A geriatric rehabilitation and assessment unit in a community hospital

This report describes functional status at admission, discharge, and six months later for 100 elderly persons treated at a community hospital assessment and rehabilitation unit. The goal of the unit is to prevent institutionalization of frail elderly persons considered at risk for nursing home placement. Characteristics of the first 100 admissions include the following: average age, 79 years; female, 77 per cent; length of stay, 23 days; average number of admitting diagnoses, 3.4. Ninety-one new diagnoses of treatable conditions were made. On admission, 81 per cent of patients were confined to bed or chair or needed assistance with ambulation, compared with 27 per cent at discharge and 22 per cent at six months. Activities showing significant improvement include dressing, housekeeping, use of toilet, and ambulation. At six months, 15 per cent had died, 67 per cent were living in the community, and 19 per cent were institutionalized. It is concluded that care at the geriatric unit probably resulted in improved function and decreased nursing home placement.     

The Functional Autonomy Measurement System (SMAF): a measure of functional change with rehabilitation

The Functional Autonomy Measurement System (SMAF) is an instrument developed for the measurement of needs of the elderly and the handicapped. As this study shows, it can be used to demonstrate progress during rehabilitation. Of the 94 patients admitted and discharged from a 22 bed acute/rehabilitation ward for the elderly, 78 were discharged home or to their original accommodation, 7 died in hospital and 9 were transferred to a continuing care ward or a nursing home. The mean total score (admission vs. discharge: 18.06 vs. 9.18, P < 0.0001) as well as the score for subsections of Activities of Daily Living (ADL) (admission vs. discharge: 15.69 vs. 8.15, P < 0.0001), Communication (admission vs. discharge: 1.01 vs. 0.5, P < 0.0001) and Mental Function (admission vs. discharge: 1.29 vs. 0.64, P < 0.0001) showed significant improvement in the 78 patients who were discharged back to their original accommodation. Patients who died or required placement into a continuing care bed or nursing home showed no change in mean scores with treatment. The inter-observer agreement between two nurses and a doctor showed that the minor modifications to SMAF did not significantly affect the instrument.     

Geriatric consultation: a functional approach

Eighty-one geriatric consultations conducted on behalf of 71 patients (mean patient age 78 years, range 59-99; M34 , F37 ) at San Francisco General Hospital were analyzed. Seventy-nine per cent of requests were for medical or psychiatric evaluation; 19 per cent social; and 3 per cent rehabilitation. The authors made 50 new diagnoses, many of which identified conditions that adversely affected patients' functional levels, including cardiovascular disorders (8), medication effects (8), malnutrition (7), misdiagnosis of dementia (7), and gait disorders (4). Recommendations focused on treating those conditions whose alleviation could improve self-care ability: medication adjustment (62 per cent), management of dementia, delirium, or depression (59 per cent), rehabilitation (32 per cent), and treatment of malnutrition (30 per cent). Geriatric consultations resulted in rerouting 18 patients (51 per cent) from nursing homes to lower levels of care. Fourteen of these eventually returned home. By focusing on reversible conditions that affect patients' functional levels, geriatric consultation can improve the management of elderly patients and prevent unnecessary nursing home placement.     

Predictors of two-year post-hospitalization mortality among elderly veterans in a study evaluating a geriatric consultation team.

OBJECTIVE: To determine predictors of 2-year post-hospitalization mortality in a cohort of elderly hospitalized patients originally assembled to assess the impact of a Geriatric Consultation Team (GCT). DESIGN: Two-year follow-up of an inception cohort. SETTING: University-affiliated tertiary care VA Medical Center. PATIENTS: One hundred sixty-seven veterans age 75 or older discharged following hospitalization on medical, surgical, or psychiatry services but not intensive care units. INTERVENTION: None specifically studied here though cohort was previously part of randomized control trial of a Geriatric Consultation Team. MEASUREMENT: Mortality during 2 years of post-hospitalization follow-up. RESULTS: Two-year post-hospitalization mortality was 28 percent with no difference between the original GCT and control groups. For the entire sample, age, mental status, admission or discharge ADLs (but not change in ADL status), number of admission problems, number of discharge diagnoses, and discharge site were significant predictors of mortality in univariate analysis. Only discharge ADLs and discharge site remained significant in multivariate analysis. CONCLUSION: Measures of ADLs during hospitalization are stronger predictors of mortality following hospitalization than disease diagnoses. Impaired ADLs and placement other than at home are significant predictors of mortality, suggesting that the decision for nursing home placement contains other independently predictive information within it and/or that the subsequent nursing home period produces excess mortality. As had been indicated in short-term follow-up, there was no survival advantage for the Geriatric Consultation Group.     

