There has been a considerable amount of dialogue recently over the cost savings associated with specialized hospital units for elderly patients, such as geriatric service lines and emergency departments.
A June study from University of California, San Francisco, suggested specialized units could save Medicare $6 billion per year — nearly one percent of the federal health program's expenditures.
Still, while patients over the age of 65 have the highest hospitalization rate, not every one needs a geriatrician. There are many subtleties in this patient population — some 65-year-olds are still playing sports while others are significantly less active, for instance — meaning hospitals will need an array of offerings to better manage the care of elderly.
Here, experts discuss some of the strongest reasons for hospitals to fine-tune and reinforce geriatric programs or elderly care strategies, as well as some of the roadblocks they may encounter along the way.
Cost savings associated with specialized care
The average length of stay in short-stay hospitals by persons age 65 and over is 5.7 days — two days more than adults in the 15-44 age group — and this age group accounts for the most annual hospital discharges out of any other age group. "If you have finite resources and you want to ensure those resources are put towards the highest yield, it doesn't take long to realize that lies in [care management] for the elderly," says Russ Richmond, MD, CEO of Objective Health.
"When elderly folks get sick, they behave differently," says Dr. Richmond. For instance, a urinary tract infection — one of the most common causes of hospitalization for elderly patients — might bring on discomfort and a fever for people under the age of 65, but elderly patients can experience confusion or abrupt changes in mental health. "When you have care specialists who are focused on the elderly, they don't miss these things," says Dr. Richmond.
The rate of delirium in hospitalized elderly patients is as high as 60 percent, according to a study published in the Journal of Hospital Medicine. For this population, care routines like waking the patient in the middle of the night for medication can elongate the length of stay and increase costs. Furthermore, post-discharge, a recent study published in Neurology found the rate of cognitive decline in older patients more than doubled after a hospital stay.
Acute-care elderly, or ACE, units try to avoid common disruptions. These specialized units are designed for patients 65 and older, and they hold big savings for national healthcare spending, as indicated by the aforementioned UCSF study. Abington (Pa.) Memorial Hospital recently opened a 21-bed specialty unit for older patients, which is designed to prevent complications elderly patients may experience during their hospitalization.
Some hospitals have had specialized units for years before precise cost savings were known. In 2008, Holy Cross Hospital in Silver Spring, Md., opened one of the first geriatric emergency departments in the country. Other hospitals have followed suit since, such as Mount Sinai Hospital in New York City, which opened the city's first geriatric ED in February.
The pioneer EDs feature floors with a wooden instead of gloss finish to avoid glares, which aging eyes perceive as holes. Nurses monitor patients via devices that resemble cell phones so patients don't have to constantly be connected to machines. The customized setting is more than just aesthetically pleasing — it can help can elderly patients avoid falls, disorientation and other ailments unique to people over the age of 65.
Geriatric service lines can provide stability in the care continuum
Along with its ACE unit, Abington Memorial also has a geriatric service line — one of few in the Philadelphia area, according to Mary Hofmann, MD, chief of geriatric medicine.
"I'm proud that we have a geriatrics service line. It's very forward-thinking," says Dr. Hofmann. "It's rare. It's more common to go along with the academic model and have a division of geriatrics within the department of medicine." Like other service lines, Abington's geriatrics program has a medical director, administrative director and nursing director. While other service lines like cardiology and oncology are disease-specific, geriatrics is unique in that it includes a wide spectrum of conditions.
Dr. Hofmann says the unit also provides specialized care management for elderly patients and their families. These patients can face difficult decisions about the next step in their care, and often need assistance in distinguishing one post-acute care setting from another, such as day care or short-term rehab.
"The continuum of care, whether it's acute care, rehabilitative services or retirement communities — those things are really hard for families to understand," says Dr. Hofmann. "This [service line] helps families understand where the right place for an adult might be at a specific time, and the finances of it."
Understanding the market for geriatric care
Dr. Hofmann is quick to say geriatric care is not for every patient over the age of 65. She compares it to cardiology, in that not every patient needs a cardiologist. This touches upon the array of opportunities — aside from acute-care geriatrics service lines — that hospitals have to meet the needs of their 65 and over populations efficiently.
