Ms. K.’s bill paying. In the subsequent months you see Ms. K. as an outpatient at regular intervals. Ms. K. experiences a slow decline in memory, which impedes her ability to perform instrumental activities of daily living such as medication management, shopping, and cooking. She also begins to experience more frequent episodes of urge incontinence, despite treatment. Her daughter schedules an appointment with you to discuss options for Ms. K.’s long-term care.
Table 4.2. Advantages (+) and disadvantages (−) of post-acute care sites
Home Nursing home Hospital
Ease of placement +/− +/− −
Recovery of physical function + − +
Return to community living + − +
Around-the-clock custodial care − + +
Comfort and autonomy + − −
High out-of-pocket and informal costs − + +
Long-Term Care
Long-term care is defi ned as assistance given over a sustained period of time to individuals with disabilities. Most long-term-care recipients also need active medical care, because their disability is often a result of one or more chronic diseases. The defi nition of long-term care does not imply care given at a particular site. In fact, the backbone of long-term care is informal care provided by family and others. Only about 8% of care pro- vided to persons living in the community comes from paid sources. Another 28% is provided by a combination of formal and informal care; and almost two thirds comes solely from informal sources (20). Even with the substan- tial amount of informal care being provided, many older people still do not receive the help they need.
Medicare and Medicaid together account for about 60% of formal long-term-care expenditures and about the same proportion of nursing home expenditures. Taken individually, Medicaid plays a much larger role in nursing home care, whereas Medicare is major funder of home care. Until now, long-term care has been largely a state responsibility because of the heavy role Medicaid has played, resulting in a wide variety of programs and quality of care. Recent efforts to measure quality of long-term care have focused on clinical outcomes such as physical functional change, maintenance of weight, and skin condition (i.e., avoidance of pressure sores). An outcomes focus allows comparisons across modalities of care. By shifting the emphasis away from structure and methods of care to accountability for outcomes, it is possible to preserve fl exibility in choice of site of care while assuring accountability.
Nursing Home
The nursing home has served as the touchstone for long-term care.
Other forms of long-term care are usually considered in relation to the nursing home. The nursing home has a mixed heritage, descended from the almshouse on one side and the hospital on the other. Because nursing home care has been closely associated with Medicaid, a welfare program, it carries the welfare stigmata. At the same time, early federal regulations used small hospitals as the template for nursing home standards.
The hospital model of multiple persons in a room, fi xed hours for eating and being awake, limited choice of food, and an overarching therapeutic philosophy does not provide a normal living environment.
These practices were developed to make care more effi cient, but they rob patients of their identity and dignity. The plight of the nursing
home has been made more serious by its efforts to provide services to many different types of patients, including those with physical frailty, cog- nitive impairment, terminal illness, and those with temporary disability.
Trying to fi ll multiple needs makes it more diffi cult to achieve good results.
Care providers should be aware of the experience of entering a nursing home from the patient’s perspective. It is a depressing and distressing event, a concrete marker of debility and disease, in which one joins with others in the same condition. The admission process to the nursing home is also highly regulated. It is a prolonged process involving paperwork and discussions of illness, code status, funeral home choice, relinquishment of belongings, and adaptation to the unfamiliar. Emotional and functional adaptation to the nursing home sometimes takes 6 months. The physical and emotional tolls are equaled by the fi nancial toll. Nearly half of nursing home care is paid for out of private funds.
Typical daily cost for nursing home care ranges from $150 to $300 per day.
Medical care in nursing homes is evolving. Nurse practitioners have been shown to improve quality of primary care in nursing homes (21,22), and, in conjunction with the emergence of managed care, teams of physicians and nurse practitioners have been effectively used to follow nursing home residents (23,24). Special managed care programs directed specifi cally at nursing home residents have been created with the hypothesis that aggres- sive primary care can avert hospitalizations (25), which are frequent events during a nursing home stay.
Assisted Living
An emerging form of long-term care is assisted living. Although there is no consistent defi nition of this style of care, most people agree that it includes an opportunity to live alone with quarters that provide one’s own toilet and bathing facilities and some means to preserve and prepare food.
At the heart of this concept is the idea that people are fi rst seen as inhabit- ants of their space with control over their lives. Services are provided as conditions dictate. Some may be offered as a part of an overall package (e.g., congregate dining, a minimum number of service hours per week);
others can be purchased as needed.
Assisted living is providing new competition to nursing homes. Private paying clients especially are attracted to the idea of being able to live in more commodious settings, often at lower costs. A few vanguard states, like Oregon and Washington, have made deliberate efforts to redirect Medicaid expenditures from nursing homes to community care, including institutional options like assisted living. But most states have been hesitant or unable to make such a shift.
