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Specialized Hospital Units for Elderly Provide Shorter Stays, Lower Costs

Jun 20, 2012, 1:08 PM

Hospital units designed specifically for the care of older patients could save as much as $6 billion a year, a study from the University of California at San Francisco (UCSF) finds. In a randomized controlled trial, patients in “acute care for elders units” had shorter hospital stays and incurred lower hospital costs than patients in traditional inpatient hospital settings. At the same time, patients’ functional abilities were maintained, and hospital readmission rates did not increase.

The Acute Care for Elders program (ACE) relies on a specially trained interdisciplinary team, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. The team assesses patients daily, and nurses are given an increased level of independence and accountability.

“Part of what ACE does is improve communication and decrease work. And that’s a strategy that’s generally popular with lots of folks involved,” Seth Landefeld, MD, senior author and chief of the UCSF Division of Geriatrics, said. “What we found was that ACE decreased miscommunication and it decreased the number of pages nurses had to make to doctors. Having people work together actually saved people time and reduced work down the line.”

The study was published in the June 2012 issue of Health Affairs.

Read the study.

Read the UCSF story.

Read a Fierce Healthcare story on the study.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Health Care Providers with Geriatric Training in Demand

Mar 13, 2012, 1:00 PM

With unprecedented numbers of Americans nearing old age, experts say the health care system will need tens of thousands more providers with training in geriatrics to handle the population’s increasing, and increasingly complex, needs. But too few physicians, nurses and dentists who specialize in geriatrics, or who have completed geriatric training, are in the pipeline.

Last week, the New York Times explored the problem, along with some emerging solutions. The story observes that geriatricians usually make much less money than other primary care providers or specialists, and Medicare reimbursements for geriatric care are comparatively low. For a doctor with debt from medical school, those factors can be a powerful deterrent to going into the field. “Geriatrics is also seen as a plodding area of medicine, set apart from the glamour of life-saving heroics,” the New York Times asserts. “That may be why the specialty has made little headway among nurses as well.”

Completing geriatric training after medical school can also pose financial challenges, as providers may be reluctant to take a financial hit for programs that would keep them out of the workplace for longer. With that in mind, the geriatric residency required for board certification has been reduced from two years to one, and the federal government and several private groups offer funding for geriatric education fellowships. The American Geriatrics Society also offers a variety of flexible training options, including weekend workshops and online courses.

Similar barriers keep nurses from specializing in geriatrics. Fewer than 1 percent of registered nurses and fewer than 3 percent of advanced practice registered nurses are certified in geriatrics, according to the American Geriatrics Society.

Geriatrics should be integrated into nursing school curricula, experts say, as a stand-alone component or included in clinical practice.

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Stop the Suffering Among Older Patients

Jan 24, 2012, 12:00 PM, Posted by Keela Herr

By RWJF Executive Nurse Fellows alumna Keela Herr, PhD, RN, FAAN, Professor and Associate Dean for Faculty, The University of Iowa College of Nursing, Co-Director, Iowa John A. Hartford Center of Geriatric Nursing Excellence

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A recent article in the New York Times highlighted an important study by Tim Platts-Mills, MD, and his colleagues that examined pain treatment of older adults in emergency departments across the country. They found that people over age 75 are about 20 percent less likely to have their pain treated than are middle-aged patients. More importantly, the researchers found that in the over-75 group, only 53 percent of those who reported pain received an analgesic or a prescription for one. In patients with severe pain, only 65 percent received an analgesic.

These findings indicate that we still have a lot of work to do to address the under-treatment of pain in older people. The findings contribute to data collected in other care settings (such as hospitals, nursing homes and hospices) that also show inadequate treatment of pain in older people.

Attention was first drawn to the problem in the early 1990s, and researchers and clinicians have since contributed knowledge to guide provider practices to improve pain care. Yet, here we are 20 years later, and the picture hasn’t improved much.

Many organizations and groups (such as the International Association for the Study of Pain, the American Pain Society, the American Society for Pain Management Nursing, the American Geriatric Society, and the American Pain Foundation) are committed to quality pain care for all people. These groups work to raise awareness, provide education and resources, develop clinical practice guidelines and advocate for research and policies that support good care.

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Navigating Care Across Settings: The Role of Caregivers

Dec 13, 2011, 1:00 PM, Posted by Alicia Arbaje

Alicia I. Arbaje, MD, MPH, is an alumna of the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program and the RWJF Clinical Scholars program. She is Assistant Professor of Medicine and Associate Director of Transitional Care Research, Division of Geriatric Medicine and Gerontology, at Johns Hopkins University.

Human Capital Blog: Can you describe the typical patient you see on a daily basis?

Alicia Arbaje: As a geriatrician, I see patients who have complex chronic illness. Usually they’re over the age of 65, and even more commonly over 80. Many of my patients have more than one chronic illness, take several medications, and see multiple doctors. These are people who are interacting with the health system frequently, and they go in and out of the hospital quite a bit. Health care takes up a big portion of their life.

