Quality and Innovations for Caring Hospitalized Older Persons in the Unites States

Abstract

Older persons are occasionally acutely ill and their hospitalizations frequently end up with complications and adverse outcomes. Medicare from U.S. federal government’s payment resource for older persons is facing financial strain. Medicare highlights both cost-saving and high quality of care while older persons are hospitalized. Several health policy changes were initiated to achieve Medicare’s goals. In response to Medicare’s health policy changes, U.S. hospital environments have been changed and these resulted in hospital quality measurements’ improvement. American seniors are facing the challenges during and around their hospital care. Several innovative measures are suggested to overcome these challenges.

Forty percent of hospitalized persons in the United States are older persons whose ages are 65 or older. Since aging population is in increasing, more portions of hospital care are devoted to older persons [1]. Like child and adolescent care, caring older persons should be approached more cautiously. Acutely ill older persons may experience more often complicated hospital courses and prolonged hospital stay than any other age groups [2, 3]. In response to recent federal government’s recent fiscal cliff, Medicare has been challenged to reduce their costs [4]. Moreover, high-quality of care has been highlighted in caring for this population, in attempts to improving safety. This article will review three aspects of acutely ill older persons in U.S.: 1) this population’s unique characteristics: vulnerability and common adverse outcomes, 2) hospital environmental changes and challenges in response to quality-emphasizing health care policies, and 3) innovative measures to achieve high- quality and safe care in this population.

Vulnerability of acutely ill older persons

Hospital-associated disability

The definition of disability for acutely ill older persons is decline of physical function [5]. Disability occurs approximately one-third of hospitalized older persons [6]. New or additional disability during or after hospital stay has been known to be associated with higher likelihood of nursing home admission and mortality [6, 7]. Occurrence of hospital-associated disability in acutely ill older persons may result from their reduced functional reserve and vulnerability to acute illness [8]. Hospitalization is known as one of the strongest predictors of developing disability than their underlying disease [9]. During hospitalization for acute medical illness, their muscle strength is relatively reserved, but endurance is significantly deteriorated [10].

Common causes of hospitalizations

The most common causes of hospitalization among Medicare recipients are heart failure, pneumonia, and cardiac dysrhythmia [11]. The oldest Medicare recipients (aged 85 years and older) are commonly hospitalized for septisemia, urinary tract infection, hip fracture, and the additional causes as noted among younger Medicare recipients [11].

Common adverse outcomes of hospitalized older persons

Delirium

Delirium is a state of an acute confusion, characterized by impaired attention and fluctuations in the course of confusion between days and nights. Delirium occurs in 50% of the hospitalized older persons in the intensive care unit and approximately 25% of those in general medicine wards [12]. In hospitalized older persons, delirium increases the risk of prolonged hospital length of stay (LOS) and hospital-associated disability [12]. Moreover, it has been shown to increase the 30-day hospital readmission rate and mortality [12]. Thus, early detection and appropriate treatment of delirium is essential in caring for hospitalized older persons [13].

Falls

Approximately 10% of hospitalized older persons experience a falling episode during their hospital stay [14]. The risk factors of a fall are usually multifactorial. Existing interventions may not reduce falls in hospitalized older persons, as shown in a series of previous studies [15]. Another issue related to falls is that hospitals cannot receive additional payment from Medicare or charge Medicare enrollees for treating hospital falls and related injuries [16]. Therefore, fall prevention is crucial in providing high-quality as well as cost-effective care.

Pressure ulcers

Pressure ulcers occur approximately 5% of hospitalized older persons [17]. Factors that contribute toward pressure ulcers are prolonged bed-ridden status (i.e., intensive care unit stay), no use of ambulatory devices, frequent ‘NPO (nothing by mouth)’ orders, urinary incontinence with use of diuretics, and delirium. Pressure ulcers are most frequently located in the coccyx, hips, and heels. As with falls since 2008, hospitals cannot receive additional payment from Medicare or charge Medicare enrollees for treating hospital-acquired pressure ulcers either stages III or IV [16].

