Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients

Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients

KFF Health News, August 23, 2016

Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls.

This article first appeared August 23, 2016 on the Kaiser Health News website

By Anna Gorman | Photos by Heidi de Marco

NEW YORK — The Mount Sinai Hospital emergency room looks and sounds like hundreds of others across the country: Doctors rush through packed hallways; machines beep incessantly; paramedics wheel stretchers in as patients moan in pain.

"It's like a war zone," said physician assistant Emmy Cassagnol. "When it gets packed, it's overwhelming. Our sickest patients are often our geriatric patients, and they get lost in the shuffle."

But just on the other side of the wall is another, smaller emergency room designed specifically for those elderly patients.

Patients like Hattie Hill, who is 105 years old and still living at home. A caregiver brought her in one rainy day in late spring because she had a leg infection that wasn't responding to antibiotics. Hill, who also has arthritis and a history of strokes, said she prefers the emergency room for seniors because she gets more attention.

"I don't have to wait so long," she said. "And it's not so loud."

Packed emergency rooms are unpleasant for everyone. But they can be dangerous for elderly patients, many of whom come in with multiple chronic diseases on top of a potentially life-threatening illness or injury.

"Who is going to suffer the most from these crowded conditions?" asked Ula Hwang, associate professor in the emergency medicine and geriatrics departments at the Mount Sinai School of Medicine. "It is going to be the older adult … the poor older patient with dementia lying in the stretcher with a brewing infection that is forgotten about because it's crazy, chaotic and crowded."

Seniors who come into traditional emergency rooms are frequently subjected to numerous and sometimes unnecessary tests and procedures, according to research and experts. They stay longer and their diagnoses are less accurate than younger patients. And they are more frequently admitted to the hospital by ER doctors overwhelmed by the constant influx of very sick patients.

"You've got this surge of more and more older adults coming to the emergency departments," said Kevin Biese, co-director of geriatric emergency medicine at the University of North Carolina School of Medicine. "Yet there hasn't necessarily been this recognition that [they need] different screening, different treatment and they are going to have different outcomes."

Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.

The staff in these specialized ERs collaborate closely not only to treat the seniors' immediate health problems but also to reduce their risk of confusion, bed sores and over-medication. Senior ERs are designed to be more quiet and tranquil.

Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls, Hwang and others said. That tends to reduce hospitalizations among the elderly.

Mount Sinai, which opened its geriatric emergency room in 2012, is part of a nationwide effort to find a better way to treat elderly patients. The first geriatric ER opened in New Jersey in 2008, and now there are more than 100 such units nationwide. Several others are being planned, including in California, North Carolina, Connecticut and Texas.

Geriatric ERs vary widely. Some are separate units with trained staff; others are merely sections within traditional emergency rooms with extra hearing aids and other senior supplies. But professional medical organizations have developed guidelines to standardize design, staffing and patient screening.

The boomlet in geriatric emergency rooms stems in part from an increase in older patients with complex conditions who are seeking care in regular ERs. That has caused some providers and hospitals to seek more effective and efficient ways to treat them.

About 20.4 million patients over the age of 65 were treated in emergency rooms in 2011, up from 15.9 million a decade earlier, according to a national hospital survey conducted by the Centers for Disease Control and Prevention. As the population ages, older patients are expected to make up an increasing share of ER patients.

The Affordable Care Act also has fueled the expansion of senior emergency rooms. The law assesses penalties when too many patients return to a hospital too soon after discharge. Facilities have tried to reduce readmissions in part by providing better emergency care and triage.

Now, that growth could continue as hospitals face additional pressure to provide more efficient and less costly care to their Medicare patients. The Centers for Medicare and Medicaid Services announced in January that within two years, half of all traditional Medicare payments will go to providers based on quality of care rather than quantity of services.

Emergency departments are the perfect places to make changes that could help control spending, because they are gateways between home and costly hospitalizations, Hwang said. About 60 percent of elderly patients who get hospitalized come through the emergency room, according to a 2013 Rand Corporation study. A quarter of those hospitalizations are preventable, according to one 2012 federal study.

"Hospitals that before didn't think there was any need for this are saying, 'Can you help us create a geriatric ED?'" Hwang said.

Hospitals also may view specialized emergency departments as a marketing tool to reach the growing elderly population.

The geriatric emergency room at Mount Sinai is set up differently than traditional emergency rooms. It has thicker mattresses to help reduce the chance of bed sores, raised toilet seats, hand rails in the hallways and reduced-noise curtains.

The department is allotted 20 beds, but the main hospital sometimes steals them for other patients. That leaves some older ER patients waiting in the hallway.

Over a two-day period in May, dozens of older patients were treated for falls, dizziness, severe pain and shortness of breath.

John Fornieri, 80, came in after falling on his floor at home. Fornieri, an artist with arthritis and a heart condition, said he nearly lost consciousness. An x-ray showed he had broken a hip.

