October 5, 2011--Confirming many
elderly patients’ worst fears, a national
study has shown that being hospitalized for
an acute event, such as a stroke or hip
fracture, can lead to long-term
institutionalization in a nursing home.
Equally alarming, researchers found that
direct discharge to a skilled nursing
facility — a common practice designed to
reduce hospital stays — put patients at
“extremely high risk” of needing long-term
nursing home care.
According to researchers at the University
of Texas Medical Branch (UTMB) in Galveston,
these findings suggest that programs aimed
at helping older patients recuperate
successfully at home instead of in an
institutional setting could greatly improve
their health outcomes and reduce healthcare
costs. The study is published online today
in the
Journals of Gerontology Series A: Biological
Sciences and Medical Sciences.
“Hospitalization is a tipping point
for older patients, often reducing their
ability to live as independently as
before,” said lead author
James S. Goodwin, MD,
director,
Sealy Center on Aging at UTMB
and the George & Cynthia Mitchell
Distinguished Chair in Geriatric
Medicine.
Goodwin also noted that certain factors
common among the elderly — cognition
problems, frailty, lack of social
support — increase the risk of nursing
home institutionalization.
“Add the enormous systemic pressure to
reduce hospital stays and a dearth of
viable programs to help patients fully
recover their health and independence
after hospitalization, and there simply
isn’t a clear path to get the patient
back home,” he said.
Medicare pays 100 percent for 20 days at
a skilled nursing facility for patients
who have just been released from the
hospital but still need extra care.
“There is a very narrowly defined view
of what Medicare will provide
post-hospital,” said Goodwin.
“If Medicare payment guidelines were
broadened to cover in-home care — bathing and food
preparation for example — there is a tremendous
potential for savings and patients could adjust
gradually back to their familiar home environment.
Medicare will not pay for the in-home care.”
Goodwin and his colleagues measured
a five percent sample of Medicare enrollees
(approximately 762,000) aged 66 or older
between 1996 and 2008 who were admitted to
nursing homes. Of that population, 75
percent were admitted to a nursing home for
long-term care within six months of a
hospital stay.
According to Goodwin, the period studied
paralleled a time of growth in the use of
skilled nursing facilities, which may have
been due to Medicare’s adoption of a
prospective payment system that encouraged
hospitals to reduce the length of stays.
Institutionalization after hospitalization
increased with older age, in women and in
patients without a primary care physician.
The odds of institutionalization were also
more than six-fold higher in patients with a
dementia diagnosis and increased in patients
with other co-morbidities, including
delirium and incontinence.
Being transferred to a skilled nursing
facility on discharge was the primary risk
factor leading to substantial long-term
care. The percent of hospitalized Medicare
patients transferred on discharge increased
from 10.8 percent in 1996 to 16.5 percent in
2008. Additionally, the study found that
nearly 65 percent of patients in a nursing
home six month after hospitalization had
first been transferred to a skilled nursing
facility. This was up from 50 percent in
1996.
Researchers also found several factors that
reduced the risk of long-term
institutionalization. Patients cared for in
larger hospitals and major teaching
hospitals were less likely to be in a
nursing home six months after discharge, as
were patients treated by their primary care
physicians. In general, rates of nursing
home institutionalization were lower in
Midwest and Western states, where
regulations, cultural and social factors may
reduce nursing home use.
Goodwin recommends that hospitals consider
alternatives to skilled nursing facilities
post-hospitalization, such as
community-based facilities, assisted living
facilities and at-home care. Developing
preventive programs that target the
population at-risk for long-term nursing
home care — hospitalized Medicare patients —
may serve as another avenue to avert
long-term institutionalization. He also
suggests exploring ways to reduce the
economic incentives of keeping patients in
long-term care and divert savings to such
alternatives and prevention programs.
“There is no perfect solution for caring for
patients who may not be able to function
completely independently and who lack a
social network of able caregivers,” said
Goodwin. “We do know that most people
fervently wish to remain at home and it is
our responsibility to help avoid preventable
nursing home admissions.”
Yong-Fang Kuo, PhD, associate
professor, Department of Internal Medicine,
Division of Geriatric Medicine at UTMB,
co-authored this study, which was funded by
the National Institutes of Health.
###
The
Journals of Gerontology Series A: Biological Sciencesand
Medical Sciences is a refereed publication of
The Gerontological Society of America (GSA),
the nation's oldest and largest interdisciplinary
organization devoted to research, education, and
practice in the field of aging. The principal mission of
the Society — and its 5,400+ members — is to advance the
study of aging and disseminate information among
scientists, decision makers, and the general public.
GSA’s structure also includes a policy institute, the
National Academy on an Aging Society, and an
educational branch, the
Association for Gerontology in Higher Education.
About the
University of Texas Medical Branch (UTMB):
Established in 1891, Texas' academic health center
comprises four health sciences schools, three institutes
for advanced study, a research enterprise that includes
one of only two national laboratories dedicated to the
safe study of infectious threats to human health, and a
health system offering a full range of primary and
specialized medical services throughout Galveston County
and the Texas Gulf Coast region. UTMB Health is a
component of the University of Texas System and a member
of the Texas Medical Center.
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