Malnutrition

Malnutrition may result from delirium, frequent NPO orders, diet restrictions (low sodium diet or fluid restriction), digestive symptoms related to acute illness or adverse drug effects (e.g., anti-cholinergic effects), inconvenience of being hooked to catheters, unavailability of dentures, and delirium. Hospital-associated malnutrition can be reduced by oral feeding in place of tube feeding or parenteral nutrition. Nutrition treatment other than oral feeding may not improve long-term survival [18].

Infections

The epidemiology of hospital-acquired infections in older persons is different from that of other age groups. Among these infections, hospitalized older adults are particularly vulnerable to diarrhea and pneumonia. At the time of diarrhea in older persons during their hospital stay, care personnel should consider the possibility of antibiotic-associated diarrhea. They should test patients for Clostridium difficile, the main cause of this type of diarrhea, and implement immediate contact isolation to prevent the spread of this pathogen to other patients. Hand washing is the easiest and most effective measure to prevent the spread of this pathogen in hospitals. Another highly prevalent infection, hospital-acquired pneumonia (HAP), generally occurs 48 hours after hospital admission. HAP is common in older persons with swallowing difficulty, that is, those with a history of stroke, patients with advanced dementia, and those on a mechanical ventilator in the intensive care unit [19]. The occurrence of HAP can be effectively reduced by providing feeding assistance with patients in the head-up position, dietary modifications, and patient assessment and management by a speech and language pathology. Yet another common infection among hospitalized older adults is urinary tract infection, the risk of which may be increased among patients with a Foley catheter or other urinary catheters [20]. To reduce the risk of hospitalized-acquired urinary tract infection, it may be effective to assess self-voiding at the earliest when an indwelling urinary catheter is inserted at hospital admission. Further, care providers should ensure that catheters are not used unnecessarily; for instance, an indwelling urinary catheter is not warranted when urinary output is the key measure of hospital treatment goals in diuretic treatment or treatment for acute renal failure.

Adverse drug events

Adverse drug events refer to the effects of inappropriate medication administration, monitoring, drug-drug interactions, or drug clearance changes due to acute medical illness [21]. These events may be reduced by the use of electronic medical records and facilitation of communications between primary care physicians and hospitalists, as shown in recent studies [22].

Early hospital readmission

Ever since the diagnosis-related group (DRG) system was implemented 30 years ago, hospital LOS has decreased [23]. Over the same period, there has been an increase in the 30-day hospital readmission rate with the same primary diagnosis, a key indicator of hospital performance [24]. These findings have attracted attention, since hospitals have been under pressure to keep timelines set under the DRG system. Further, there is a trend of patients being discharged from hospitals “quicker and sicker” [25]. Medicare releases each hospital’s 30-day readmission rates for AMI, heart failure, and pneumonia to the public with comparisons with the U.S. national average rates [26].

Quality of care in hospital care setting

General principles of quality of care

Donabedian, a pioneer in developing a framework for evaluating care quality, proposed that the quality of health care can be measured by observing structure, processes, and outcomes [27]. The framework has been used as a basis for defining quality. There has been considerable debate about whether processes or outcomes should be assessed as measures of quality of care [28, 29]. According to the aforementioned theoretical framework, healthcare quality must be assessed in conjunction with both structures and processes [30, 31], but, in general, process measures are better indicators of quality of care because processes are common, under the control of health professionals, and more rapidly be altered [31]. However, process measures suitable for assessing quality should be clearly linked to evidence of improved outcomes [31].

Many studies have investigated the process aspects of quality care, suggesting that process improvement improves process quality and communication [32] and reduce errors, variation [33], and operating costs [34]. To achieve better outcomes, initiatives toward process improvement should be initiated by quality improvement tools including clinical practice guidelines, critical pathway, and continuous quality improvements [35].

Key challenges in quality measurement are the absence of a single definition of quality that can be applied to management, marketing, or health care plans. In fact, a study identified more than 100 definitions of quality of care in the literature [35]. However, the Institute of Medicine proposed the following all-inclusive definition of quality applicable to health care systems: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [36].

With its various meanings, however, it is essential that quality needs to be viewed from both a micro and macro perspectives. The micro-view focuses on services at the point of delivery and their subsequent effect. This dimension of health care quality encompasses the clinical and interpersonal aspects of care delivery, as well as quality of life. The macro-view looks at quality from the standpoint of populations. It reflects the performance of the entire health care delivery system [37].

