Thanks to advances in medicine, elderly patients now live much longer. But they’re also much sicker, and skilled nursing facilities are often ill-equipped to handle patients in need of such high levels of care.
“Once they are discharged from the hospital and go to either home or to a skilled nursing facility, that kind of level of attention that kind of level of monitoring, that kind of level of immediate remediation just isn’t possible,” says David Reuben, UCLA School of Medicine’s chief of geriatrics.
The result is that growing numbers of medically fragile patients are sent by ambulance to local emergency rooms—over and over again.
It’s estimated that 20 to 30 percent of elderly patients discharged from the hospital find themselves back within a month, many of them arriving from nursing homes.
That’s frustrating for patients, and it’s expensive, says Brian White, President of Northwest Hospital in Baltimore. In an effort to reduce hospital readmissions White prompted his hospital to bring the doctors to the patients rather than the other way around.
“We’re looking at bringing those resources to the bedside, rather than putting the patient in an ambulance and bringing them to a facility that supposedly has those resources,” White says.
Dr. Raymond Miller works for a group of Maryland physicians called Post Acute Physician Partners – a group White helped launch in March of this year. On a recent day, Miller checked up on Dorothy Terkowitz, a patient at Levindale Geriatric Center in Baltimore, where she is recovering after a hospital stay.
As part of that outreach, Miller asks Terkowitz how she’s doing, if she is in any pain, if the rehab is helping.
Miller and his partners follow patients discharged from four Baltimore area hospitals to surrounding nursing facilities. They see patients like Terkowitz daily, with the goal of heading off problems before they become critical and land patients back in the hospital.
In a pilot project with a single nursing home over the last year, hospital readmissions were reduced by about half, says White. And while he says the cost of running the group just breaks even, it adds up to huge savings for the hospital.
"You’re talking about tens of thousands of dollars for every patient you can impact – times lots of patients," says White
White hopes Baltimore will serve as a model for other hospitals to imitate. But not everyone is quite so certain that blurring the lines between hospital and nursing homes will be the panacea he hopes.
Mary Tinetti, chief of geriatrics at Yale New Haven Hospital and Medical School, worries that there are some patients who are simply too sick for nursing homes. They will always need the hospital she says, and reproducing the hospital setting in nursing homes to care for these patients is less efficient and potentially more costly. Instead, Tinetti argues the real problem is that patients often believe they are getting better, when they aren’t.
“I think having a more frank and open discussion with these patients might mean that the care that they would prefer would change from having these frequent hospitalizations to perhaps moving to palliative care or even hospice care sooner than currently,” Tinetti says.
Tinetti says the real measure of quality is whether a patient’s care meets their goals – and that’s much harder to quantify than the number of patients coming back to the hospital.
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