Nursing home candidates: hospital inpatient trial to identify those appropriately assignable to less intensive care

Primary care physicians are often confronted with demands that elderly patients be institutionalized. Patients who appear to have no new medical problems present a therapeutic dilemma. Should they be admitted to a general hospital or should they be placed directly in a nursing home? This longitudinal prospective study involved 29 consecutive elderly patients judged to be in need of nursing home placement but who were without medical indications for admission. They were assessed and treated in a 30-bed ward of a general hospital. The mean length of stay was 19 days. Of the 29 patients, 8 (24 percent) benefited from the hospitalization; the outcome was placement and retention at a level of care less intensive than that in a nursing home. On admission to this special ward, the presence of 2 of the following 3 characteristics identified the patients who would benefit from this preplacement hospitalization (with 75 percent sensitivity and 86 percent specificity): 1) a score of A or B (Katz Scale) for activities of daily living; 2) a score of 3 or fewer errors on the mental status scale (Pfeiffer); and 3) the presence of family members willing to care for the patient, although unable to do so at the time of admission. These 3 factors constitute a screening tool to differentiate elderly patients who will benefit most under a regimen of intensive rehabilitation from those who will be inevitable recipients of long-term care.     

Urinary incontinence in the geriatric population of an acute care hospital

To determine the incidence, prevalence, and duration of urinary incontinence, a survey was undertaken of all patients aged 65 and over admitted to a university hospital during a six-week period. The daily prevalence of incontinence, which was 19 per cent for the entire study population, was highly variable from one nursing unit to another. Twenty-five per cent of those on the acute care general medical units and 17 per cent of those on the general surgical units were incontinent on any given day. The burn unit had the highest daily prevalence of incontinence (75 per cent). The incidence of incontinence per hospital stay, which was determined for the 315 patients who were followed from admission to discharge, was 19 per cent. Of the 348 patients discharged to home during the survey period, 10.9 per cent were incontinent within the 24 hours prior to leaving the hospital, and, of the 27 referred to another institution, 48 per cent had been incontinent during that interval. The authors conclude that a substantial proportion of geriatric patients are incontinent at some stage during their hospital stays.     

Trends in Hospital Discharge Disposition for Elderly Patients with Infective Endocarditis: 1993 to 2003

OBJECTIVES: To examine hospital discharges of elderly patients hospitalized with infective endocarditis (IE).
DESIGN: A retrospective analysis of hospital discharges from 1993 to 2003.
SETTING: The Nationwide Inpatient Sample (NIS), which approximates a 20% sample of all U.S. acute care hospitals.
PARTICIPANTS: All patients aged 65 and older with a primary or secondary International Classification of Diseases, Ninth Revision , diagnosis code for IE were included.
MEASUREMENTS: The main outcome measures were in-hospital mortality and, for survivors, discharge disposition: to home (with home health care) or to a facility.
RESULTS: Hospitalizations for IE increased 26.0% over the 10-year period, from 3.19 per 10,000 elderly patients in 1993 to 3.95 per 10,000 in 2003. Over the study period, a trend toward increasing discharge to nursing home and decreasing discharge to home and home health care was evident. Discharge to home for survivors decreased from 57.7% to 35.0% over the study period, whereas discharge to nursing facilities increased from 27.7% to 44.3%. Over the 10-year study period, elderly patients hospitalized with IE were 2.3 times as likely to be discharged to a facility as to home.
CONCLUSION: Hospital discharge dispositions have changed for elderly patients admitted with IE. Changes in the patient's age, severity of illness, or comorbidities do not explain these trends. Financial incentives are the most likely factor influencing the substitution in discharge dispositions for elderly patients with IE.     