Emerging quality of care in hospital care

The hospitals industry is on a never ending journey of improving quality of care, which is one of the most critical national and international health policy issues. Ever since the 2001 report of the Institute of Medicine, Crossing the Quality Chasm, there has been a growing demand for the establishment of monitoring and tracking processes to evaluate the health system, in terms of the six principles advocated in this report: effective, safe, patient-centered, timely, efficient, and equitable [36].

In order to meet the need for measures of quality, the Agency for Healthcare Research and Quality (AHRQ) released in 2003 the National Healthcare Quality Report (NHQR), which includes performance on a broad set of 57 measures [38]. This report provides data on the trends in the quality of services for several clinical conditions [38]. In addition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented evidence-based standardized measures of performance in over 4,000 accredited hospitals. The measures were designed to track hospitals’ performance over time and encourage quality improvement through quarterly feedback in the form of comparative reports to all participating hospitals [39].

Quality measures have become an important outcome of Medicare’s reporting on the performance of American hospitals. Many studies substantiate the notion that quality measures can be used to encourage improvement in hospitals and to monitor hospitals’ performance, as called for by the Institute of Medicine [40, 41]. They provide strong evidence that making performance information public stimulates quality improvement in the areas where performance is reported to be low. Quality improvement efforts appear to be significantly greater in hospitals whose reports are for private use only. Thus, there is added value in making performance information public [41].

Quality of care and patient outcomes

National efforts to track hospital quality have shed light on areas where hospitals have made significant quality gains [42]. For example, the median 30-day mortality rate for acute myocardial infarction (AMI) decreased from 19.9% to 19.4% over the last four years [43]. In addition, hospitals achieved very high levels of performance on many of the Joint Commission’s core measures, including AMI, pneumonia and surgical care, in 2010 [44]. Moreover, hospitals have been found to provide evidence-based AMI treatment more than 98% of the time, a notable increase from 87% in 2002 [44].

These improvements in inpatient care have also produced better patient outcomes. From 2004 to 2008, the inpatient mortality rate for hospital admissions with heart attack decreased significantly overall, as well as for each age group and geographic location [45]. This improvement is tied to timeliness of heart attack care; for instance, from 2004 to 2008, an increasing number of heart attack patients received percutaneous coronary intervention within 90 min and fibrinolytic medication within 30 min [45].

Medicare’s hospital policy changes

Many Medicare’s hospital policy initiatives has been proposed and prepared, however, its ultimate never-ending goal is to increase quality of patient care and reduced costs and we need continually pay attention for various attempts.

Linking hospital outcomes to reimbursement: Hospital-Acquired Conditions

In response to the Deficit Reduction Act in 2005, Medicare listed “preventable” hospital-acquired conditions (HACs) since 2008 [46]. As of 2013, there are 13 HAC’s, including new-onset pressure ulcers and in- hospital falls/trauma [16]. Hospitals cannot receive additional payment from Medicare or charge Medicare enrollees for treating these conditions. The rate of HAC’s has gradually declined, but, this trend may not be attributable to this payment policy [47]. The HAC policy has had a direct financial impact on only 2,991 discharges, saving Medicare $19 million in decreased payments to hospitals ($6,478 per discharge) in year 2011, according to the Research Triangle Institute [48].

Hospital outcomes open to the public: Hospital Compare

Since 2005, Medicare’s public reporting initiative, called “Hospital Compare”, has provided data on hospitals’ performance on quality measures for three medical conditions (AMI, heart failure, and pneumonia). However, this public reporting mechanism has not resulted in any additional decrease in mortality beyond the existing downward trends [49].

Value-based purchasing and bundle payment programs

Shifting to a culture of shared accountability for patient and community outcomes and costs will be a journey. In order to both improve care quality and reduced costs, health policy initiatives have been theorized and attempted in U.S. U.S. needs a health system that achieves better health and better care at lower costs. Value-based purchasing (VBP) is a potentially important tool for achieving these goals. It has been portrayed as a pillar of quality improvement in a market-based health care system [50–53]. Under this paradigm as it was originally conceived, employers and other large purchases of health care are expected to contract with health plans on the basis of quality and cost [54]. Other key elements of VBP include the promotion of quality improvement in negotiations with health plans and quality information to employees [54]. A number of high-profile, employer-based efforts have been recently made to play an active role in improving the quality of care, with a more direct focus on providers of health care rather health plans alone [55].