Home Care
Home care recipients are community-dwelling individuals who depend on the assistance of others to perform ADLs. In the absence of this help, they would be at high risk of nursing home placement. Thus, the term home care includes all health and social services that may be provided in the home, ranging from homemaker, chore, and meal services to nursing and physician care (Table 4.3). Nationwide, some 9.5 million people older than 50 receive help with at least one basic ADL (bathing, dressing, eating, toi- leting, continence, transferring, and ambulating) or IADLs (management of fi nances, use of the telephone, organizing transportation, meal planning and cooking, shopping, taking medications) (26). Of people receiving home health services in 1996, 72% were aged 65 or older, 67% were female, 65% were white, 29% were married, and 35% were widowed (27).
In 1990, the American Medical Association suggested that medical care at home could be (1) preventive, including home safety evaluation, patient education, provision of assistive equipment, or monitoring; (2) diagnostic, including home assessment, comprehensive geriatric assessment, or evalu- ation of functional capacity and the environment; (3) therapeutic, from
“high tech” to hospice; (4) rehabilitative, especially with family involve- ment; and (5) long-term maintenance for chronically ill and disabled patients, with supportive care by formal and informal caregivers (28).
Table 4.3. Services available in the home
Medical
Professional Ancillary/supportive Diagnostics equipment
• Physician • Home health aides • Phlebotomy • Intravenous
• Nurse • Personal care • X-rays infusion for
• Dentist assistants • Electrocardiograms hydration,
• Podiatrist • Homemakers • Holter monitoring chemotherapy,
• Optometrist • Chore aides • Oximetry blood
• Rehabilitation • Volunteers • Blood cultures transfusion, therapists: • Home-delivered antibiotics, occupational meals total parenteral
physical nutrition, pain
speech management
respiratory and other
• Psychologist medications
• Dietitian • Mechanical
• Pharmacist ventilators
• Social worker • Dialysis
• Medical alert
devices
• Glucometers
Source: Levine SA, Barry PP. Home care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003.
Situations in which a home visit by the physician may be required include ambiguities in reports of the patient’s status, acute declines in health or function in frail patients, unexplained failure to thrive, unexplained failure of the care plan, request for physician evaluation in the home by another team member, need for a patient/family meeting to make an important decision, and routine medical care for the patient who cannot leave home (29).
The vast majority of care provided in the home is unpaid, nonmedical, informal care; 72% of caregivers are female, mostly wives and daughters, and over one third of all caregivers are 65 or older. One-third of caregivers themselves are in fair or poor health and most are poor or nearly poor (31%) or low to middle income (57%). Due to the competing demands of elder caregiving with childcare or employment, 9% have left work and 20%
have reduced work hours (30).
Funding for home care services comes from a variety of public and private sources. Medicare is the largest single payer of home care services, accounting for 31.6% of total estimated home care expenditures in 2002, followed by private out-of-pocket spending (18.0%) and Medicaid (13.3%) (31). Medicare covers services deemed to be “reasonable and necessary for the treatment of an illness or injury,” and therefore is not intended to cover long-term care provided by an individual or a nursing home.
However, long-term home care recipients require active medical care because, like other long-term-care recipients, their disability is a result of one or more chronic diseases. Such medical care, as well as post-acute care after hospitalization, is covered at home by Medicare. Services that are 100% covered under Medicare Part A include skilled nursing, skilled therapy, home health aide services, and social services. It is im portant to be aware of exclusions in Medicare coverage, including homemaker services, long-term-care nursing, home-delivered meals, transportation that is nonemergent, all bathroom equipment, and patient care for those who do not require skilled nursing services. From 1997 to 2003, Medicare home care expenditures increased from $3.9 billion to
$12.2 billion.
Medicaid funding for long-term home care services is provided jointly by the federal and state governments. The regulations are federal, but eli- gibility is determined on a state-by-state basis. Coverage is designed for those who not only meet state income eligibility guidelines but also are blind or disabled. The majority of states cover nursing and home health aide services, durable medical equipment, and medical supplies. Coverage for diagnostics, medication, transportation, adult day care, social work, personal care, and physical, speech, or occupational therapy varies from state to state. Medicaid payments for home health services fall into three main categories: the traditional home health benefi t, which is a mandatory benefi t provided by all states, and two optional programs: the personal care option and home and community-based waivers. Medicaid spending for
home health services has grown enormously in the last two decades, from
$70 million in 1975 to $24.3 billion in 2000. Home care services made up 14.4% of Medicaid payments in 2000 (31).
An interdisciplinary-team approach and the use of a home care coordi- nator for case management are essential in implementing complex plans that may include numerous referrals and services as well as education for the patient and family. This approach also allows continuous assessment of outcomes over time so that the plan can be revised as the patient’s needs and health status change. The collaborative nature of this practice requires communication among the varied disciplines that provide services in the home. The role of physicians in home care may include authorization of services; communication with providers, patients, and families; and home visits. Advantages of house calls include patient convenience, support, and reassurance, and the availability of assessment information. Disadvantages of house calls are that they are time-consuming, ineffi cient, and poorly reimbursed, with concerns about safety and lack of equipment (32). In small practices where the physician does not have the luxury of an inter- disciplinary team, the physician must act as the case manager in concert with a visiting nurse.
