The baby boomer population is growing older and the healthcare system must adjust to accommodate their needs and reactions, which are different from those of younger patients.
• Case managers should start discharge planning early in the stay, take the time to get to know older patients, and include family and caregivers in the discharge plan.
• Keep in mind that seniors are frustrated because they may have trouble with vision, hearing, and mobility, and are concerned about losing their independence. Have patience and treat them with respect.
• Sit down when you talk to patients, gear the discharge instructions to their healthcare literacy, and connect them with a case manager in the community, either at their Medicare Advantage plan or an organization like the Area Agency for the Aging.
You may have already noticed a change in the demographics at your hospital. The over-65 baby boomer population is increasing daily, and two-thirds of this ever-growing population has two or more chronic conditions, according to the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Health.1
The U.S. Census Bureau estimates that the population of people age 65 or older hit 50 million in November 2016 and will reach 70 million by 2030. That’s a lot of potential hospital patients. But you can’t just treat them like you do younger patients, say healthcare professionals with expertise in geriatric issues.
“All of us in healthcare should recognize senior patients have different needs and different reactions from those of younger patients, and we need to adjust our interventions to take the difference into account and ensure that they get the services they need,” says Michelle Moccia, RN, DNP, ANP-BC, CCRN, Senior ER Center program director at St. Mary Mercy Hospital in Livonia, MI.
For instance, some elderly patients do not show the same symptoms as younger patients do for some conditions, Moccia says. Older patients may experience weakness or symptoms of delirium due to a urinary tract infection, something that is not common in younger patients. Or, a patient with pneumonia may not exhibit common symptoms like coughing and fever.
Many senior patients may be unable to tolerate a normal dose of pain medication, Moccia points out. “We start low and go slow and check back to see if the patients feels the effects. We don’t want them to experience a fast, cumulative effect and become very drowsy,” she says.
St. Mary Mercy Hospital offers an ED for senior care, designed to accommodate elderly patients and staffed by clinicians with expertise in geriatric care. (For details, see related article in this issue.)
Case managers are in a good position to see that their elderly patients get the kind of services they need, says John Gutzwiller, BS, RN, managing consultant for Berkeley Research Group.
“Case managers see the entire picture of the patient and can be the eyes and ears of the multidisciplinary team. They should attend multidisciplinary rounds every day and point out the special needs of the seniors,” he says. Then, keep a keen eye on patients to make sure they are getting the kind of care they need to recover as quickly as possible, he adds.
Multidisciplinary rounds are vital for all patients, but especially for the elderly, he says. The rounds always should include a pharmacist to perform medication reconciliation and ensure optimal dosages. Many elderly patients have polypharmacy issues, a large contributing factor to readmissions, Gutzwiller says.
The Transitional Care program at Baylor Scott & White Health has found that medication issues often cause readmissions, says Alexis S. Early, LMSW-IPR, ACM-SW, transitional care social worker at the Dallas-based health system. Patients don’t fill their prescriptions, or they stop taking antibiotics as soon as they feel better. Seniors may misunderstand their medication instructions or take their old medication along with the new and wind up back in the hospital, she adds.
“A pharmacist on the team can explain the medication, review the instructions, and emphasize the importance of following their medication regimen. The pharmacist on our team has prevented several problems, such as someone who isn’t taking their blood thinner, doesn’t understand how to use the inhaler, or is confused about the dosage,” she says. (For details on Baylor Scott & White’s transitional care program, see related story in this issue.)
Case managers should make sure their senior patients ambulate frequently as soon as they are cleared to get up, Gutzwiller advises. “Patients should not stay in bed for long periods of time. They need to get up and move around. Some hospital staff think only physical therapists can ambulate patients, but the nurses should be getting them up as well,” he says.
When patients are in bed and sedated for several days, it takes a toll on them physically, Gutzwiller points out. Instead of going home with physical therapy and nursing help, elderly patients often become so debilitated that they must enter a skilled nursing facility or a long-term acute care hospital. If patients stay in bed, particularly if they’re taking opioids, they are at increased risk for small bowel obstructions, pressure ulcers, and other avoidable issues, he says.
Long length of stays also increases risk for the elderly, Gutzwiller adds.
“The hospital is not the safest place to be. Every day elderly patients remain in the hospital, the chance of them developing pneumonia, C. difficile, or methicillin-resistant Staphylococcus aureus infection goes up. Patients in an unfamiliar setting may get confused and that can lead to a fall. They’re much better when they can be discharged to home,” he says.
A lot of times, the children of elderly patients live in another state and don’t understand what’s going on with the seniors who are struggling to stay self-sufficient, Gutzwiller says.
“Some older patients won’t let the home health nurse in their house because they are afraid of theft,” he says.
When patients decline services in their home after discharge, they are likely to be readmitted, Early says. She recommends that hospitals establish flexible post-acute programs with a variety of interventions from which patients can choose.
Start planning the discharge for seniors as soon as they are admitted, Gutzwiller says. He recommends conducting a thorough assessment that covers activities of daily living, the patient’s support system, where the family lives, cognitive issues, and durable medical equipment.
“Most hospitals struggle with early assessments and there is a lot of reactive discharge planning on the day the physician issues the discharge orders. We need to get a snapshot of the patient’s comorbidities, deficits, and needs early in the stay if we are going to create a successful discharge plan,” Gutzwiller says.
“There are a lot of older people who end up being readmitted to the hospital with a chronic, debilitating condition and nobody addresses the need for long-term follow-up,” he adds. “Case managers have to start early to make sure their needs are covered.”
Working with seniors in the transitional care program at Baylor Scott & White was “truly an eye-opener” for Early. “Patients in the hospital would tell me everything is great at home, but after discharge I’d find out that it wasn’t so great,” she says.
Early recommends that the assessment cover finances and social support as well as patients’ physical and cognitive functions.
“Include the family and caregivers in discharge planning and be aware that patients are not going to retain all of the discharge instructions and family members may be able to give a clearer picture of the patient’s situation,” she says.
When the staff at LIFE Geisinger (Living Independently for Elders) conduct intake interviews, it’s not unusual for the potential participant to assure the staff that everything is going well at home while the family members in the room shake their heads and roll their eyes, says Robert McQuillan, MHA, NHA, associate vice president of LIFE Geisinger/skilled nursing facility operations in Pennsylvania.
“Seniors are embarrassed to say they can’t take care of themselves, and they are fearful that their family will put them in a nursing home. Some of them would rather do without the things they need than ask for help,” he adds. (For details about LIFE Geisinger, which provides support at its day center and in the home for seniors who otherwise would go to a nursing home, see related article in this issue.)
McQuillan suggests that case managers and discharge planners take a few minutes to sit down and talk to their older patients. Ask them where they want to go after discharge and how they will manage in the community, he says.
Don’t ask directly if patients can manage their regular routine. They might not be truthful, McQuillan advises. Instead, ask questions like: “Does your daughter work regular hours?” “How often does your son visit?” Get a feel for how much time somebody is in the home, he says.
Make it a point to talk to the family, McQuillan says. “The patient may be telling a story that’s not accurate,” he says.
Gutzwiller laments that case managers have to prepare so much documentation that they seldom have time to spend with patients. He urges them to find the time to get to know their older patients.
“The more time you spend with patients, especially when they are older and more vulnerable, the less anxious they will be and the quicker they will recover,” he says.