30-day hospital readmission rate

Medicare has attempted to implement a readmission reduction program, since hospital readmissions are receiving increasing attention as a largely correctable source of poor quality of care and excessive spending [56]. Readmission rates have also emerged as a quality marker in public reporting programs. According to a 2009 study, nearly 20% of Medicare beneficiaries are rehospitalized within 30 days after discharge, at an annual cost of $17 billion [57]. Therefore, the Affordable Care Act (ACA) created a financial penalty for “excessive” readmissions at hospitals. As per this view, Medicare calculates the average risk-adjusted, 30-day readmission rates for patients with AMI, pneumonia, or heart failure by using claims data. If a hospital’s risk-adjusted readmission rate for such patients exceeds that average, Medicare penalizes it in the following year for all Medicare admissions. This penalty is made in proportion to the hospital’s rate of excess rehospitalizations of patients for the target conditions. Medicare readmissions-penalty policy has drawn the attention of hospitals and stimulated similar approaches among other payers. This part of the law has stimulated hospitals, professional societies, and independent organizations to invest substantial resources in finding and implementing solutions for the readmissions problem [58]. However, their efforts to reduce the readmission rate are associated with program costs and spillover effects that decrease hospitalization rates for non-targeted diagnoses. These can be problematic because hospitals, unless are at maximum capacity, face two major economic disincentives to reducing readmissions for the specified diagnoses: the direct costs of the program itself and decreased revenues resulting from successful interventions [56]. Although these effects are desirable outcomes for patients and payers, they have a detrimental effect on hospitals’ finances. If a penalty is more than offset by program costs and lost re-hospitalization revenue, hospitals would be better off financially if they maintained the status quo [56].

Episode-based payment and patient-centered care

To remedy the shortcomings of Medicare’s readmission reduction program, a prospective payment system based on episodes of care proposed recently [56]. Episode-based payment is a system— in which reimbursement for medical services delivered during defined episodes of care is bundled together [59] such that episode payment encompasses the services delivered not only during the hospitalization itself but also during pre-hospitalization and post-hospitalization delivery of care (e.g., outpatient care, ancillary care, or visits to the physician office) [60]. The Medicare Payment Advisory Commission has noted that a bundled payment that includes all services rendered during an episode of care creates an incentive for providers to deliver “the right mix of services at the right time” [61]. The FY2010 budget from the Obama administration proposes episode payment bundles based on inpatient hospitalization as a means of reducing healthcare costs [60]. The bundle includes the inpatient, outpatient, and physician services provided in the treatment of a healthcare problem over a specified period and it provides strong financial incentive for efficiency. Expansion of the scope of payment bundle shifted financial risks from Medicare (payer) to the hospital (provider). As per the definition of episode care, providers need to be patient-centered rather than disease-centered. An episode payment system must include not only a recognition of the acute problem(s) that precipitated a patient’s hospitalization but also the patient’s overall burden of chronic disease [60].

Ambulatory care sensitive conditions (ACSCs)

In 1994, Agency for Healthcare Research and Quality (AHRQ) launched ACSCs representing conditions for which hospitalization could be avoided if the patient receives timely and adequate outpatient care [62]. Many factors influence the quality of outpatient care, including access to care and adequately prescribed treatments, once care is obtained. In addition, patient compliance with those treatments and other patient factors may play a role. However, 5 of 16 ACSCs are increasing since launching policy [63]. Low-income and ethnic/racial minority older persons pose high risk of being hospitalized due to ACSCs [64].

Meaningful use of electronic health record (EHR)

The Medicare and Medicaid EHR Incentive Programs are intended to disseminate EHR to eligible and critical access hospitals [65]. These programs provide financial incentives for the “meaningful use” of EHR resulting in communication facilitation among health care providers and reducing medical errors. Disseminating EHR to hospitals is expected to improving quality and safety for caring acutely ill older persons. As noted, many policy initiatives have been proposed and prepared; however, the constant underlying goal is to increase quality of patient care and reduced costs, and we need to continually innovate to achieve this. Examples of such innovations will be examined in the next section.

