Transitional care lacking in elderly

The most vulnerable population in the United States is the elderly, and the highest-risk phase of care for these patients is at discharge.

However, in most cases, hospitals provide no coordination in transitional care for elderly patients. Information doesn’t transfer from one point to the next in the delivery of care, leaving elderly patients discharged from hospitals with unresolved issues and with care needs too complex for themselves and their caregivers to handle.

For example, in the course of an acute exacerbation of an illness, a patient might receive care from a primary care physician or specialist in an outpatient setting, then move to a hospital physician and nursing team during an inpatient admission before moving on to another care team at a skilled nursing facility. Finally, the patient might return home, where he/she would receive care from a visiting nurse. Each of these shifts is defined as a transition.

“The physical movement of an elderly patient from location to location is certainly achievable and happens every day” says Kate O’Malley, RN, senior program officer for the California Healthcare Foundation in Oakland, Calif. “The real challenge is taking the sum total of knowledge of that elderly patient’s condition and making sure that it transfers from one healthcare setting to another.”

Part of the problem is the “silo” effect of healthcare. A hospital physician is focused on the acute event that brings the patient into the hospital, while the next physician is focused on rehabilitation or other post-hospital care.

“We may give fantastic care at a hospital and at a nursing home,” says James E. Lett, MD, senior medical director for health process improvement for Lumetra, a San Francisco-based healthcare consulting company. “But if they [the hospital and nursing home] aren’t in sync, then the patient is not well-served.”

Perhaps the most serious issue in the lack of transitional care has to do with prescription medications. In one clinical study by the University of Pennsylvania, 70% of patients experienced some form of medication reconciliation error during care transition.

Eric Coleman, MD, director of Care Transition Programs at the University of Colorado Health Sciences Center in Aurora, Colo ., says that it is important for elderly patients and their caregivers to become more active participants in their transitional care.

A lack of transitional care directly leads to a high readmission rate within 30 days of discharge, which leads to higher healthcare costs.

Many of these readmissions could be prevented by improved transitional care, says Mary Naylor, RN, professor in the School of Nursing at the University of Pennsylvania. Naylor and her staff have done numerous studies analyzing the cost and outcomes of transition care.

One of the most common reasons for the hospitalization of elderly patients is heart failure, and patients with heart failure typically have multiple chronic conditions.

In 2005, according to Naylor, there were 600,000 indexed hospitalizations for elderly patients being admitted to hospitals for heart failure. The readmission rate within 30 days was 27% and by 90 days, the rate was nearly 40%.

CMS is taking a hard look at the issue. It has begun a three-year pilot project that will examine readmission rates of elderly patients to hospitals, especially within 30 days, from the same diagnosis. The agency will seriously consider not paying hospitals that readmit patients for the same diagnosis within 30 days or substantially reduce payments, according to a spokeswoman.