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Special Perspectives on Acute Hospital Care Joseph W. Westbrook The National Education Association, Retired (NEA-R) is an affiliated program of the National Education Association MEAD. Some 85,000 retired teachers and educational employees are members. AU are a part of the I.~-miDion-member national organization that functions under the leadership of President Mary Hatwood FutreU. The major concern of the NEA-R, as wed as the NEA, in the health care area is the provision of adequate and affordable health care for its members. Therefore, availability, cost, and quality of services are most important factors. Many of my observations and recommendations may seem simplistic, but Hey are based on what members ten me. They are worried, they are very concerned, and they want to fee} more secure about their health care as Hey get older. Many recipients and potential recipients of medical services are covered by some type of insurance or by Medicare or both, and therefore they do not or have not made direct payments for services. The average rebred person looks at medical services as a right, not as something that is provided as a welfare handout. The tendency has been to forget that the health care industry is a business. The profit motive is the force that drives the vehicle. The acute care hospital, whether profit or not-for-proBt, concentrates on earning returns on their investments. Development, research, expansion, and tech- nology are at least pardy dependent on such returns. The escalating cost of medical care in an acute hospital setting is of great concern to all. Cost- containment measures seem to be one of the dominant forces in hospital management. Medicare reimbursement changes and the advent of diagno- sis-related groups (DRGs) have also contributed to this movement. 109

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110 JOSEPH W. WES179ROOK The impact of reimbursement by DRG guidelines on the sick and elderly is not clear. Some reports are negative and some are not. My understanding is that this system of reimbursement places a greater strain on hospitals because elderly patients in a DRG may be sicker and require more time and services than their younger counterparts. In addition, elderly patients are becoming He majority in many acute care hospitals. Some administrators report Hat more than 50 percent of their patients are over age 65 and a percentage of these are age 85 and older. To the patient and family, major research and emphasis needs to be placed on how to care for the sick elderly patient more effectively. NEEDS OF SICK ELDERLY IN HOSPITALS I am told that the elderly require more services and time than younger patients because they are usually sicker and are not able to perfonn many normal functions for themselves. They require more attention, supervision, and care by staff persons. In addition to the prescription and administration of drugs, the sick elderly often need more time with the professionals. Shad I say "tender, loving care?" Consulta- tion, counseling, dealing with depression, management of pain, and drug use are t~me-consuming areas in which doctors' and practitioners' serv- ices are sorely needed, but often missing. It seems as if the present system of reimbursement contributes to the absence of these services. Profes- sionals, health care administrators, practitioners, and others need to con- centrate on developing a comprehensive, geriatric treatment system and a compensation model that will make participation in such a system attrac- tive. POST-HOSPITAL PROBLEMS OF THE SICK ELDERLY In the post-hospital setting, many elderly persons are more afraid of living than of dying. The position of the LEA that adequate and affordable health care be available to its members throughout their life- t~me becomes more acute during the retirement years. The cost in- creases for health care have been disproportionately greater Can increases in income and other benefits. Many people believe Hat one extended hospital stay can reduce the average person or family to indigency. This is why He greatest problem and concern of many older persons is long- tenn care beyond He acute hospital phase.

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SPECIAL PERSPECTlKES ON ACUTE HOSPITAL CARE 111 . Data and feedback from NEA-R members verify this fear. When say that the elderly are more afraid of living than of dying, ~ am referring to the uncertainty of what might happen to them after they leave the hospital. . . Home care. Many patients do not have any suitable place to go after discharge. Usually adequate home care is not available because family members are absent or incapable of providing care. The spouse may be too infirm, or no children or other active relatives are available. A more tragic situation involves hostility in the home, be it that of the patient, the spouse, the children, or other relatives. This breeds neglect and even cruelty or physical abuse. The patient is aware of these problems but is helpless to do anything about them. Hospitals generally are not prepared to deal with such situations. Psychological problems. Two major areas in the post-acute- care setting are alcohol and drug abuse caused by depression, boredom, and loneliness. Pain, illness, or the feeling of sickness cause me overuse of drugs that usually have been prescribed by doctors because the patients complain about feeling sick or hurting. The need for nursing home care. The major trauma for the patient revolves around the emotional impact of being removed from the home setting and family if Here is one. It does not matter how poor or meager these resources may be. It marks He end of a way of life and, for many persons, an end of life. The quality of care provided by most nursing homes. Neglect, impersonal treatment, abusive, or hostile care are commonplace in many facilities. Even where state standards exist, few facili- ties meet them. Meeting Medicare and Medicaid guidelines does not ensure the presence of a desirable level of quality of care. The cost or economic impact. The financial effect on He pa- tient, family, and estate makes the nursing home the least desir- able and most traumatic of aD of the alternatives. According to existing practices, one is reduced to indigency by a short stay in a nursing home. A person's lifetime accumulation is quickly consumed, and one is reduced to poverty in order to receive long-term nursing care.

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112 JOSEPH W. WESTBROOK Victimization. Patients and families are too frequently victim- ized by red tape, regulations, misinformation, and Me absence of complete information about He availability of services and how to obtain them. We have many examples of families that have had all kinds of problems trying to get a difficult or unbearable situation resolved. This might be one of the most widespread problems reported to us by our constituency. NEA RECOMMENDATIONS Because the LEA is an action-or~ented organization, it is appropn- ate to close with some recommendations. I. AU acute-care hospitals should have geriatric teams or genatr~c evaluation units to plan and direct He complete and comprehensive care of the sick elderly patients. 2. All acute care hospitals should be required to have discharge planning teams. Their responsibilities would include working win the patient and family until adequate and suitable continuing care facilities are available and the patient has been placed therein. Follow-up services should ensure continued adequate care. 3. A system of not-for-profit nursing homes should be developed by state and local heady agencies. Such facilities would be for persons who are able to pay nominal fees out of their retirement income. Once these facilities are established, they would be operated at minimal cost to the state or local agencies but would be quality controlled. A person would not have to become personally impoverished to gain admission. 4. Medicare and Social Security should assign health care infor- mation specialists to every office. It would be advertised that these persons are available to all families or persons who need information or services. Their jobs would be to inform, direct, and procure needed services for eligible persons who inquire, apply, or have been referred. 5. The health care community should universally support federal legislation covering long-term heals care for He elderly. In conclusion, He gap is wide between the "ought-ness" and the "is-ness" in health care for the sick elderly. The `'ought-ness', has been thoroughly discussed; ~ have touched on some of the "is-nesses" in this paper. If the acute care hospital is to continue as He most viable link in

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SPECIE P~SP~WES ON ACME HOST CARE 113 Me care and treatment of sick elderly patients, then it must bring the cost of its services back In line wad what persons can pay. Altemative treatment centers, such as heals maintenance organizations, preferred provider organizations, and the like, are not un~versaBy reliable or desir- able and should not represent me wave of the future ~ versal health care.