Academic affiliation with a nursing home. Impact on patient outcome

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.     

The Sepulveda VA Geriatric Evaluation Unit: data on four-year outcomes and predictors of improved patient outcomes

Data from its first four operating years indicate that the Sepulveda VA Geriatric Evaluation Unit is having consistent beneficial effects on patient care. These benefits include improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. However, not all patients benefit equally, and differences between patient responses highlight the need to select those who will benefit most from relatively costly Geriatric Evaluation Unit services. Discriminant and regression analyses were performed on 98 consecutive patients to determine which patients admitted to the Geriatric Evaluation Unit would show greatest improvement in terms of placement, functional status, one-year survival, and living location, and which patients would be treated most efficiently in terms of length of stay. Patient characteristics on admission significantly associated with discharge home included a relatively high functional and cognitive status, the absence of an unstable medical problem, and not being expected to need nursing home placement by the referring physician. The latter two factors alone predicted actual placement location on the next 101 patients admitted to the Geriatric Evaluation Unit with high predictive accuracy (88.5 per cent). Factors predictive of patients whose functional status would improve on the Geriatric Evaluation Unit included absence of an unstable medical problem and being over 75 years old (predictive accuracy was 82.5 per cent). Two major factors associated with long patient stays on the Geriatric Evaluation Unit were low functional status scores and not living in own home or with family. These analyses indicate criteria that may be useful in selecting patients for inpatient geriatric evaluation and rehabilitation programs.     

Discharge destination from an acute care for the elderly (ACE) unit

Older adults age 65 and over account for a disproportional number of hospital stays and discharges compared to other age groups. The objective of this paper is to describe placement and characteristics of older patients discharged from an acute care for the elderly (ACE) unit. The study sample consists of 1,351 men and women aged 65 years or older that were discharged from the ACE Unit during a 12-month period. The mean number of discharges per month was 109.2 ± 28.4. Most of the subjects were discharged home or home with home health 841, 62.3%. The oldest elderly and patients who had been admitted from long term care institutions or from skilled nursing facilities to the ACE unit were less likely to return to home.     

Clinicians' predictions of nursing home placement for hospitalized patients.

Identifying patients who will need long-term care may improve the efficiency and effectiveness of acute hospital care. This prospective study evaluated clinicians' ability to identify patients requiring nursing home care. The study had two principal objectives. The first objective was to measure whether registered nurses, physicians, and social workers made similar estimates of the probability of nursing home placement early in an acute care hospitalization. The second objective was to identify the clinical characteristics of patients for whom the clinicians incorrectly predicted that they would return home. The study subjects were 342 patients older than age 55 who were admitted to the medicine, surgery, and neurology services of two university-affiliated Veterans Affairs hospitals. Fifteen percent were discharged to nursing homes. The nurses, physicians, and social workers had high agreement in their estimates of the probability of nursing home placement for each patient. However, each of the provider groups assigned low probability estimates to more than 20% of the patients discharged to nursing homes. Examination of the characteristics of patients assigned low probability estimates revealed that mental impairment and functional disability were higher in those patients who ultimately were discharged to nursing homes than in those patients who returned to their homes. These findings suggest that better assessment and interpretation of patient characteristics early in the hospital stay may improve discharge planning. Some clinicians appear to underestimate mental and functional impairment as risk factors for long-term care needs.     