Fornieri said he was grateful that the geriatric emergency room staff was trained to care for the elderly. "Seniors need a different kind of attention," he said. "We can't see and we can't hear like we used to. We can't even talk the same."

Denise Nassisi, a physician who runs the geriatric ER, said her patients are at greater risk of falling, medication errors and infections than younger patients. Seemingly routine injuries can have devastating effects. Broken arms, for example, can make it difficult for elderly people to care for themselves.

Many also have dementia or other cognitive impairments that make it harder to get an accurate account of their medical history and the reason for their ER visit, she said. About half of the patients arrive unaccompanied by relatives or caregivers.

In the past, Nassisi said, doctors frequently just admitted the patients, leaving it to the hospital staff to do a more complete workup. But now, Nassisi and her team of social workers, therapists, nurses and others try to screen, diagnose and treat patients more thoroughly in the ER, she said.

Part of their job is to determine whether older patients can be safely discharged. That means they aren't automatically admitted to the hospital, which would raise their risk of confusion and loss of independence. "We are trying to change the culture of just admitting," Nassisi said.

A patient doesn't need a clean bill of health to be discharged. One 81-year-old patient came in for a toothache but also had a long list of illnesses: coronary artery disease, chronic pulmonary disease, arthritis, high blood pressure, prediabetes and high cholesterol. She was released with pain medication, antibiotics and an appointment with a surgeon.

Another patient, who was 83 and had high blood pressure, anxiety and cancer, had fallen in her kitchen. She, too, was discharged after staff ensured she could walk on her own and had help at home.

As providers determine where the patients should be treated, they also try to prevent them from becoming delirious, developing additional problems or taking potentially harmful medications.

Physician assistant Jaclyn Schefkind evaluated Hill, the 105-year-old patient.

"How are you doing?"

"Bad," Hill said, wincing in pain.

Schefkind looked at Hill's leg, red and swollen. She said they were going to get her some stronger antibiotics and something to relieve the pain.

"Let's start with Tylenol," Schefkind said. "I don't want to give you something too strong because it's not safe when you're older."

Shortly afterward, the team decided the best place to admit Hill so doctors could get her infection under control. A nurse pulled Hill's blanket up to her chin, packed up her belongings and rolled her through the door toward the main hospital.

AORN: Evidence Supporting ACS Surgical Attire Guidelines is Lacking

Interpreters Key To Easing Patients' Final Days

KFF Health News, August 22, 2016

Interpreters routinely help people who speak limited English understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.

This article first appeared August 22, 2016 on the Kaiser Health News website

By Eryn Brown | Photos by Heidi de Marco

MORENO VALLEY, Calif. — Alfredo David lay in bed, looking deflated under an Avengers blanket, as a doctor, two nurses, and medical interpreter Veronica Maldonado entered his hospital room. He wrapped up a call from his wife, then fiddled idly with his phone.

He had received distressing news from the team at the Riverside University Health System Medical Center: His sharp abdominal pains and difficulty eating, previously diagnosed at another hospital as gastritis, were actually caused by metastatic cancer. The tumor was growing. David, 45, was not going to recover.

Maldonado pulled up a chair for herself and another for palliative care specialist Dr. Faheem Jukaku, and the two sat at David's eye level. Pointing to an MRI image of David's abdomen, Jukaku explained in English how surgeons would attempt to ease his symptoms the next day. Maldonado translated Jukaku's words into Spanish, modulating her tone of voice to match the doctor's delivery.

David listened — seeming resigned, but grateful that some relief might be on the way. Occasionally he'd ask a question in Spanish about the procedure, which Maldonado translated back to Jukaku. Asked about his earlier misdiagnosis, he rolled his eyes.

David, a mechanic and father of three teenagers, understands some English. But he said Maldonado's help had been crucial to deciding on his new course of treatment. Thanks to her, he said in Spanish as she translated, "I don't have any misunderstandings. I'm more at peace."

Interpreters routinely help people who speak limited English — close to 9 percent of the U.S. population, and growing — understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.

Many doctors and nurses need the assistance of interpreters not only to overcome language barriers but also to navigate cultural differences. Opportunities for miscommunication with patients abound. Words don't always mean the same thing in every language.

Medical staff, already nervous about delivering bad news, may speak too quickly, saying too much or too little. They may not realize patients aren't comprehending that the team can no longer save their lives.

"That's when it gets interesting," Maldonado said. "Does the doctor understand that the patient isn't understanding?"

At Riverside and some other hospitals, interpreters have completed special training and work closely with palliative care teams to help patients and their families decide when the time has come to stop trying to cure a disease and start focusing on comfort and quality of life.

