Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 87
Special Perspectives on
Acute Hospital Care
wiDiam R. Hazzard
For many years, my particular focus has been on developing systems
that would be appropriate teaching models for the care of the elderly
in the acute care hospice. In Seattle, where ~ began this work, more than
half a dozen hospitals participate In a network of teaching arrangements
with the University of Washington. ~ was based at Harborview Medical
Center, fonnerly known as King County Hospital. CThis is the hospital
where prehospital coronary care in this nation began and where venous
other hyperacute health care strategies were developed.) Ale challenge
was veer clear: if we were to develop a ger~atnc teaching and research
program, we needed to do it in a very competitive environment. Our
clientele was distributed between younger patients, mostly alcohol and
drug abusers and otherwise indigent, disadvantaged people, and a smaller
proportion of elderly. The chief focus was the care of He desperately in.
DEVELOPING A GERIATRIC HEALTH PROGRAM
How can you develop a geriatric health care program in that
setting? Because of He nature of the hospital, Dr. Marsha Fretwell (cur-
rendy on He geriatric faculty at Brown University) and I, and others who
followed us, decided to begin with the inpatient arena. It was this area
that we knew best and could get attention and participation by the house
staff and students. In that particular setting, we developed the Harbor-
view SeniorCare Program. Although we developed an entire continuum
of care, including nursing home and ambulatory clinic care, the hospital
focused and still focuses on the care of acutely ill, elderly inpatients.
87
OCR for page 88
88
WILLIAM R. HAZZARD
What are the special problems that such a unit or program must
face? It faces the fact that scattered throughout an acute care hospital
some people are especially vulnerable and disadvantaged by virtue of
Heir age and disease-dependent processes. How can one identify these
people? How can one make sure Hat the set of services furnished to these
people was the most appropriate? And, how can one continue to care for
these individuals when Hey leave the hospital and go Trough the process
of convalescence, to whatever their outcome might be?
In that context, we developed a prototype that we subsequently
implemented at Johns Hopkins (Francis Scott Key Medical Center in
Baldmore). We are now setting up such a program at Bowman Gray
Medical SchooUNorth Carolina Baptist Hospital.
Consultation Teams
The process begins with the development of a consultation team to
identify individual patients on aU services throughout the hospital who
might especially benefit by the specialized services developed in a geriat-
nc care program. The consultation team, generally consisting of a nurse,
a social worker, and a geriatncian, makes frequent rounds throughout the
hospital, identifying the patient with He hip fracture, identifying the
patient with the stroke, identifying the patient on the burn unit, identifying
the traumatized patient who came in through the emergency room, and
indeed identifying any patients who might need a different or focused
approach to their continuing care.
The team was often asked to transfer a particular patient to the
special unit for continuing care. Oftentimes, the answer was that the
patient did not need such special care or that the services Hey were
already receiving, in orthopedics or wherever, were appropriate and need
not be interrupted, and the patient could be discharged home from Pose
units. However, In about one-half of the cases, we found that it was
appropriate to transfer the patient to the SeniorCare geriatric unit; the
current census on that unit is about 12 in a 300 bed hospital, a number that
has evolved and seems to be steady at He present time.
Geriatric Outpatient Clinic
Another part of He care continuum that must be developed—under
at least He partial control of the geriatric consultation team, and ~ empha-
OCR for page 89
SPECIAL PERSPECTIVES ON ACUTE HOSPITAL CARE
89
size this is an outpatient clinic. We developed a primary care outpatient
clinic that stressed assessment Mat generally was multidisciplinary but
also was un~disciplinary where appropriate for both front-door, first-
encounter assessment and continuing primary care. In Seattle, we became
affiliated with Wee nursing homes, ranging from private nursing homes
to a public nursing home, where we could help control and foster me
appropriate aftercare of patients under our responsibility, a home care
alternative, and a rehabilitation and day care alternative.
The principal function that evolved for We geriatricians was largely
Mat of management; the clinician assumed responsibility for care of
patients as they progressed through various stages of convalescence or
furler dependency. All of this was done in the hospital setting because
we needy to be highly visible' we needed to be research oriented, and we
needed to recruit felBows, faculty, and residents into the effort.
COMMUNITY CARE ALTERNATIVES IN BALTIMORE
When I left Seattle for Johns Hopkins, a different set of problems
and opportunities presented themselves. In my opinion, the system that
evolved at the Francis Scott Key Medical Center (fonnerly the Baltimore
City Hospitals) is one of the best in the nation because it exists in an
institution that has a traditional orientation toward the care of the elderly
and that has a major research and intellectual organization in the Geron-
tology Research Center (sponsored by the National Institute on Aging) as
well.