Psychotropic Medication Use in a Sample of Frail,Elderly Inpatients in Sydney,Australia

Objective: To examine rates of use and predictors of psychotropic drug use among a group of frail, aged inpatients admitted under the care of a geriatrician. To examine correlates of psychotropic drug use at discharge with inpatient characteristics. Method: The number of psychotropic medications taken were obtained from a medical records audit of 311 frail inpatients under the care of a geriatrician. Medication taken at the point of admission and at discharge, and rates of commencement and cessation of different psychotropic agents were measured. Results: Patients discharged to a nursing home were more likely to be admitted and discharged on anti-psychotics and anxiolytics/hypnotics. Subjects from an English-speaking background were more likely to be prescribed anti-depressants on discharge and there was a trend for females to be discharged on anxiolytic/hypnotic medication. Subjects discharged on anti-psychotics were also more likely to have lower MMSE scores and higher average DRG cost weights. However, lower numbers of patients admitted from nursing homes and hostels were discharged on psychotropic medication. For those discharged home, the reverse was true. Conclusion: The finding that fewer nursing home and hostel patients were discharged on such medication that admitted on it, suggests that careful review of psychotropics for frail aged inpatients admitted under the care of a geriatrician is practised.     

Readmission to hospital of medical patients – A cohort study

IntroductionThe incidence of acute readmissions is higher among elderly medical patients than in the general population. Risk factor identification is needed in order to prevent readmissions.ObjectiveTo estimate the incidence of acute readmissions among medical patients ≥ 65 years discharged from departments of internal medicine and to identify risk factors associated with readmissions.Material and methodsWe included patients discharged between 1st of January 2011 and 1st of December 2014 and collected data regarding primary diagnosis and comorbidities. The primary outcome was acute readmission within 30 days of discharge. We determined risk factors using a multivariable Cox proportional hazards model.ResultsOut of 21,634 discharged patients, 3432 (15.9%) patients had an acute readmission. Risk factors were: age per decade (HR: 1.06, 95%CI: 1.02–1.11), male sex (HR: 1.07, 95%CI: 1.00–1.15), receiving home care service (personal care) (HR: 1.33, 95%CI: 1.15–1.55), nursing home residency (HR: 1.30, 95%CI: 1.14–1.48), a previous admission within six months (HR: 1.59, 95%CI: 1.48–1.72), increased length of index admission (HR: 1.14, 95%CI: 1.11–1.17), and moderate or high level of comorbidities (HR: 1.22, 95%CI: 1.13–1.32, HR: 1.52, 95%CI: 1.38–1.67, respectively).ConclusionAround one in six patients had an acute readmission and we identified several risk factors. The risk factors a previous hospital admission within six months, a long or very long length of index admission and a high level of comorbidities were strong risk factors for an acute readmission.     

Statistical analysis of post-stroke patients in a rehabilitation institution]

A retrospective analysis of 312 stroke patients (200 men, 112 women; average age 65) admitted to Yamaguchi Rehabilitation Hospital during the past three years showed the following results. 1) After an average period of stay of 244 days 225 patients were discharged to home, general hospitals, extended care facilities, or nursing homes. 2) The group of patients over 80 years of age at admission had a lower ratio of home returns than in other groups (p less than 0.01). 3) Patients who returned home had higher scores not only on discharge Barthel index scores but on admission Barthel index scores, compared with other discharged patients (p less than 0.01). 4) The higher the admission Barthel index score, the shorter the period of stay (p less than 0.01). Concerning discharge Barthel index scores, patients who stayed over two years had lower scores than patients who stayed less than two years (p less than 0.01). The results of this analysis suggest the importance of determining goals and programs taking admission Barthel index scores as well as other available factors into consideration for patients with stroke admitted to rehabilitation institutions.     

Risk factors for nursing home admissions and exits: a discrete-time hazard function approach

Discrete-time hazard functions were estimated to determine factors associated with the probability of admission to a nursing home from the community, and the probability of discharge to the community from nursing home care, for 3,332 individuals enrolled in The National Long Term Care Channelling Demonstration. This was a relatively frail elderly population assessed to be at high risk for nursing home use. In predicting admissions, major factors were found to be ethnicity (Blacks and Hispanics were at much lower risk), homeownership, advancing age, living alone, exhibiting higher cognitive and functional impairment levels, physician use, and living in an area with a larger nursing home bed supply. The probability of being discharged alive was predicted by several factors, including ethnicity (Blacks being less likely to be discharged), homeownership, being of younger age, better (self-rated) health, functional and cognitive capacities, and medical acuity.     

