Dedicated Teams Keep Seniors Out of Hospital

Fran Lowry

May 07, 2019

Healthcare programs focused on the specific needs of elderly patients can reduce unnecessary visits to the emergency department, inpatient stays, and hospital readmissions, and improve postdischarge treatment plans.

"We know that a lot of our seniors want to be at home," said Stephanie Chow, MD, from Mount Sinai Hospital in New York City.

The current system is not good at supporting the needs of seniors, who often "pose the greatest challenge to the primary care physician," she explained. And the caregiver gap is increasing because people are living longer and traditional caregivers — women 25 to 45 years of age — have become part of the paid workforce.

But, "with a different model of care for primary care geriatrics, we can reach these challenging high-risk patients and support them in the community," she told Medscape Medical News.

Chow and other researchers with an interest in keeping older adults out of the hospital presented their experiences with such initiatives at the American Geriatrics Society 2019 Annual Scientific Meeting in Portland, Oregon.

In the model Chow and her colleagues assessed, two clinicians, a social worker, and a care coordinator — known as the Geriatrics Preventable Admissions Care Team, or GERIPACT — provided services for seniors at risk for hospitalization, including temporary intensive ambulatory care services, and made house calls "to keep older patients at home."

Initially, the primary care physician identifies a patient who needs more care and services and makes a referral to GERIPACT. A typical patient has just received a significant diagnosis, such as stroke, myocardial infarction, or cancer, and is dealing with different doctors and new therapeutic regimens.

The intervention is short — most last about 60 days — and then the patient returns to primary care.

"We meet with them regularly, sometimes once a week," said Chow. During the meeting, which takes almost an hour, the doctor and nurse practitioner make sure that the medical issues are taken care of, and then the social worker and care coordinator "make sure that things like health insurance, transportation, meals, housing, and caregivers are in place, and that the caregivers are well supported."

The researchers reviewed the use of healthcare resources by 78 patients 6 months before and 6 months after GERIPACT intervention.

In the study cohort, there were 14 fewer visits to the emergency department after GERIPACT intervention than before (35 vs 49), and 16 fewer hospitalizations (29 vs 45).

"Even with this small group of patients, we have seen a big improvement," Chow said. "Our hope is that the GERIPACT model will help primary care doctors, many of whom do not do geriatrics."

No Easy Fix

"Trying to keep older adults out of the hospital is not simple, and there is no one easy fix," said Maureen Dale, MD, from the University of North Carolina in Chapel Hill. "It really takes multiple components to an intervention in order to decrease readmission for older adults."

To that end, she and her team assessed the use of a discharge summary template with geriatric-specific content designed to improve communication between inpatient and outpatient providers.

The discharge summary documented whether the patient had delirium during the hospital stay, noted any cognitive and functional assessments that were conducted, reported any changes in functional status that occurred, and listed any advance care planning that was done during hospitalization.

"We made sure it had content that was helpful in caring for older patients," Dale told Medscape Medical News, and that "we were getting the outpatient providers the information they needed when patients left the hospital."

A geriatric pharmacist performed medication reconciliation for each patient at discharge.

"We made sure that the patients had a clear list of medications that they were going home on, and our pharmacist double-checked to make sure that we had them on the medications they should be on and dropped medications they no longer needed," Dale said. "We also made sure everyone understood why we were doing those things."

During the 6-month study period, there were 353 admissions to the acute care of the elderly unit and 45 readmissions.

The 30-day readmission rate decreased from baseline to the end of the study period (24.0% vs 9.4%).

About 30 internal medicine residents were trained to perform geriatric assessments with the discharge summary template.

When the residents graduated, the intervention was put on hold and hospital readmissions began to creep up again. "But once we started the program again with new residents, the rates of readmission came back down," Dale reported.

"I think there were a couple of things that were helpful in getting these reductions," she said.

Documenting what "patients are able and not able to do functionally helped both the inpatient team and outpatient providers understand the patient's limitations and abilities," she explained. "That helps both sides make sure that the patients have the help they need at home in order to stay out of the hospital."

Cognitive assessments were also helpful, Dale added, so that patients "understood what they needed to do to take care of themselves at home," and so that caregivers could be put in place for patients with "underlying dementia or mild cognitive impairment."

Chow and Dale have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2019 Annual Scientific Meeting: Abstracts P20 and P23. Presented May 3, 2019.

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