We, the faculty, were responsible for the long-term care of about
225 patients on that campus. The patients were divided into two levels of
care a skilled nursing facility level of care and a chronic hospital level
of care. We developed the locus of activities at Johns Hopkins within the
Mason F. Lord Chronic Hospital and Skilled Nursing Facility, located
about 100 yards from the acute care hospital.
We replicated the consultation team at the Mason F. Lord facility.
Under Dr. John Burton's continuing leadership, we developed a rehabili-
tative unit; much of the continuing care was developed under the leader-
ship of Mary Pat Clarke (now president of the City Council of Baltimore).
We developed a series of home care and community-based alternatives,
including care of individuals in their homes by a team of physicians,
nurses, and social workers who also work with the community to develop
better housing, better transportation, better family care, and so form.
OCR for page 90
9o
WIlLlAA~ R. HEARD
~ have described how we moved from a more focused, acute
hospital-based program in Baltimore to a system that eventually capital-
ized on a series of community alternatives. Physicians-in-tra~ning and the
faculty were heavily involved In this spectrum of care. Having access to
He nursing home beds, access to the rehabilitative units, and access to
home care enable this program to manage about 130 patients in their
homes. Those patients are as dependent as are those in the nursing home.
Actually, they are more dependent, but they are maintained in their homes
with the support of their families and have access to the community
resources and collaborative relationships that maintain the effectiveness
of the geriatric clinicians in this particular setting.
The acute care hospital was pnmanly an intake point. The prob-
lems identified in the acute care setting were resolved mainly outside of it,
but the continuum of care and the ability to plug in at all levels made the
team effective. If He team functioned only In the hospital, then it would
have remained ineffective and fn~strated. The point is that any strategy
that is targeted only toward the acutely hospitalized patient In that setting
is likely to frustrate the clinicians practicing within it.
How do cI~cians outside the academic establishment or tertiary
care hospitals cope? They cope by having developed, over time, a
knowledge of the resources and liaisons that exist in their communities,
the trust of their patients and their families, and the knowledge of the
backgrounds, tastes, and values of their patients and their families, which
allows them, to a large extent, to be effective.
ACUTE CARE BACKGROUND
I inflected my own interests, from metabolism and endocrinology
to geriatric medicine, during a sabbatical year in Great Anton about 10
years ago. That evolution began during a pre-sabbatical visit a year
earlier. That first exposure to the geriatric health care system was in the
United Kingdom took place in Oxford at the Cowley Road Hospital (the
place has since been tom down). Like He Mason F. Lord Hospital, it was
built in the nineteenth century as a poor farm out in the country. It
provided life care for the disadvantaged from bird though death.
When they showed me the "acute care unit" at the Cowley Road
Hospital, ~ had a sense of being in the wrong place. Patients were in their
daily clothes; people were sitting in dayrooms and walking around.
thought, "Something is wrong here. This is not acute care." When
OCR for page 91
SPECIAL PERSPECTIVES ON ACUTE HOSPITAL CARE
91
asked, "What are you doing with this chap?", they said, "We are investi-
gating his B,2 metabolism because he might have pernicious anemia." ~
asked when they were doing a SchiBing test. They said, "The day after
tomorrow." '1his is acute care?", ~ thought.
The average length of stay in this unit was about IS days. ~
Bought that this was not acute medicine as I knew it. But, that particular
institution, in Me absence of technology, took a more contemplative
approach toward a care system that included investigation, rehabilitation,
and reintegration into We community over the long term. The hospital
served as the entry point to other levels of acute and chronic rehabilitative
long-tenn care and return to the community, similar to the programs later
developed in Seattle and Baltimore. The experience made me realize how
effective this place, mode, time flame, and pace of assessment could be.
It also made me realize that this mode of health care was particularly
appropriate to fig a gap in the care of the elderly in the United States.
GERIATRIC ASSESSMENT
What has subsequently evolved In the United States is the concept
of geriatric assessment. It has become known by venous names and
applies to venous modes of heady care delivery in this country. In
October 1987, the National Institutes of Health ~H) held a consensus
conference on geriatric assessment. Just holding Hat conference implied
that this technology has reached a point at which one can describe it,
quantify it, and judge its effectiveness, cost, and the like.
We have demonstrated, for example, Hat though a more contem-
plative approach, not just to assessment but also to rehabilitation, the
health care of dependent and sick elderly can be improved and that it can
be cost effective. Geriatnc assessment programs have not been tested to
any significant extent outside the Veterans Administration (VA) system.