Older adults discharged from the hospital with delirium: 1-year outcomes

OBJECTIVES: To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital. DESIGN: Secondary analysis of prospective cohort data from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000. PARTICIPANTS: Four hundred thirty-three patients aged 70 and older who were not delirious at admission. MEASUREMENTS: Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1-year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60-4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43). CONCLUSION: Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1-year follow-up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.     

Coping with diagnosis related groups. The changing role of the nursing home

In an attempt to document the changing role of a specific nursing home in the delivery of medical care since the initiation of diagnosis related groups (DRGs), we studied 100 consecutive patients initially admitted to the Veterans Administration Medical Center-Milwaukee Nursing Home Care Unit (NHCU) during the first 23 weeks of 1986 (post-DRGs). Patient characteristics, reason for NHCU admission, and patients' final disposition were determined and compared with those of consecutive patients admitted to the same facility during an identical time period in 1983 (pre-DRGs). More than seven times as many patients were admitted in 1986, and prior to NHCU admission the acute care hospital stay was significantly shorter in 1986 (22 vs 60 days). Whereas in 1983, most patients (94%) were admitted to the NHCU for long-term care placement, in 1986, the majority of patients (64%) were admitted for continuation of therapy started in the acute care hospital. In 1983 only two patients (9%) required hospital readmission within ten days of NHCU admission, compared with 22 (22%) of the patients in 1986. At the termination of the study period, none of the 31 patients admitted to the NHCU in 1983 had been discharged; in comparison, 33% of the patients in 1986 were discharged home. We conclude that in 1986 certain nursing homes drastically changed their role in the delivery of medical care, and are now functioning as extensions of acute care hospitals. Such a role is advantageous in allowing patients to be quickly discharged from the acute care hospital; however, the changing role presents new problems and challenges.     

Factors associated with short- versus long-term skilled nursing facility placement among community-living hip fracture patients

Characteristics associated with long-term placement among community-living patients admitted to a skilled nursing facility (SNF) after a hip fracture were identified. Subjects were 151 consecutive, elderly, community-living persons discharged from two acute hospitals to SNFs after surgery for a hip fracture. Medical, functional, psychological, social, and outcome data were collected from hospital and nursing home charts. Ninety-seven subjects (64%) were discharged home within 6 months; 50 (33%) became permanent SNF residents; and four died. Multiple logistic regression identified orientation, younger age, ability to bathe independently, family involvement, ability to ambulate or transfer independently, and greater number of available physical therapy hours as factors contributing independently to returning home. Likelihood of returning home increased from 7% among subjects with fewer than two of the patient characteristics to 82% among subjects with four or more characteristics (P less than .0005). These results suggest that hip fracture patients at high risk of permanent SNF placement can be identified at time of hospital discharge. Investigations are needed to determine whether more intensive rehabilitation and discharge planning may improve the chance of returning home for a large percent of hip fracture patients.     

Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status

This article presents results of a prospective multivariate study of hospitalized elderly patients at an acute-care Veterans Administration (VA) hospital to identify factors on hospital admission predictive of several short- and long-term outcomes: in-hospital and 6-month mortality, immediate and delayed nursing home admission, length of hospital stay, and 6-month rehospitalization. All patients aged 70 years and over admitted to acute-care beds on the medical service wards during a 1-year period were included in the study (N = 396). Factors most predictive of 6-month mortality (using logistic regression) were decreased functional status, admitting diagnosis, and decreased mental status. Factors most predictive of nursing home admission were decreased functional status, living location, and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than was principal admitting diagnosis--of relevance to the current emphasis on diagnosis-related groups (DRGs). These data may be helpful in improving discharge planning, in resource allocation, and in targeting patients for different specialized geriatric programs.     

A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients

OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post-discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and post-discharge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients.