Medical system struggles to deal with growing number of high-risk elderly patients

From The New York Times:

With a nudge from the new health care law and pressure from Medicare, hospitals, doctors and nurses are struggling to prepare for explosive growth in the numbers of high-risk elderly patients.

More than 40 percent of adult patients in acute care hospital beds are 65 or older. Seventy million Americans will have turned 65 by 2030. They include the 85-and-older cohort, the nation’s fastest-growing age group.

Elderly people often have multiple chronic illnesses, expensive to treat, and they are apt to require costly hospital readmissions, sometimes as often as 10 times in a single year.

The Obama administration is spending $500 million from last year’s stimulus package to support the training of doctors and nurses and other health care providers at all levels, “from college teachers through work force professionals on the front lines of patient care,” said Kathleen Sebelius, the secretary of health and human services.

But the administration and Congress seem to be paying less attention to geriatric health issues. For example, only 11 percent of research funding at the National Institutes of Health went to aging research last year.

“In every area of aging — education, clinical care, research — people just don’t realize how dire the situation is,” said Dr. David B. Reuben, chief of the geriatrics division of the David Geffen School of Medicine at the University of California, Los Angeles.

Dr. Judith Salerno, a geriatrician who is executive officer of the Institute of Medicine in Washington, agreed. “All the most common causes of death and illness and functional impairment in the general population are diseases of aging,” she said.

At N.I.H., the director, Dr. Francis S. Collins, sees the picture in different terms. He says N.I.H. budgets are tight across the board, not just for aging research, after a $10 billion spike from stimulus funds.

“The opportunities in aging research are compelling,” Dr. Collins said in a telephone interview. He mentioned a study last year on mice that lived significantly longer after being given rapamycin, a cancer and immunosuppressive drug.

“That is turning out to be the most exciting new pathway for extending normal life span that has ever been discovered,” Dr. Collins said. But he said the opportunities were also compelling in cancer, diabetes, mental illness and autism.

“It is frustrating to have such great opportunities and limited budget resources,” Dr. Collins said. They all need more funds, he added.

In hospitals and doctors’ offices, where explaining to elderly patients how to deal with their often-complicated problems can be time-consuming, payments from Medicare, Medicaid and most private insurers are not sufficient, said Dr. J. Fred Ralston Jr., president of the 129,000-member American College of Physicians.

“The payment system doesn’t finance the kind of resources we need to take care of the 20 percent of Medicare patients who use 80 percent of resources,” he said.

Dr. Mark R. Chassin, a former New York State health commissioner, said, “The biggest challenge that we face with the increasing numbers of very elderly folks is how to preserve as much independence in their lives as possible.” Dr. Chassin heads the Joint Commission, which accredits thousands of hospitals and other health care providers.

To stay independent, the elderly will need to stay healthy.

“Many of these people could be back on the golf course and enjoying their grandchildren if we did the right thing for them,” said Mary D. Naylor, a longtime geriatric care researcher and professor of gerontology in the School of Nursing at the University of Pennsylvania.

Her research showed that even fragile older people could avoid a quick return to the hospital if they are managed by teams of nurses, social workers, physicians and therapists, together with their own family members. Hospital readmissions, which cost $17 billion a year, could be reduced by 20 percent — $3.5 billion — or more, she said.

Hospitals will be penalized by cuts in their Medicare payments, starting in 2012, if too many patients are readmitted within 30 days after being discharged.

Dr. Reuben at U.C.L.A. said research showed that “vulnerable elderly people who are at risk of becoming frail often do not get appropriate care. For dementia, falls, bladder incontinence, depression, they get about a third of the care they need.”

He added: “If somebody is falling, it makes sense to examine their gait and their balance. If someone has bladder incontinence, you might want to have them do exercises, but their doctors commonly reach for the next drug they can give them.”

Hospitals are training their staffs to make special assessments of patients who may be at risk of falling, a major threat for the elderly. A fall-prevention program is a requirement for Joint Commission accreditation.

Many internists, family physicians and other primary care doctors are lobbying for payments for a team approach based in the physician’s office. The concept, which they call a patient-centered medical home, will be tried out under the new health care law by Medicare, Medicaid and some private insurers. Secretary Sebelius has called the medical home idea “one of our most promising models for improving the quality of care and bringing down health care costs.”

Geraldine Goldsmith, a patient at New York University’s Langone Medical Center, said a team of N.Y.U. geriatric care specialists “taught me how to survive” during her long fight against sickle cell anemia, a genetic blood disorder.

To stave off a painful sickle cell crisis, which may put her in the hospital as often as every six weeks, Ms. Goldsmith, who is 73, gets continuous support from Marilyn Lopez, a geriatric nurse practitioner.

Caring for the elderly is “a profession of the heart,” Ms. Lopez said.

Ms. Goldsmith said the geriatric team “makes sure that I eat proper food, take my medications, keep my appointments — as you get older, you forget.”

She added that Ms. Lopez “calls and says: ‘Geraldine, look at your calendar. I’m going to see you tomorrow.’ ”

At the N.Y.U. medical center, an electronic screening system tracks patients who may be at risk for problems with cognition, falls, nutrition, pain, skin conditions like pressure ulcers, and taking multiple medications, Ms. Lopez said. Similarly, at the University of Alabama Hospital at Birmingham, Susan B. Powell, a nurse practitioner, sees to it that medications prescribed for older patients are checked by a pharmacist against a list of drugs found to be unsafe for the elderly. So many of these patients are seeing six or eight doctors and end up with many prescriptions, Ms. Powell said.

After elderly patients are sent home, she telephones to remind them to contact a physician and to follow orders from their nurses and doctors.

Both hospitals use a precise set of methods and principles for geriatric care called Niche (for Nurses Improving Care for Healthsystem Elders). With support from the John A. Hartford Foundation and the Atlantic Philanthropies, the Niche program has spread to 300 hospitals around the country.

Although the recession has made finding jobs difficult for recent nursing graduates in places like New York and California, the Labor Department has said that 600,000 new nurses would be needed within 10 years to replace those who retire and to meet growing demand.

Currently, 11,000 of the nation’s 3.1 million registered nurses are certified as geriatric nurses or nurse practitioners. But tens of thousands of student nurses are now learning about the special needs of the elderly as part of their regular studies, said Geraldine Bednash, chief executive of the American Association of Colleges of Nursing.

Every student nurse at N.Y.U. spends time working with elderly patients. “Before long, 90 percent of American nurses will have to provide care for older adults,” said Terry Fulmer, dean of the N.Y.U. College of Nursing. Ms. Fulmer helped create and develop the Niche approach.

This year, the National Health Service Corps, a unit of the Department of Health and Human Services, is doubling its program that repays student loans for caregivers who work in rural and underserved urban neighborhoods. Family practice doctors, nurse practitioners, dentists and others who care for the elderly are among those eligible. The administration has allocated $300 million in stimulus funds to support about 7,800 graduates.

With stimulus money and $34 million more under the new health care law, the administration is also expanding training for geriatric specialists who commit to teaching student physicians and nurses.

“As we talk about needing more health care providers of all kinds,” Ms. Sebelius said in a telephone interview, “we are also retraining current providers” to become better at geriatric care.

But doctors are generally not paid extra for the time they spend in lengthy meetings listening to elderly patients with multiple problems. “Geriatricians work in one of the few fields where the more you know, the less you are paid,” said Dr. Salerno of the Institute of Medicine.

Not surprisingly, specialists in geriatric care are in short supply. There are only about 7,000 geriatricians to deal with the aging boomer generation over the next 10 years, Dr. Reuben said. More than 20,000 will be needed, according to the American Geriatrics Society, a professional and advocacy group. To help fill that gap, all first-year interns in internal medicine at the Birmingham medical school are spending four weeks with geriatric patients this year. They are part of a $200 million national effort to promote geriatric education principally financed by the Donald W. Reynolds Foundation, based in Las Vegas.

Dr. Kellie Flood, a geriatrician who directs the Birmingham program, discusses newly admitted elderly patients at 10 a.m. daily with Ms. Powell and other nurses and doctors, as well as therapists, dietitians and social workers.

“We start planning for their departure from Day 1,” Dr. Flood said. By some counts, her geriatrics unit outperforms comparable general medical units in the hospital. “We have a lower average length of stay — four days — and a lower 30-day return rate — 16 percent,” she said. The national average is close to 20 percent for Medicare patients discharged from a hospital and readmitted within a month.

Dr. Flood, Ms. Powell and their team have a fan in William Mullins, 88, a retired pharmacist who lives in nearby Pelham, Ala. Mr. Mullins, who had a small stroke in April, praised the “great care” at Birmingham. “They treated me,” he said, “like they was my daddy or my mother.”