After Party Rubenstein and his associates in Sepuiveda had some promis-
ing results, the VA decided that every hospital should have a geriatric
assessment unit, and now they are in operation in VA hospitals aU over
the country. Very few units, however, behave or function the way Hat
Rubenstein set up. But his unit was not really an assessment unit; it was a
rehabilitative unit with continuing assessment. The average length of stay
is in He 40-day range. The point is Hat a substantial, targetable, and
identifiable subset of patients in the acute care hospital win benefit by a
more contemplative and rehabilitative mode of aftercare.
OCR for page 92
92
WILLIAM R. HAZARD
I have described a mode of care Hat is a cndcal gap in our geriatric
health care system. Although it has been venously caned transitional
care, progressive care, alternative care, or rehabilitative care, it is a kind
of care that proceeds at a slower pace and Hat allows convalescence in a
supportive, nurturing, and functionally oriented environment to proceed
without the time pressure to make a decision about what win happen after
acute hospital care.
BENEFITS OF A GERIATRIC ASSESSMENT PROGRAM
This system serves a number of purposes. If such a unit or
program were available to the health care team, it could prevent acute
hospitalization. The goal of much of what should be developed in such
programs is to prevent exposing the patient to the acute care environment.
My experience at Seattle, Johns Hopkins, and Bowman Gray shows
that hospitals and house staff do what Hey know how to do best. Once a
patient enters the emergency room at Bowman Gray, ~ can be very sure
chat no technology available win be spared during the first 12 hours. But,
if I am to prevent the unnecessary, hazardous, and costly exposure of
patients to this panoply of ready services, ~ must prevent or at least control
the need for patients to enter that system.
For example, we have developed an arrangement with the Baptist
Homes of North Carolina at which one of our faculty is the medical
director. She and the colleagues in our new section of gerontology and
genatr~c medicine under Walter Ettinger are the primary care physicians
of aD the patients in this particular nursing home. About 3 weeks ago, Dr.
Ettinger received a can from the nursing home about a 92-year-old woman
with advanced dementia, who had developed a puIseless right lower
extremity. It was clear that a gangrenous leg was developing that would
have a predictable fatal outcome unless something dramatic was done. It
was decided, because it had been discussed previously win the patient's
family, Hat advanced high technology or heroic therapy was inappropr~-
ate, but a diagnosis nevertheless had to be made.
Dr. Ettinger asked that the patient be brought to the emergency
room where he would meet the patient and make a decision. This he did,
and despite the exhortations of the emergency room staff, the residents,
the students, and others, he made He diagnosis and sent her back to the
nursing home. Had he not been there, it would have been impossible, in
my experience, for He system not to have followed the usual emergency
OCR for page 93
SPECIAL PERSPECTIVES ON ACUTE HOSPITAL CARE
93
room procedures. This is an example of why control is very important.
With the subacute, transitional level of care, you have the ability to
develop a care plan that emphasizes rehabilitation, restoration of function,
and support for me padent in a natural evolution toward independence,
without necessarily sending the patient to a nursing home. As we all
know, if patients are sent from a hospital to a nursing home for convales-
cence, the risk is great that they win live the rest of their lives in the
nursing home. Having alternatives such as we described defers that
decision and may avoid it entirely.
Finally, an atmosphere in the transitional care center evolves
wherein heroic therapy application of the ultimate in high technology
is not necessarily the norm. It is a more humane environment, a more
nurse clin~cian-dr~ven environment. Less high technology is used, less
high cost is involved, and more humane care results.
CONCLUDING REMARKS
These are the hypotheses underlying the development of this tran-
sitional level of care. Such care is not explicitly reimbursed in Norm
Carolina or Maryland and because it is reimbursed virtually nowhere, a
political and an economic strategy will be needed to overcome its exclu-
sion from the system of payments.
If the hypothesis is correct, if we can develop an alternative forth
of care of the elderly, then we may be able to reassert control and
minimize costs by avoiding the unnecessary application of high technol-
Ogy. In the academic setting, these kinds of programs and units also
provide a setting for research where we can test the cost effectiveness and
nsk/benefit ratio of venous technologies and approaches to geriatric
health care.
Thus, transitional care between acute hospital and long-term
care is the missing link in geriatric health care in this country. Specific
programs at institutions willing to accept the risks and challenges of
leadership will have to develop this level and integrate it into a managed
continuum of care in a demonstration mode to test its efficacy. If such
demonstration projects prove the efficiency and effectiveness of this
system of care, reimbursement can be expected to follow and a mold for
meeting the challenge of the "demographic imperative" of an aging soci-
ety will be available for widespread replication.
Representative terms from entire chapter:
nursing home