HCB: Do these patients have caregivers?

Arbaje: Most of them do. The ones who are fortunate do. Most often that caregiver is a daughter or a son, sometimes a spouse, neighbor, or a friend. Their responsibilities range from supervising – making sure the patient gets to an appointment or taking notes during a visit – all the way to doing things for the patient like feeding them and helping them dress. Some caregivers have an additional responsibility of making health care decisions, like what kind of treatments they get and the end of life care they receive. It’s very important that I work with their caregiver too because most of the patients aren’t able to do all the things they need to do to stay healthy on their own.

HCB: Your job and research focus on transitional care. What exactly is that? What role do caregivers play in transitional care?

Arbaje: Any time a patient moves from one health care setting or provider to another, that’s a care transition. For example, going home from the hospital or going from home to a doctor’s office. Care transitions are actually dangerous moments, and when caregivers need to be most involved in their loved one’s care.

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The 'Burden' of Family Caregiving Never Ends...

Dec 1, 2011, 1:00 PM, Posted by Anna Beeber

By Anna Song Beeber, PhD, RN, Assistant Professor at the University of North Carolina at Chapel Hill and a Robert Wood Johnson Nurse Faculty Scholar

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A common view in our culture is that residential long-term care services, such as nursing homes and residential care/assisted living communities, are a replacement for family care provided in the home. In general, older adults and families want to avoid long-term care placement, in part because they fear loss of independence, loss of a home life, and neglect at the hands of staff. Thus, a bulk of the research literature has focused on measuring, preventing and intervening to reduce the burden on family caregivers with the goal of avoiding nursing home placements.

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As clinicians, we try to work with older adults and their family caregivers to preserve function and safety, and to find the best community-based support services – all in the hopes of preventing the need for residential long-term care services and keeping the older adult in the home.

At the same time, family caregivers work hard to provide what their family members need, often at a high cost; financially in terms of lost wages, as well as costs to caregivers’ physical and psychosocial health.

All of this work to prevent the use of long-term care services can create the suggestion that, once an older adult enters residential long-term care, the system and the family caregiver have failed to meet the older adult’s needs.

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Caregiving: A Transformative Experience Like No Other

Nov 23, 2011, 1:24 PM, Posted by Jennie Chin Hansen

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As societies around the world grapple with aging populations, the challenges to caregiving have garnered considerable attention. Already an under-supported group in so many countries, today’s caregivers face an array of new pressures that strain the vital services they provide to older adults. Around the world, unsung heroes assume caregiver roles without question, without hesitation, and without recognition. It is often said that caregiving is the backbone of our global long-term care system.

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While caring for an older adult can be one of the most rewarding experiences of a lifetime, it can also be stressful and frustrating. This is especially likely if the older adult has dementia or needs around-the-clock complex care. In fact, most family caregivers are spouses or children. They may have age-related health problems of their own; or they may have small children to care for, or work outside the home, or all of these.

In 1984, my father suffered a second debilitating stroke that left him unable to continue caring for my mother. Widowed and raising a 7-year-old, I decided to move my parents across the country to San Francisco where I was living and where I happened to work at On Lok Senior Health Services, which became the prototype for the now recognized PACE program, caring for elders who want to remain in the community despite their frailty.

I first brought my mother out with me, and she lived with me for a few months. When I went to see my father in Boston, I noticed that my father actually had greater capacity than many of the physicians at the nursing home thought he did. I didn’t agree with their treatment and decided we were going to bring him to San Francisco. So I discharged him “against medical advice” – there’s a term for that, called AMA.

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Time to Get Moving: How a Function-Focused Approach Helps Caregivers and Those They Care For

Nov 22, 2011, 12:00 PM, Posted by Elizabeth Galik

By Elizabeth Galik, PhD, CRNP, Assistant Professor at the University of Maryland School of Nursing and a Robert Wood Johnson Foundation Nurse Faculty Scholar

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Older adults with dementia are more likely to be physically inactive, require assistance with personal care activities, and have more medical problems than older adults without dementia. There is a tendency to promote sedentary activities rather than exercise among older adults with dementia for fear that they will fall or injure themselves if they are allowed to be mobile and physically active.

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Despite the gradual and progressive cognitive and functional decline associated with dementia, there are benefits to keeping older adults engaged in their own personal care and physical activity. These benefits include slight improvement or maintenance of functional abilities, fewer behavioral and depressive symptoms, better sleep, and fewer falls. A function-focused philosophy of care is designed to prevent or minimize functional decline and optimize the function and physical activity of older adults regardless of their memory impairment. It promotes the belief that all older adults are capable of and benefit from some improvement or maintenance of functional potential, even though the function may not be entirely independent, such as passive range of motion through hand-over-hand feeding, or encouragement of self-propulsion in a wheelchair.

Caregivers also benefit from using a function-focused care approach. Even small improvements in the functional performance of older adults with dementia may decrease the physical requirements of caregiving, such as heavy lifting, and also may result in psychological benefits for the caregiver, such as increased self-confidence and improved satisfaction with his/her caregiving role.

