Thursday, 1 February 2018

The Aged You Are, The Worse The Hospitalisation is For You

The Aged You Are, The Worse The Hospitalisation is For You.
                                                                            Roshan Jacob                                                                                                                                       
This is one thing everyone can agree on: these unnecessary hospital trips cost money, and aren't good for the health of older adults. In developed  countries public health policymakers are looking at ways to protect the well-being of our vulnerable seniors and, in the process, to save money for insurance and the patients. Ours is no different but we dodge the issue. Here is the issue of potentially avoidable hospitalisations and our time tested model.

Very much a common scenario familiar to most of you is illustrated as a case study.  An 82-year-old resident of our care facility — call him Mr. Shenoy — has moderately senile but not dementia, congestive heart failure with severe left-ventricular dysfunction. He develops a non productive cough and a fever of 100.4°F. The care facility nurse calls an on-call physician who is familiar with Mr. Shenoy. Told that he has a cough, fever and sodium imbalance, the physician says to admit him to a close by hospital, where he's found to have normal vital signs except for the low-grade fever, a normal basic-chemistry and white-cell count, but a possible infiltrate on chest x-ray. He is admitted to the hospital and treated with intravenous fluids and antibiotics. During his third night in the hospital, Mr. Shenoy becomes confused and agitated, climbs out of bed, and falls, fracturing his hip. One week after admission, he is discharged back to the care centre.  The episode results in about Rs. 3.6 Lakhs in hospital expenditures, as well as discomfort and disability for Mr. Shenoy.

Now let’s assume an alternative scenario, however, in which, when the same symptoms develop, the  facility nurse evaluates Mr. Shenoy using a standardized protocol and calls the on-call doctor  who visits the nursing home weekly twice. “Late this evening, the resident developed a non productive cough and a temperature of 100.4°F,” the nurse reports. “His other vital signs are normal, and his lungs sound clear. He isn't complaining of shortness of breath or chest pain, and there is no leg edema. I think we can watch her and call back if something changes.” The Doctor agrees and says he'll see Mr. Shenoy in the morning, at which point he finds a persistent low-grade fever and crackles in the right posterior lung field. After consulting with Mr. Shenoy’s son who lives abroad, the Doctor orders an oral antibiotic and increased oral fluid intake. Mr. Shenoy recovers over the next several days. The episode costs about Rs. 1650/- including Doctor’s visit and results in no complications for Mr. Shenoy.

In most geriatric conditions, more care centre residents with acute changes in their clinical condition could be cared for safely and effectively without having to be admitted to a hospital or nursing home. We admit that the causes of preventable hospitalizations in this population are complex. One fundamental problem is not clinical but financial, stemming from the unethical practices of our private hospitals to make a fast buck by admitting and starting with futile interventions. Even though the care centre incurs expenses when managing changes in condition without hospital transfer, it is very much affordable, comfortable and less cumbersome.

Different strategies should be adopted to address the current trends for hospitalization even at the drop of a hat. We need to change our mind sets and conventions if we are to improve institutionalised care and prevent unnecessary hospitalizations, with their related complications and costs. Let’s know the two caveats that are critical in this scenario. First, not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable. Second, given financial constraints and the dearth of geriatric care professionals or long-term care professionals, very few care facilities have the capacity to safely evaluate and manage changes in the condition of the clinically complex care centre population. Setting unrealistic expectations and entrusting care to poorly managed care centres to manage such care could have unintended negative effects on the quality of care and health outcomes. 

"The aged you are, the worse the hospitalisation is for you," retorts Soumya with her 17 years of experience in long term care. "A lot of the interventions we do in hospitals does more harm than good. And here Soumya’s points to another case study. 

Most elders hate and fear hospitalisations. Interrupted sleep, unappetizing food and days in bed can cause lasting damage to older ones. ‘Prejudiced hospital staff’ often fail to feed older patients properly, get them out of bed enough or control their pain adequately. The unique needs of older patients are not a priority for most hospitals. Doctors and other hospital staff’s focus is on treating injuries or acute illnesses — like pneumonia or an exacerbation of heart disease — that they dodge all other aspects of caring for the patients. In general, hospitals frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to all sort of procedures and prescribe redundant or potentially harmful medications. And nurses deprive them of sleep by placing them with younger patients in noisy wards or checking vital signs at all hours of the night. thus making the stay at hospitals a harrowing experience.

