Preparing More Care of Elderly

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Preparing More Care of Elderly By MILT FREUDENHEIM

With a nudge from the new health care law and pressure from Medicare, hospitals,

doctors and nurses are struggling to prepare for explosive growth in the numbers

of high-risk elderly patients.

More than 40 percent of adult patients in acute care hospital beds are 65 or

older. Seventy million Americans will have turned 65 by 2030. They include the

85-and-older cohort, the nation's fastest-growing age group.

Elderly people often have multiple chronic illnesses, expensive to treat, and

they are apt to require costly hospital readmissions, sometimes as often as 10

times in a single year.

The Obama administration is spending $500 million from last year's stimulus

package to support the training of doctors and nurses and other health care

providers at all levels, " from college teachers through work force professionals

on the front lines of patient care, " said Kathleen Sebelius, the secretary of

health and human services.

But the administration and Congress seem to be paying less attention to

geriatric health issues. For example, only 11 percent of research funding at the

National Institutes of Health went to aging research last year.

" In every area of aging — education, clinical care, research — people just don't

realize how dire the situation is, " said Dr. B. Reuben, chief of the

geriatrics division of the Geffen School of Medicine at the University of

California, Los Angeles.

Dr. Judith Salerno, a geriatrician who is executive officer of the Institute of

Medicine in Washington, agreed. " All the most common causes of death and illness

and functional impairment in the general population are diseases of aging, " she

said.

At N.I.H., the director, Dr. Francis S. , sees the picture in different

terms. He says N.I.H. budgets are tight across the board, not just for aging

research, after a $10 billion spike from stimulus funds.

" The opportunities in aging research are compelling, " Dr. said in a

telephone interview. He mentioned a study last year on mice that lived

significantly longer after being given rapamycin, a cancer and immunosuppressive

drug.

" That is turning out to be the most exciting new pathway for extending normal

life span that has ever been discovered, " Dr. said. But he said the

opportunities were also compelling in cancer, diabetes, mental illness and

autism.

" It is frustrating to have such great opportunities and limited budget

resources, " Dr. said. They all need more funds, he added.

In hospitals and doctors' offices, where explaining to elderly patients how to

deal with their often-complicated problems can be time-consuming, payments from

Medicare, Medicaid and most private insurers are not sufficient, said Dr. J.

Fred Ralston Jr., president of the 129,000-member American College of

Physicians.

" The payment system doesn't finance the kind of resources we need to take care

of the 20 percent of Medicare patients who use 80 percent of resources, " he

said.

Dr. Mark R. Chassin, a former New York State health commissioner, said, " The

biggest challenge that we face with the increasing numbers of very elderly folks

is how to preserve as much independence in their lives as possible. " Dr. Chassin

heads the Joint Commission, which accredits thousands of hospitals and other

health care providers.

To stay independent, the elderly will need to stay healthy.

" Many of these people could be back on the golf course and enjoying their

grandchildren if we did the right thing for them, " said D. Naylor, a

longtime geriatric care researcher and professor of gerontology in the School of

Nursing at the University of Pennsylvania.

Her research showed that even fragile older people could avoid a quick return to

the hospital if they are managed by teams of nurses, social workers, physicians

and therapists, together with their own family members. Hospital readmissions,

which cost $17 billion a year, could be reduced by 20 percent — $3.5 billion —

or more, she said.

Hospitals will be penalized by cuts in their Medicare payments, starting in

2012, if too many patients are readmitted within 30 days after being discharged.

Dr. Reuben at U.C.L.A. said research showed that " vulnerable elderly people who

are at risk of becoming frail often do not get appropriate care. For dementia,

falls, bladder incontinence, depression, they get about a third of the care they

need. "

He added: " If somebody is falling, it makes sense to examine their gait and

their balance. If someone has bladder incontinence, you might want to have them

do exercises, but their doctors commonly reach for the next drug they can give

them. "

Hospitals are training their staffs to make special assessments of patients who

may be at risk of falling, a major threat for the elderly. A fall-prevention

program is a requirement for Joint Commission accreditation.

Many internists, family physicians and other primary care doctors are lobbying

for payments for a team approach based in the physician's office. The concept,

which they call a patient-centered medical home, will be tried out under the new

health care law by Medicare, Medicaid and some private insurers. Secretary

Sebelius has called the medical home idea " one of our most promising models for

improving the quality of care and bringing down health care costs. "

Geraldine Goldsmith, a patient at New York University's Langone Medical Center,

said a team of N.Y.U. geriatric care specialists " taught me how to survive "

during her long fight against sickle cell anemia, a genetic blood disorder.

