Elderly Patients and Modern Healthcare System Challenges

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Hospital admissions are increasing due to our ageing population, and this creates a healthcare system challenge across the globe. Elderly patients are most often high-users of healthcare services. Health care systems and administrators will need to implement care models that will focus on the needs of older people. With a multitude of social and health factors, older patients tend to be in the hospital longer, are unprepared for hospital discharges, and are most likely to return to the hospital. One of our current healthcare system goals is to minimize older patient length of stay. Minimizing their length of stay will save hospital system costs, and prevent older patients of being exposed to even more health issues, such as infections, ulcer sores, delirium and etc., and cause greater expenses for the patient and healthcare organization. If we look at things on a psychosocial level and the psychological effects to the older patient, we will find that communication is key. In the commentary “Telephone follow-up Calls for Older Patients after Hospital Discharge”, it was found that phone calls to patients after discharge showed, that the majority of older patients felt alone, socially isolated, and unaware of community resources.

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In addition, that post-discharge telephone follow-up calls is potentially a cost-effective strategy to providing timely referrals and comfort to patients. The key points of this study found the following: a) that a large proportion of older patients are appreciative of a call after an acute hospital stay, b) telephone calls to older patients provided necessary information for community resources, bereavement resources and end-of-life support, and c) follow up phone calls can be a cost-effective way to ascertain patient outcomes. Frailty Levels Comans et al. did a study in hopes to get a better understanding of the physiological systems that result in frailty, and how it affects healthcare cost and resource utilizations in Australia. The study consisted of a group of older people who transferred to a community-based transition care program or transferred to transitional care at home, upon discharge from the hospital. Frailty levels were determined by gathering various patient attributes, such as demographics, cognition, continence, communication, functional status, nutritional status, social support etc. In addition, healthcare resources dictate if these patients utilized emergency services, pharmaceutical services, admissions, and readmissions. The patients that were transferred to a transition home care program were found to average over $12,000 per episode and the patients that were transferred to residential care, based on government daily subsidy rate, a medium level of dependency and complex health issues, averaged a little over $19,000 per 6-month period.

Although this study had limits and did not account for costs for social and community care (other than transitional care), the conclusion was found to show that transition home care programs are aimed to help older people live in their own home after a hospital admission. In addition, the patients that returned to a transition home care in their homes were found to provide higher levels of function and increased quality of life with returning and living in their own home. Ultimately, transition care programs will provide a cost savings to the government as well. Some of the key points found in the study were that living at home would most likely reduce overall health and social care costs. A frailty index scale can be helpful in monitoring increased frailty scores of the older population, so that a utilization of services per frailty rate are assessed, and for the creation of a carefully coordinated care/discharge plan can go in place to decrease re-admission rates. ACA, Readmissions and Telehealth With hospital returns being higher among the older population, the strain on the patient s and healthcare systems are profound.

For instance, the Affordable Care Act Hospital Readmissions Reduction Program of 2012 restricts reimbursements to providers and hospitals for patients with chronic conditions. Let us use the chronic condition of heart failure, which is found in many older people. Once a heart failure patient is discharged from an acute care facility, and they return within a 30-day time span, reimbursements to the hospital or provider are restricted. One way to combat such reimbursement restrictions would be to implement telehealth. Because of National Health care trends like value-based care, telehealth is growing. The connection between public and private payers and reimbursement to patient outcomes is currently a great focus for healthcare organizations, as well as quality reporting measures and quality assurance.

Therefore, telehealth is prompting healthcare leaders to implement telehealth for decreases in costs and patient outcome improvements. A Human TouchIn an article posted on Kaiser Health News, “A Hospital’s Human Touch: Why Taking Care in Discharging a Patient Matters”, Graham expresses how patients and caregivers want to feel informed when they are discharged from the hospital. Patients and caregivers want someone to make sure that follow-up and recovering is in the hands of someone, and that they are accountable for their recovery and care. Many hospitals have adopted strategies to reduce problems with transition care of discharged patients, however, most patients and caregivers continue to feel unprepared to go home and handle things on their own. Dr. Suzanne Mitchell, Assistant Professor of family medicine at Boston University School of Medicine and lead author of the report of Project ACHIEVE, a study that investigates the effectiveness of interventions that are in place to improve care transitions. One part of this study is looking to see what hospitals are actually doing to improve care transitions, and the other part of the study is to ask people who have went through these types of care transitions. The study focuses on older Medicare patients and caregivers to find out their wants and needs upon discharged to home after a hospital stay. Most of the people that participated in the study, pointed out the following areas:

  1. Getting Actionable Information,
  2. Planning Collaboratively,
  3. Expressing Caring,
  4. Anticipating Needs, and
  5. Ensuring Continuity of Care. This type of information is what older adults, caregivers want when they get ill, and have to move back to home, back t the hospital or other settings.

Growing Need

With patient-centered care being a focus for hospitals, healthcare systems will need to provide enhanced discharge services to older patients. Hospital admissions continue to increase for older patients and older patients can take longer to recover, meaning that they will need a stronger continuity of care. Effective communication and collaboration between the patient, caregiver, provider and facility for a clear and thorough discharge plan with follow-up, will need to be a major focus in order to keep hospital systems costs and readmission rates low.

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