Of late, there is new trend in few countries called Acute Care for Elders (ACE). Aged infirm patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units. Acute Care for Elders (ACE) ward, has special accommodations and a team of geriatricians and gerontoloy nurses to address the unique needs of older patients. Here the original diagnosis is secondary but the emphasis is more on how to get patients back home, to live as independently as possible. None of our corporate hospitals adopt this into our tertiary care system. 

Padma Natrajan was active and outspoken, living by herself after retirement from Kendriya Vidyalaya but as a person who wants to give back to society she  started a new role as a special education tutor. Then, in March, a bad fall while negotiating a  pothole in front of her gate landed her in the hospital.
Doctors cared for her wounds but fortunately no fracture and treated her pneumonia. But Padma, 74, didn't sleep or eat well at a well known corporate hospital. She became confused and agitated and ultimately contracted a serious lung infection. After more than three weeks in the hospital, she emerged far weaker than before, shaky and unable to think clearly. The sudden turn of events made her  totally infirm.

She had to stop working and wasn't able to move around for months. And now, she's considering a move to the care facility as she is convinced that she is no more independent.

“Considering my mother’s bustling energy, it's a big, big change," said her daughter, Vatsala who visited her from New Jersey soon she heard the news of fall.  "I am hopeful with this move to the care centre that she will regain a lot of what she lost in the hospital, but I am not sure.”

“Many elderly patients like Padma deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About half of patients over 70 years old and more than half of patients over 80 leave the hospital more infirm than when they arrived.   As a result, many elders are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.” Said Soumya Nair.

How hospitals treat the old — and very old — is a pressing issue which is yet to be discussed in our society though this is considerably discussed in developed nations. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. A rough estimate says patients over 65 already make up more than one-third of all admissions, though we don’t have exact numbers. Because of the slow recovery they stay longer than younger patients. Many seniors are already positioned precariously between independent living and resource crunch. They are weakened by multiple chronic diseases and medications. “One bad hospitalisation can tip them over the edge, and they may never return to normalcy.”, cautions Soumya Nair.  

In our health-care system, primarily hospitals are at the centre, and the disadvantage is that there is an inward focus of one part of health care instead of the entire system. With a shortage of primary care physicians who specialise in geriatrics, it is challenging to get hold of a physician to get quality, timely care, making hospital utilisation preferable. The advantAGE Care Home model  which we want to espouse, involves nurses and care coordinators to be available for management of chronic conditions between physician visits. Utilising a team of non-physician professionals to address care issues and concerns increases accessibility to more comprehensive primary care services. This advantAGE Care Home model, time tested by our care homes has been shown to reduce hospitalisations drastically, improve management of chronic conditions, and cost effective in health-care spending. Here, we suggest to  reduce heavy dependence of tertiary care set-ups in the treatment of infirm older adults and rather we accept the futility of active interventions. Considering our experience, it is recommended that all primary care providers offer the advantAGE Care Home model so all infirm older adults can experience timely, quality care to live a healthier, more satisfying life. This model exists in few countries and is very successful in mitigating the suffering. 

Potentially avoidable hospitalisations are described as unnecessary hospitalisations despite the possibility of outpatient treatment . These hospitalisations can also be due to unnecessary or arbitrary practices. These hospitalisations can be seen in all age groups but it is fatal in many older adults because of the co-morbidities. The practice of reducing (avoiding) the hospitalisation of the infirm elders has started to take an important place in the health policies of developed countries in recent years. Because unintended consequences such as medical errors, nosocomial infections, delirium, patient falls, and nutritional issues can often develop in the elderly admitted to the hospital, and cognitive and functional losses after discharge can be unavoidable. Other than the health issues, hospitalisations bring untold miseries and financial burdens to the patients and their families.  It is possible that a good care plan for the elderly can prevent most hospitalisations, and thus, it would be possible to get rid of unnecessary expenditures, which could affect the limited resources of the family. Again, increased health expenditures affect the health system of a country the most.

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