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Raise our Voices to Care for the Caregiver

Nov 14, 2011, 12:00 PM, Posted by Lynn Feinberg

By Lynn Feinberg, MSW, Senior Strategic Policy Adviser, AARP Public Policy Institute

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My father was one of the smartest, most caring, and endearing persons I have ever known. An attorney by profession and a veteran of World War II, he was a loving husband, father, and grandfather, and a true friend. Everyone liked and respected my dad. And I mean everyone. He had that unique ability to connect with people of all ages. Quiet and gentle by nature, he was a listener. When he spoke, it was always with words of kindness and wisdom. Caring for my father—along with my mother, two sisters, and four home care aides—and ensuring that he lived in old age with the dignity and respect that he deserved was one of the most important, and profoundly meaningful, experiences of my life. It was also one of the hardest roles I’ve ever had. He died nearly 3 years ago at the age of 94. I miss him deeply.

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As a social worker and policy researcher, I’ve been working on family care issues for about 25 years now – before family caregiving for an aging relative or friend became the “new normal” of the baby boom generation. Even with my professional knowledge in the areas of gerontology, health care, and long-term services and supports (LTSS), we couldn’t always get it right for my dad. As a family, we faced what many of the 62 million family caregivers in the U.S. experience day in and day out: our health care and LTSS systems are enormously fragmented, very expensive, and are not set up to meet the needs of family caregivers or those for whom they care.

By default, the real coordinators of care for frail elders and adults with disabilities are their family caregivers. The economic value of the unpaid care they provide is estimated at $450 billion in 2009 by the AARP Public Policy Institute, up from $375 billion in 2007. If family caregivers were no longer available—or let’s say hypothetically, went on strike for a day—the health care and LTSS systems would be overwhelmed by the increasing need for services and supports.

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Caregivers: Partners in Improving Care for Older Adults

Nov 11, 2011, 4:26 PM, Posted by Cynthia Boyd

By Robert Wood Johnson Foundation Physician Faculty Scholar Cynthia M. Boyd, MD, MPH and Jennifer L. Wolff, PhD

With increasing numbers of Americans living to older ages, it is no surprise that a growing number are challenged by complex medical needs and disability. Being able to perform activities of daily living (bathing, dressing, etc.) and instrumental activities of daily living (shopping, managing medicines, housework, etc.) make a great difference to independence, quality of life, and peace of mind.

Although these functional measures matter tremendously, older adults also often struggle with managing multiple chronic conditions. Older adults’ ability to navigate our fragmented health care system, to process the complex medical information needed to inform their health care decisions, and to carry out a treatment plan that often includes multiple medication and lifestyle changes are not reflected by ADLs/IADLs (activities of daily living/instrumental activities of daily living), yet are essential to the quality and outcomes of their health care.

Family and friends often assist with medical tasks and communicate with health care providers, and yet the health system is not well equipped to support patients in the broader context of their helping networks. For example, by some definitions, the daughter who stops by everyday to check morning blood sugar, takes off of work three times per month to bring her dad to get blood drawn for blood thinner monitoring and accompany him to various routine appointments would not be considered a caregiver. (Wolff J, Kasper J. Gerontologist. 2006, Giovannetti E, Wolff J. Milbank Quarterly 2010) Yet, the ability of health care providers to care for the dad, including both making health care decisions and implementing his treatment plan, is very dependent on the daughter’s willingness and ability to help.

So this month, we’d like to honor the many “caregivers” who are so critical to caring for patients with complex health care needs, but whose roles and contributions are too often under-recognized. Treatment burden – the aggregate effects of everything people with multiple chronic conditions are asked to do for their health – affects patients’ quality of life, quality of care, and likely their adherence and health care decision-making. Caregivers play a crucial role in helping older adults with multiple chronic conditions manage their health-related tasks, and they may also experience difficulty as a result of doing so.

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Preparing the Nursing Workforce for the Demographics of Aging and Chronicity

Jul 14, 2011, 12:00 PM, Posted by Jennie Chin Hansen

Jennie Chin Hansen, R.N., M.S., F.A.A.N. is the chief executive officer of the American Geriatrics Society (AGS) and past president of the AARP. Prior to joining the AGS, she was CEO for OnLok, Inc., a nonprofit family of organizations providing integrated and comprehensive care community-based services in San Francisco. Read more about her work.

Since the release of the October 2010 Institute of Medicine (IOM) report on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, there has been significant interest in the key report recommendations: having nurses practice to the full extent of their education and training, ensuring a strong anchor in baccalaureate nursing education, positioning nurses as strong and full partners in the redesign and leadership of an effective health care system, and creating a sound approach to projecting nursing workforce needs.

My particular interest in each of these areas is to see that our profession, as well as other providers and caregivers, will implement these recommendations with full consideration of our rapidly expanding aging population. It is this growth of age, diversity, and chronicity, separately and together, that will shape and define the type of workforce and the competencies needed for nurses to be effective stakeholders in and contributors to our health care system.

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