Hospital environmental changes

In response to Medicare’s policy changes, hospital environment has been changed over two decades. Hospital environment changes led to prioritizing high quality of care and safety. As discussed in the section 4c, Joint Commission’s core quality measures achieved improvement [43–45]. Also, hospital environment changes led to new trends in hospital service utilizations and challenges in caring hospitalized older adults.

Trends in hospital service utilizations

The hospitalization rate of Medicare enrollees has decreased over the past decade. During the same period, the average hospital length of stay (LOS) for Medicare enrollees decreased from 8.4 days to 5.4 days [23]. In the last few years, health service utilization has shifted from inpatient to outpatient hospital services [66]. From 2004 to 2011, the number of outpatient hospital services used per Medicare enrollees increased by 34% and the number of inpatient hospital admissions per Medicare enrollee decreased by 8% [67]. At present, as many as 1 out of 6 older persons in a general medical nursing unit are under observation status. These individuals may have unique needs that are taken into account by hospital care providers (e.g., difficulty in obtaining/administering home medications). Providers should also consider the fast pace at which diagnostic services are provided [68].

Trends of Medicare expenditures

In 2012, Medicare Part A inpatient accounted for 24% of total Medicare expenditure, while this figure was 32% in 1992 [69]. However, the amount of expenditure per Medicare enrollee for acute hospital care increased from $2,107 (1992) to $3,778 (2009) [70]. These trends may be linked to implementation of the DRG system for Medicare Part A enrollees. This system provides is a time frame of hospital care and has been used for deciding reimbursement from Medicare to hospitals. For example, the DRG LOS for community-acquired pneumonia with complications is 5 days. When hospital LOS for this DRG is 7 days, the hospital may not receive reimbursement from Medicare for the expenditure related to days 6 and 7.

Geographic variations of hospital care utilizations

The rate of hospitalization varies by geographic location in America. The rate of hospitalization per 1,000 populations is 75.7 in Alaska and 212.9 in Washington DC [71]. The variation in the utilization of acute care hospitals provide an opportunity to pose questions about shortages to avoid acute care needs, and improve health outcomes. Perhaps, the health care systems’ marketing (e.g., supplier-induced demand), bed availability, and providers’ practice patterns that relate to hospital use differs from one region to another [72].

Challenges in caring hospitalized older adults

Challenges in continuity of care

Much of acute care provided to older Americans has shifted from primary care providers to hospital-based providers. Although acutely ill older persons are seen by their primary care providers and are sent to acute hospitals for admission, these older persons are cared during their hospital stay by hospitalists who never met them previously. Most hospitalists may not follow up with these older persons when they are discharged from hospital. This phenomenon is called as the “divorce of primary care and hospital care [73].

Frequent procedures during hospital stay

Acutely ill older persons are often being prepared for or recovering from interventional or surgical procedures. Procedure-centered hospital care increases the frequency of NPO orders, restricted activity, and hooking to catheters, resulting in sleep and eating disturbances [74].

Hospital, site of starting care transitions

Much of the care provided during hospital stay is intended a first step of care plans that are be complete at other sites (home, rehabilitation facilities, and skilled nursing facilities) [75]. This care planning is often not completed during the hospital stay. Thus, it is important to coordinate the transition from the hospital to the next site of care.

Lack of expertise work force

The greatest challenges in the future of geriatric care will probably be encountered in providing patient-centered care with limited resources. Older persons have diverse needs and require high-quality care during acute illness. This care should be provided by a competent workforce, in a manner that keeps the patient safe. However, shortage of geriatricians or geriatric nurses is likely, especially in the face of the aging society [76]. Hospitalized older persons are increasingly receiving care provided by hospitalists [77]. The Association of American Medical Colleges estimated there to be approximately 28,000 actively practicing hospitalists in America in 2009 [78]. There are approximately 6,700 board-certified geriatricians in America [79]. It is not entirely clear if these geriatricians are primarily based in hospital or in outpatient settings. The limited access to geriatricians in acute care hospitals requires thoughtful review of how we use well-trained work force to incorporate the principle of geriatrics into caring hospitalized older persons.

