A new year for improving care for the elderly

Improving care after hospitalizations

In the US, one of the most dangerous times for an older person is being discharged from a hospital.   After even a brief stay in a hospital, often many things have changed: important medications, disease-specific care plans (for example diet or activity), or follow-up plans with doctors.  And a bad discharge can mean readmission to the hospital in less than a month for as many as 20% of patients.

Assimilating new and critical information at discharge can be difficult.  For one thing, an elder may have reversible cognitive dysfunction, which is memory and thinking difficulty during an acute illness that improves over the course of weeks to months.  This is not to mention those elders that we know already have cognitive problems, eg. dementia.

However, a known and likely more potent contributor is how badly discharges are done—hastily, without communicating to the patient’s outpatient doctors, and sometimes without caregivers there to help process information.  I cannot say how many times I have seen a patient in clinic who was recently discharged from the hospital and I have no record of the hospitalization, medications changes made and what, if anything, I was supposed to follow-up on.

This needs to change.  In 2013, US health care reform will mean that for certain conditions hospitals and their affiliated systems (clinics, medical centers) will be penalized for “unnecessary readmissions”.

This is an added push to innovators to work now on the issue of transitions.  One approach is the Support from Hospital to Home for Elders (SHHE) Project at the San Francisco General Hospital where they have a nurse visit the patient before discharge to make an individualized plan and follow-up with them afterward for several weeks.  Another is to standardize how the discharge is done through a checklist, one way that Better Outcomes for Older adults through Safe Transitions (BOOST) in Atlanta tackles the problem.  Further still, some programs focus on providing a new team of providers—doctors, nurses, social workers—who will take over care of the patient during the critical transition time and do all that is needed to make it a success, for example by doing more home visits.  This is the model that GeriTraCCC has started in San Francisco for heart failure patients.

There is no right way to improve hospital transitions in all systems and for all patients, but more innovations surely will follow as we feel the pressure to change over the next year.


1)   General information on innovations in health care to improve quality: http://innovations.ahrq.gov/innovations_qualitytools.aspx

2)   BOOST: www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

3)   GeriTraCCC: http://geriatrics.medicine.ucsf.edu/care/geritraccc.html


About Anna H. Chodos, MD

I am an Assistant Professor of Medicine at the University of California at San Francisco. A geriatrician and primary care doctor, I see patients in an urban safety net health care system. My work is focused on improving the care of older adults, and I write about issues affecting their health and health care.

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