Dr. Richmond says there is a wide gap between the health needs of many seniors. Some might be highly active for their age while others have more chronic conditions. Using Objective Health data, Dr. Richmond analyzed data from 400 hospitals to identify some of the fastest-growing diagnosis-related groups for the patient population over age 65. The top three? Sports medicine, orthopedics and cardiology.
"There's some real markets that hospital managers need to pay attention to," says Dr. Richmond. "Hospitals can get active in the community and be considered not as a resource that treats the sick, but as a place to keep [the elderly] active, healthy and involved in their sports, like tennis and golf."
America's geriatrician shortage
One of the most significant hurdles for any geriatric program is the gaping shortage of geriatricians. Physicians predicted a geriatrician shortage in a 1980 New England Journal of Medicine article, urging that "additional medical manpower will be required to meet the growth in the elderly segment of the United States population over the next 50 years." Yet despite the forecasting and recognition of a pending shortage, geriatricians remain few and far between today, due in part to the challenging nature of the work and modest compensation.
Elderly patients often have multi-factored conditions, such as a combination of mental health problems such as delirium, acute-care issues like joint problems, and chronic health issues. This leaves physicians managing a wide range of conditions and diseases in addition to precautions to avoid accidental falls.
Despite the breadth of their expertise, geriatricians' compensation generally falls on the low end of the spectrum. According to the 2010 Medical Group Management data, geriatricians earned a mean of $194,634. That figure falls below internists' mean earnings of $214,906 and even further below most specialists' pay.
"It's a very difficult field from a physician's point of view. It's incredibly rewarding, because you're helping the greatest generation live healthily, but it is hard work," says Dr. Richmond.
Conclusion
If hospitals can surpass the obstacle of the longstanding geriatrician shortage, geriatric service lines or departments represent ample opportunity for savings, patient satisfaction and improved clinical outcomes. It's also important to look at the elderly population through different lenses.
For instance, Dr. Richmond's finding that sports medicine and orthopedics are two of the largest DRGs for this group may be somewhat surprising. People ages 65 to 80 may require care that helps maintain their active lifestyles, but when they are ages 80 to 100, then they may need more geriatric expertise that preserves quality of life. Hospitals that adopt a dynamic approach to geriatric care and promote themselves as centers for elderly health may find themselves meeting a large need, depending on the marketplace.
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A June study from University of California, San Francisco, suggested specialized units could save Medicare $6 billion per year — nearly one percent of the federal health program's expenditures.
Still, while patients over the age of 65 have the highest hospitalization rate, not every one needs a geriatrician. There are many subtleties in this patient population — some 65-year-olds are still playing sports while others are significantly less active, for instance — meaning hospitals will need an array of offerings to better manage the care of elderly.
Here, experts discuss some of the strongest reasons for hospitals to fine-tune and reinforce geriatric programs or elderly care strategies, as well as some of the roadblocks they may encounter along the way.
Cost savings associated with specialized care
The average length of stay in short-stay hospitals by persons age 65 and over is 5.7 days — two days more than adults in the 15-44 age group — and this age group accounts for the most annual hospital discharges out of any other age group. "If you have finite resources and you want to ensure those resources are put towards the highest yield, it doesn't take long to realize that lies in [care management] for the elderly," says Russ Richmond, MD, CEO of Objective Health.
"When elderly folks get sick, they behave differently," says Dr. Richmond. For instance, a urinary tract infection — one of the most common causes of hospitalization for elderly patients — might bring on discomfort and a fever for people under the age of 65, but elderly patients can experience confusion or abrupt changes in mental health. "When you have care specialists who are focused on the elderly, they don't miss these things," says Dr. Richmond.
The rate of delirium in hospitalized elderly patients is as high as 60 percent, according to a study published in the Journal of Hospital Medicine. For this population, care routines like waking the patient in the middle of the night for medication can elongate the length of stay and increase costs. Furthermore, post-discharge, a recent study published in Neurology found the rate of cognitive decline in older patients more than doubled after a hospital stay.
Acute-care elderly, or ACE, units try to avoid common disruptions. These specialized units are designed for patients 65 and older, and they hold big savings for national healthcare spending, as indicated by the aforementioned UCSF study. Abington (Pa.) Memorial Hospital recently opened a 21-bed specialty unit for older patients, which is designed to prevent complications elderly patients may experience during their hospitalization.