To stave off a painful sickle cell crisis, which may put her in the hospital as

often as every six weeks, Ms. Goldsmith, who is 73, gets continuous support from

Marilyn , a geriatric nurse practitioner.

Caring for the elderly is " a profession of the heart, " Ms. said.

Ms. Goldsmith said the geriatric team " makes sure that I eat proper food, take

my medications, keep my appointments — as you get older, you forget. "

She added that Ms. " calls and says: `Geraldine, look at your calendar. I'm

going to see you tomorrow.' "

At the N.Y.U. medical center, an electronic screening system tracks patients who

may be at risk for problems with cognition, falls, nutrition, pain, skin

conditions like pressure ulcers, and taking multiple medications, Ms.

said. Similarly, at the University of Alabama Hospital at Birmingham, B.

, a nurse practitioner, sees to it that medications prescribed for older

patients are checked by a pharmacist against a list of drugs found to be unsafe

for the elderly. So many of these patients are seeing six or eight doctors and

end up with many prescriptions, Ms. said.

After elderly patients are sent home, she telephones to remind them to contact a

physician and to follow orders from their nurses and doctors.

Both hospitals use a precise set of methods and principles for geriatric care

called Niche (for Nurses Improving Care for Healthsystem Elders). With support

from the A. Hartford Foundation and the Atlantic Philanthropies, the Niche

program has spread to 300 hospitals around the country.

Although the recession has made finding jobs difficult for recent nursing

graduates in places like New York and California, the Labor Department has said

that 600,000 new nurses would be needed within 10 years to replace those who

retire and to meet growing demand.

Currently, 11,000 of the nation's 3.1 million registered nurses are certified as

geriatric nurses or nurse practitioners. But tens of thousands of student nurses

are now learning about the special needs of the elderly as part of their regular

studies, said Geraldine Bednash, chief executive of the American Association of

Colleges of Nursing.

Every student nurse at N.Y.U. spends time working with elderly patients. " Before

long, 90 percent of American nurses will have to provide care for older adults, "

said Terry Fulmer, dean of the N.Y.U. College of Nursing. Ms. Fulmer helped

create and develop the Niche approach.

This year, the National Health Service Corps, a unit of the Department of Health

and Human Services, is doubling its program that repays student loans for

caregivers who work in rural and underserved urban neighborhoods. Family

practice doctors, nurse practitioners, dentists and others who care for the

elderly are among those eligible. The administration has allocated $300 million

in stimulus funds to support about 7,800 graduates.

With stimulus money and $34 million more under the new health care law, the

administration is also expanding training for geriatric specialists who commit

to teaching student physicians and nurses.

" As we talk about needing more health care providers of all kinds, " Ms. Sebelius

said in a telephone interview, " we are also retraining current providers " to

become better at geriatric care.

But doctors are generally not paid extra for the time they spend in lengthy

meetings listening to elderly patients with multiple problems. " Geriatricians

work in one of the few fields where the more you know, the less you are paid, "

said Dr. Salerno of the Institute of Medicine.

Not surprisingly, specialists in geriatric care are in short supply. There are

only about 7,000 geriatricians to deal with the aging boomer generation over the

next 10 years, Dr. Reuben said. More than 20,000 will be needed, according to

the American Geriatrics Society, a professional and advocacy group. To help fill

that gap, all first-year interns in internal medicine at the Birmingham medical

school are spending four weeks with geriatric patients this year. They are part

of a $200 million national effort to promote geriatric education principally

financed by the W. Reynolds Foundation, based in Las Vegas.

Dr. Kellie Flood, a geriatrician who directs the Birmingham program, discusses

newly admitted elderly patients at 10 a.m. daily with Ms. and other

nurses and doctors, as well as therapists, dietitians and social workers.

" We start planning for their departure from Day 1, " Dr. Flood said. By some

counts, her geriatrics unit outperforms comparable general medical units in the

hospital. " We have a lower average length of stay — four days — and a lower

30-day return rate — 16 percent, " she said. The national average is close to 20

percent for Medicare patients discharged from a hospital and readmitted within a

month.

Dr. Flood, Ms. and their team have a fan in Mullins, 88, a

retired pharmacist who lives in nearby Pelham, Ala. Mr. Mullins, who had a small

stroke in April, praised the " great care " at Birmingham. " They treated me, " he

said, " like they was my daddy or my mother. "

This is the 12th in a series of articles on how the health overhaul will affect

everyday lives.

http://www.nytimes.com/2010/06/29/health/29geri.html