Sometimes physicians need distance to understand today's major health delivery issues. This year's meeting of the Gerontological Society of America revealed issues with long-term care, hospital readmissions and the number of geriatric emergency departments in the U.S.
Academic gerontologists stand on hilltops watching battles. They see the big picture better than practicing geriatricians toiling in the trenches.
And sometimes physicians need distance to understand today’s major health delivery issues. Any geriatrician attendee at GSA12, the 65th Annual Scientific Meeting of the Gerontological Society of America in San Diego might have been fascinated to discover the academic world worries as much as physicians about society’s problems.
Emergency department use
The University of Maryland, Baltimore County Center for Aging Studies, University of Maryland Baltimore School of Medicine has a poster display that shows only a dozen states have hospital emergency departments for geriatric patients. All those states have high percentages of elderly residents; the lowest percentage in the 12 — Texas — has an aging percentage of 10.2%. Yet of the “top 10 aging states” only Florida and Iowa have GEDs (geriatric emergency departments).
A symposium on Geriatric ED Care: An Uncharted Frontier was chaired the same day by Mary P. Cadogan, DrPH, RN, GNP-BC, Professor Adjunct Series UCLA School of Nursing, with three of her colleagues. This presentation from four academics at UCLA offered substantial useful common sense approaches because they also had practical nursing experience.
For a geriatrician it was like listening to ideas from a parallel universe. For example, the UCLA School of Nursing Center for Advancement of Gerontological Nursing Science found 18 particular geriatric syndromes brought the elderly to their emergency departments.
A medical school pathologist once said to us, the med school students of the 1950s, “Understand tuberculosis and syphilis — and all other diseases will be made known unto you.”
He was exaggerating, of course, to make a point. Understood. But listening to Mary I did think of Willie Sutton, robbing banks because that’s where the money is. She’s putting her energy into where it may do some good. Surely we need to redefine assets into not better EDs but rather different ones, perhaps ones more loaded with social workers.
None of the UCLA geriatric syndromes are “quickies.” Elderly patients can linger in EDs forever with nurses seeking relatives and searching for information while patients block cubicles and dominate labs.
UCLA found that of 18,316 geriatric encounters, 11,889 came in once only — but 6,427 were repeater users. This suggests the “revolving door” of hospital admissions can be initiated in the emergency departments even earlier.
Reducing hospital readmissions
Kaiser Health News published a story in collaboration with The Washington Post on July 19, 2012 that declared the nation’s hospitals were making little headway in reducing the frequency of patient readmissions. One patient in five was returning to the hospital within one month of discharge.
The news story quoted Harvard’s Ashish Jha, MD, MPH, associate professor of Health Policy and Management as saying, “Either we have no idea how to really improve readmissions, or most of the readmissions are not preventable and the efforts being put on it are not useful.”
Yet there were flyers at the GSA12 from the Sub-Acute Care Rehabilitation Program at the University of Michigan Geriatrics Center & Institute of Gerontology that claimed significant reductions in readmissions.
Numbers were dropping from an “average length of stay at the U-M Health System of 10.6 days to eight days, and inpatient stays were reduced by nearly 2,908 days a year,” says lead author and Ann Arbor geriatrician, Darius K. Joshi, MD.
This was apparently achieved due to seamless communications between the hospital and the rehabilitation facilities with patient records integrated into the same heath computer system and the rehab facility having immediate access to hospital records including physicians’ examinations, laboratory records and imaging studies.
A poster by Kristie Kimbell, PhD, MP.Aff., MSSW, The University of Texas, School of Social Work discussed Long-Term Care: Who Is Responsible? Dr. Kimble pointed out 69% of individuals will need some form of long-term care (LTC) at some point in their older adult lives. The cost of LTC is rising — the total national spending for LTC in 2010 was $208 billion.
“And the current LTC system is not sustainable with the silver tsunami,” she says.
Kimbell also found baby boomers were no better at planning than any other group.
Some speakers at GSA12 felt LTC insurance was not continually feasible, that insurance companies (overwhelmed where natural calamities had hugely impacted their balance sheets) were looking for a way out of offering LTC.
I have always thought the documentation for LTC claims was potentially dishonest. Families would bring insurance forms to me and say, “You have to sign here at the bottom, doctor!” in a document that swore there was no other way the patient could be handled except in permanent LTC. That was almost true except many families without LTC had been forced to work out successful caregiver alternatives that would give the lie to any physician signature that declared LTC in a nursing home the only way.
We heard from a panel “Family Caregiving — The Elephant in America’s Health Care Bed” that discussed the reality that “almost half of the 42 million family caregivers in the U.S. perform complicated, exhausting, and sometimes high tech medical and nursing tasks for loved ones with inadequate training and support.”
The panel included Susan Reinhard, PhD, RN, FAAN, the senior vice president for public policy at AARP who, although she holds a PhD in sociology from Rutgers, declares she is first and foremost a nurse.
She sees “Caregivers doing work that would make a nursing student tremble.” The problem of LTC is compounded by the reality that many elderly live in rural areas long vacated by young family members. There’s no one around to be a caregiver.
Reinhard, the sociologist, wonders if America doesn’t need an integrated support plan for caregivers like the one that encouraged national use of seat belts. Meantime she has these five pieces of advice for caregivers:
1. Recognize you are a caregiver
2. “You need to put your oxygen mask on first!” (Maintain your own health.)
3. You deserve support
4. Ask for help and build up support for your network
5. Understand the cultural world you live in. (And perhaps, I think, its limitations.)
Because there are limitations to how much can be done in the real world. Physicians don’t have the answers to aging nor the sociologists.
Maybe GSA 13 in New Orleans in 2013 will have some better ideas.
Eric Anderson, MD, lives in San Diego. He is the one-time president of the NH Academy of Family Practice. His commentaries on aging are part of the MetLife Foundation Journalists in Aging Fellows Program organized by The Gerontological Society of America and New America Media. Anderson was a senior contributing editor at Physician’s Management from 1983 until 1998 (when the magazine ceased publication). He wrote a monthly column for both Postgraduate Medicine and Geriatrics for many years. Anderson is the only physician in the Society of American Travel Writers. He has also written five books, the last called The Man Who Cried Orange: Stories from a Doctor's Life.