Case (Part 4)
Ms. K., at her daughter’s suggestion, opts to enter a nearby assisted living facility, where she can have her meals prepared and medications administered. In the next 12 months Ms. K. has a recurrent episode of pneumonia that requires hospitalization. After this illness she returns to the nursing home subacute care unit where she stayed previously for rehabilitative treatment. After completing this course of rehabilitation she still needs help transferring, toileting, and dressing. At this point she and her daughter decide that the best option for her is to move to another fl oor in the nursing home permanently for long-term care.
Optimizing Continuity of Care
As portrayed in this chapter’s unfolding case, older adults often fi nd them- selves transferred to and from different levels of care in a collection of institutions. Each of these transitions causes discontinuity in care. This includes the change in physician and nursing staff and change in environ- ment that can be disruptive to care and hazardous to patients. Coordina- tion of care between sites of care is important to avoid duplication of work
and provider errors. Optimally a single provider follows the patient throughout their medical course. In the absence of a single provider, con- tinuity of care depends on communication between providers at different sites. Often the plan for communication between sites of care is a transfer of paper documents that occurs with, or just following, the physical transfer of a patient. Several authors have proposed standards for what type of information should be included in transfer documents (33–36). Because older adults have a high prevalence of complex medical histories, long medication lists, disability, and surrogate decision makers, most authors recommend including these classes of information, as each is crucial for providing health care to an individual (Table 4.4).
When transfer documents do not include all the information that a pro- vider needs, or there is some question as to their accuracy, other methods of interinstitutional communication should be employed, such as telephone communication between providers or sharing of electronic data. In U.S.
Veterans Affairs Medical Centers, providers in the hospital, nursing home, and outpatient practice can look at the complete medical record from medical encounters anywhere in the system, because all records are carried electronically on a common server. To optimize the transfer process, efforts should be made by providers at different sites to contact one another by phone to communicate more detailed information, especially for patients who cannot provide a medical history due to communicative impairments.
This can occur at all levels (e.g., between physicians, nurses, social workers, physical therapists), and can be useful well after the transfer to help trou- bleshoot unanticipated changes in patients’ conditions. In addition, primary care providers, especially physicians and physician extenders, should visit patients in the hospital and other sites (including post-acute care sites, nursing home, and home) whenever possible. This allows primary care providers to get updates on the individual’s condition and to give sugges- tions on the plan of care to providers at each site.
Table 4.4. Checklist of items to be included in transfer documents
Physician contact information Family contact information Clinical course
Advance directives
History of adverse drug reactions Chronic conditions
Vital signs
Recent laboratory results Assistive devices Physical function Sensory function Cognitive function Medications
General Principles
• Because the hospital exposes older adults to signifi cant risk of iatro- genic harm, one should routinely consider appropriate alternatives to hospitalization for ill older adults (e.g., outpatient workup, treatment in the nursing home).
• When older adults are hospitalized, interventions should be imple- mented that have been shown to reduce the risk of inpatient adverse events such as delirium and functional decline.
• When deciding among sites for post-acute care, one should consider results of studies that have suggested that individuals who receive post-acute care at home or in acute rehabilitation units have better physical function outcomes than those who receive post-acute care in nursing homes.
• Long-term care should be provided in the least restrictive environ- ment possible that ensures the health and safety of individuals (i.e., consider home with home care or assisted living prior to nursing home placement).
• Providers who discharge and admit geriatric patients to/from new sites of care are responsible for complete and accurate communica- tion of medical information, and for communication of the plan of care with patients and their surrogates. Reliance on written transfer forms may be inadequate.
Suggested Readings
American Medical Association. Medical Management of the Home Care Patient:
Guidelines for Physicians. Chicago, IL: AMA, 1998. An invaluable guide to practitioners in the home care setting.
Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669–
676. The fi rst large-scale trial proving that modifi able risk factors for delirium could be identifi ed and addressed to prevent delirium among hospitalized patients.
Kane RL. The long and the short of long-term care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003:
99–112.
Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M. The optimal outcomes of post-hospital care under Medicare. Health Serv Res 2000;35:615–
661. This study estimated the differences in functional outcomes attributable to discharge to one of four different sites for posthospital care. It found that nursing homes are generally associated with poorer outcomes and higher costs than the other posthospital care modalities.
Levine SA, Barry PP. Home care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003:121–132.
Palmer RM. Acute hospital care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003:133–148.
Rubenstein LZ. Contexts of care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003:93–98.
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