Making Hospitals Better Places for Sick Older Persons

Hospitalizations are landmark events in the lives of older persons and frequently mark the transition from health to frailty. Almost one-third of Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, stroke, hip fracture, or pneumonia are dead within 6 months of the hospitalization.1 Moreover, approximately 6% of all persons aged 65 years or older who are hospitalized die before being discharged.2 Such poor outcomes are the result of three factors: (1) age-related physiologic changes that afford less resiliency in responding to acute illness; (2) diseases that precipitated hospitalization, pre-existing co-morbidities, and newly acquired disorders; and (3) the healthcare delivery system that renders care. The first of these is immutable and the mutability of the second is integrally linked to the last factor. In fact, the only ways we can currently improve health outcomes are to adopt lifestyle changes and to provide better health care (e.g., implementing optimal medical regimens for specific diseases, providing preventive and rehabilitation services, increasing continuity-of-care). The hospital has been viewed as a major culprit in the genesis of bad outcomes for old people.3 This reputation is, in part, attributable to the basic substrate of hospitalized patients, who are sick and in need of accurate and precise health care. Moreover, because of their illnesses, they are frequently helpless and cannot protect themselves from medical errors. Unfortunately, sick old people do not tolerate mistakes or inadequate care very well. In addition, the resources available to care for hospitalized patients are sometimes inadequate. Hospitals have been hit hard by efforts to contain costs. Finally, the organizational and administrative structures of hospitals have evolved in response to a variety of influences (e.g., economic, regulatory, labor unions), many of which are tangential to the goal of providing optimal care for sick older people. However, there may be hope on the horizon, both at the level of individual clinicians who care for hospitalized older persons and at systems levels. With the increasing use of electronic order systems and hand-held computer programs, clinicians are finally getting needed information about potential drug problems (e.g., interactions, contraindications) when they need it, at the time when they write the orders. More comprehensive “systems approaches” (e.g., the Institute for Healthcare Improvement's Breakthough Series) have been developed using continuous quality improvement methods to change components of hospital care. Finally, the basic structure of how hospitals care for older patients is beginning to change. The redesign of hospital care for older persons has its roots in comprehensive geriatric assessment and management. During the past 2 decades, a variety of models have been designed to improve the care of hospitalized older persons. These have included consultation services, which have not been very effective,4, 5 and geriatric evaluation and management units, which have had considerable success,6 but at a cost (i.e., length of stay) that is incompatible with 21st century healthcare delivery. In 1995, Landefeld and colleagues published a landmark study demonstrating the effectiveness of an Acute Care of the Elderly (ACE) unit designed to counter the adverse effects of hospitalization.7 This model of care consisted of a 15-bed unit that employed key elements tailored to each individual patient's needs. These elements included: a more friendly physical environment designed to foster functional independence; multidimensional assessment linked to treatment aimed at maintaining neurocognitive and psychosocial function; medical care (especially medications and procedures) review to prevent iatrogenic complications; interdisciplinary team rounds; and home (discharge) planning.8 In the original randomized clinical trial comparing the ACE unit to conventional care at an academic medical center, older persons receiving care in the Unit had better functional status at discharge and decreased likelihood of going to a nursing home than those receiving usual care.7 See also p 1572 and p 1697 In 1999, Inouye and colleagues published a controlled trial demonstrating the effectiveness in preventing delirium of a different model of improved hospital care for older persons.9 In this issue of the Journal, this model of care (the Hospital Elder Life Program or HELP) is described more fully.10 This program is hospital-wide rather than unit-based. After systematic screening, protocols are applied on an as needed basis and include: daily visitor/orientation, sleep enhancement, dehydration and feeding assistance, therapeutic activities, early mobilization, and vision and hearing adaptations. The program has a robust volunteer component, which is also noteworthy; in the United States, the use of volunteers to provide healthcare for older persons has been uncommon. The hospital care provided through both of these models is neither “high tech” nor biomedical. Rather, these programs rely on systematic implementation of good geriatric care for common geriatric problems—immobility, cognitive impairment, malnutrition, sensory impairment, and adverse drug events. However, implementing good geriatric care in acute care hospitals is no small feat. Changing systems of care requires major commitment and willingness to take risk by administrators and clinicians representing many health professions. So which of these should a health care system adopt? An old adage states that “all politics are local.” So too, with improved hospital care of older persons. Since both of these programs have demonstrated effectiveness, healthcare systems can decide which might be the best fit for their hospitals or develop hybrid programs that draw components from both. However, the real key to improving the care of hospitalized older persons is the maintenance and, more important, the dissemination of programs like ACE units and the HELP program. Too often, demonstration programs, even effective ones, vanish once the initial enthusiasm and funding for the project dissipate. To their great credit, the successful Yale program has become a permanent hospital program. A second paper in this issue11 addresses the other important issue, dissemination of a successful innovation. In this study, the ACE Unit concept was implemented and tested in a community hospital. This second randomized clinical trial examining the effectiveness of an ACE unit also demonstrated some benefits on functional status and institutionalization, though not quite as dramatic as those found in the original study. Better process-of-care and higher satisfaction rates were also noted for patients receiving care on the ACE unit. Of note, this study was supported by a grant from the foundation of the healthcare system that owns the hospital. Thus, these are two examples of the adoption of successful models by healthcare organizations that are committed to improving hospital care of older persons. Unfortunately, inaction is the most common response of hospital administrators to reports describing these innovations. Many hospitals are in a state of perpetual crisis precipitated by increasing economic pressures to operate leaner and more efficiently. Too often this is accomplished by draconian, and sometimes irrational, cuts. In fact, an entire consulting industry has been developed to guide this slash-and-burn approach to healthcare cost containment. Beyond the sheer financial issues, innovations in hospital care are constrained by regulatory bodies, labor issues, and attitudinal resistance to change. Overcoming such inertia requires vision, leadership, perseverance, and courage. Nevertheless, as presented in this issue of the Journal, the rewards of such innovation can be substantial.