Questionable effects of Medicare’s health policy changes

Although hospital quality measures improved progressively, it is hard to confirm that Medicare’s health policy changes contributed to improving hospital quality measures. As discussed in the section 5a, studies reported that hospital quality measures’ improvement did not result from Medicare’s health policy changes [47, 48]. More Medicare’s health policy changes would be examined whether these changes contribute to hospital quality of care improvement.

Innovative measures for hospitalized older persons

Innovative care for acutely ill older persons should not be limited to an individual hospital site. Models of care will need to be implemented to (1) avoid hospital admission, (2) prevent re-hospitalization, and (3) coordinate health services in an increasing complex health care system [80].

Hospital care

The Acute Care for the Elderly (ACE) tracker and e-Geriatrician are examples of software capable of identifying hospitalized older persons at a high risk for a complicated hospital course, transition to nursing home, early hospital readmission, and mortality [81]. Both are especially effective tools for identifying patients at high risks early and electronically; thus, these tools can be used by hospitals to provide high-quality care without changing their structure or actually hiring geriatrician expertise. Intensive rehabilitation therapy during hospital stay was reported to prevent older persons from hospital-associated disability and subsequent transition to nursing home [82]. Interdisciplinary care was proven to facilitate communications among health care providers and subsequently to result in less transition to nursing home (decrease by 60%) and shorten hospital length of stay (decrease by 0.7 days). Yoo JW, Nakagawa S, Kim S. Delirium and transition to a nursing home of hospitalized older adults: a controlled trial of assessing the interdisciplinary team-based “geriatric” care and care coordination by non-geriatrics specialist physicians [83]. ACE unit-based care proved efficient care process through cost-saving effects [84]. Hospital administrators are hesitant to make investment to build a specific medical unit or to hire geriatrics expertise to run this unit. To overcome this barrier, business strategies are up-front necessary.

Emergency care

A series of innovative models were recently introduced in this domain. For instance, the application of tele-medicine technology to improve communications between the emergency care team and community-dwelling elderly adults may reduce unnecessary hospital admission by facilitating communication among health care providers at different sites [85].

Transitional care

Transitional care, as a continuation of hospital care, is closely linked to aspects of home health care such as medication management. Transitional care emphasizes the need for longitudinal care among vulnerable older persons recently discharged from a hospital. Transitional care is particularly important to reduce early hospital readmission [86].

Program of All-inclusive Care for the Elderly (PACE)

PACE is an example of patient-centered medical care. It has been reported to lower costs and increase patient or caregiver satisfaction [87]. However, this program is limited to persons eligible for both Medicare and Medicaid even though it involves interdisciplinary care and free provides transportation services.

Skilled nursing facility (SNF)

More than 1.7 million Medicare enrollees utilized SNF services and spent $31.3 billion for this care in 2011 [88]. Medicare enrollees who stay longer than three nights at hospital are eligible for being cared for at a SNF at least 20 days. After day 21, they are responsible for co-payment each day. To reduce unplanned and unnecessary hospital admission, interventions of improving communications have been conducted to improve communications between the SNF and hospital [89].

Palliative/hospice care

The use of formal end-of-life services has increased over the last decade. In 2009, 42% of Medicare decedents utilized hospice care services in the last 30 days of their lives compared to 19% in 1999 [90, 91]. Further, compared to 1999, fewer Medicare decedents died in the hospital in 2009 [91]. Many of those who received end-of-life care had recently been in an intensive care setting [91]. Integrative palliative care screening, as integrative care, may prevent prolonged hospital stay and death at hospital intensive care units [92].

Summary

America faces important challenges in caring for acutely ill older persons. Medicare is putting more emphasis on quality and is linking quality to payment mechanisms. We reviewed three parts of acutely ill older persons in U.S.: 1) vulnerability and common adverse outcomes, 2) hospital environmental changes and challenges in response to quality-emphasizing Medicare’s hospital care policies, and 3) innovative measures to achieve high-quality and safe care in this population. Our review helps readers having insights about multiple aspects of caring acutely ill older persons in American hospitals.