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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

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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 developedunder at least He partial control of the geriatric consultation team, and ~ empha-

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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.

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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

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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.

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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

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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.