Some hospitals have had specialized units for years before precise cost savings were known. In 2008, Holy Cross Hospital in Silver Spring, Md., opened one of the first geriatric emergency departments in the country. Other hospitals have followed suit since, such as Mount Sinai Hospital in New York City, which opened the city's first geriatric ED in February.
The pioneer EDs feature floors with a wooden instead of gloss finish to avoid glares, which aging eyes perceive as holes. Nurses monitor patients via devices that resemble cell phones so patients don't have to constantly be connected to machines. The customized setting is more than just aesthetically pleasing — it can help can elderly patients avoid falls, disorientation and other ailments unique to people over the age of 65.
Geriatric service lines can provide stability in the care continuum
Along with its ACE unit, Abington Memorial also has a geriatric service line — one of few in the Philadelphia area, according to Mary Hofmann, MD, chief of geriatric medicine.
"I'm proud that we have a geriatrics service line. It's very forward-thinking," says Dr. Hofmann. "It's rare. It's more common to go along with the academic model and have a division of geriatrics within the department of medicine." Like other service lines, Abington's geriatrics program has a medical director, administrative director and nursing director. While other service lines like cardiology and oncology are disease-specific, geriatrics is unique in that it includes a wide spectrum of conditions.
Dr. Hofmann says the unit also provides specialized care management for elderly patients and their families. These patients can face difficult decisions about the next step in their care, and often need assistance in distinguishing one post-acute care setting from another, such as day care or short-term rehab.
"The continuum of care, whether it's acute care, rehabilitative services or retirement communities — those things are really hard for families to understand," says Dr. Hofmann. "This [service line] helps families understand where the right place for an adult might be at a specific time, and the finances of it."
Understanding the market for geriatric care
Dr. Hofmann is quick to say geriatric care is not for every patient over the age of 65. She compares it to cardiology, in that not every patient needs a cardiologist. This touches upon the array of opportunities — aside from acute-care geriatrics service lines — that hospitals have to meet the needs of their 65 and over populations efficiently.
Dr. Richmond says there is a wide gap between the health needs of many seniors. Some might be highly active for their age while others have more chronic conditions. Using Objective Health data, Dr. Richmond analyzed data from 400 hospitals to identify some of the fastest-growing diagnosis-related groups for the patient population over age 65. The top three? Sports medicine, orthopedics and cardiology.
"There's some real markets that hospital managers need to pay attention to," says Dr. Richmond. "Hospitals can get active in the community and be considered not as a resource that treats the sick, but as a place to keep [the elderly] active, healthy and involved in their sports, like tennis and golf."
America's geriatrician shortage
One of the most significant hurdles for any geriatric program is the gaping shortage of geriatricians. Physicians predicted a geriatrician shortage in a 1980 New England Journal of Medicine article, urging that "additional medical manpower will be required to meet the growth in the elderly segment of the United States population over the next 50 years." Yet despite the forecasting and recognition of a pending shortage, geriatricians remain few and far between today, due in part to the challenging nature of the work and modest compensation.
Elderly patients often have multi-factored conditions, such as a combination of mental health problems such as delirium, acute-care issues like joint problems, and chronic health issues. This leaves physicians managing a wide range of conditions and diseases in addition to precautions to avoid accidental falls.
Despite the breadth of their expertise, geriatricians' compensation generally falls on the low end of the spectrum. According to the 2010 Medical Group Management data, geriatricians earned a mean of $194,634. That figure falls below internists' mean earnings of $214,906 and even further below most specialists' pay.
"It's a very difficult field from a physician's point of view. It's incredibly rewarding, because you're helping the greatest generation live healthily, but it is hard work," says Dr. Richmond.
Conclusion
If hospitals can surpass the obstacle of the longstanding geriatrician shortage, geriatric service lines or departments represent ample opportunity for savings, patient satisfaction and improved clinical outcomes. It's also important to look at the elderly population through different lenses.
For instance, Dr. Richmond's finding that sports medicine and orthopedics are two of the largest DRGs for this group may be somewhat surprising. People ages 65 to 80 may require care that helps maintain their active lifestyles, but when they are ages 80 to 100, then they may need more geriatric expertise that preserves quality of life. Hospitals that adopt a dynamic approach to geriatric care and promote themselves as centers for elderly health may find themselves meeting a large need, depending on the marketplace.
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