Palliative care is unusual among medical specialties, said Dr. Neil Wenger, an internist who is chair of the ethics committee at the UCLA Medical Center. Rather than curing or eliminating disease, its purpose is to manage symptoms for patients who are not expected to recover.

Physicians and nurses talk at length with dying patients and their families about their wishes, collaborating with social workers, chaplains and hospice workers. Under any circumstances, the clinical shift from curing disease to treating symptoms can be difficult for doctors and patients. Advance care planning — a process used to help patients understand their prognoses and explore preferences for future care — is more like psychotherapy than a routine medical consult, Wenger said.

"This is not a straightforward set of questions," he said. "You ask a question, and the next question is dependent on the response. It's very easy to use the wrong words and startle the person and put them off. It's a dangerous conversation."

When there's a language or culture gap, Wenger added, the interaction becomes much more difficult. Both sides can fail to recognize important nuances, such as body language and variations in the meaning of words.

Wenger said that he finds it hard to speak with patients about palliative care through an interpreter because, in his experience, unexpected turns in the conversation and difficult emotions can literally get lost in translation.

Others say that interpreters are key for helping patients make sense of palliative care — that they just need extra training to be good at it.

Kate O'Malley, a senior program officer at the California Health Care Foundation, said she started thinking about interpreters when the Oakland, Calif.-based foundation funded new palliative care programs in safety net hospitals throughout the state. It found that vast numbers of patients did not speak English as their primary language.

At Los Angeles County-USC Medical Center, for instance, 68 percent of palliative care patients in 2011 spoke a first language other than English. At San Francisco General Hospital, that number was 45 percent; at Riverside County Medical Center, 33 percent.

"One of the key tenets of palliative care is to have goals-of-care discussions," O'Malley said. So when patients speak a different language, "How do you do that?" Her team found that palliative care providers sometimes brought in interpreters to assist, but that many of them didn't have the knowledge, training, or vocabulary to convey key concepts.

Take the idea of hospice, the comprehensive palliative care services available to patients in their last months, often at home. For people from Mexico, the Spanish equivalent hospicio "conjures up the image of the worst nursing home you could ever imagine, where people are disabled and left for dead," said Dr. Anne Kinderman, who runs the palliative care service at Zuckerberg San Francisco General Hospital. "If I come into the room and say, 'I'm here to tell you about this great thing called hospicio,' there's a cognitive disconnect," she said.

Interpreters have to learn how to bridge that gap. "You have to know how to present [hospice] in Spanish," said Viviana Marquez, supervisor of the department of language and cultural services at Riverside, and Maldonado's boss. "It's not a matter of finding an equivalent word, because there is none. You have to get into a deeper explanation."

Without that kind of clear communication, many Latino families never understand that hospice isn't a place but rather a suite of comfort-focused extra services, available at home, that relatives usually can't provide on their own, said Beverly Treumann, a medical interpreter in Los Angeles who now works as head of quality assurance for the Health Care Interpreter Network, an Emeryville, Calif.-based cooperative that lets member hospitals share interpreters through videoconferencing.

Treumann said she once trained an interpreter who had refused hospice for her own mother because of such a misunderstanding. "This interpreter, she was heartbroken," Treumann said. "The family took care of the mother — but without the extras that hospice could provide. The mother suffered because the concept wasn't explained adequately."

Cultural differences can breed other misunderstandings too, Kinderman said. Families from many parts of the world approach health care decisions as a group. That can make a palliative care concept like a health care proxy — a person who makes medical decisions when a patient becomes incapacitated — hard for them to grasp.

Hoping to bypass all these potential minefields, the California Health Care Foundation recruited Kinderman and other experts to help develop a palliative care curriculum for interpreters.

It introduces the palliative care concept, defining terms and providing vocabulary to help interpreters accurately convey key ideas. It encourages interpreters to alert physicians when they suspect a patient and his family don't understand what they are told. It also includes materials to help interpreters deal with their own complicated emotions during palliative care encounters.

Marquez said that all 10 of the Riverside medical center's interpreters have completed some version of the curriculum, which is taught in person or on the web.

For Maldonado, who has been interpreting for about five years, working with palliative care patients has become a passion.

She attends the palliative care team's weekly meetings, working closely with staff and patients. If Maldonado is around when a difficult conversation arises, she's the first person Marquez sends to interpret. If Maldonado or another interpreter who is comfortable with palliative care work is not available, Jukaku said, "we try to postpone the talk."

Last year, Maldonado taught a palliative care training course for interpreters. The session, held at the Moreno Valley hospital, attracted around 50 participants from throughout Southern California.

The participants wanted to talk about terminology and "vicarious trauma" — the emotional toll that interpreting for palliative care patients can take. They shared self-protection techniques. Marquez recommended using the third-person voice instead of the customary first person: rather than directly translating the doctor's words and saying "I recommend," an interpreter might create emotional distance for herself in difficult moments by saying, "your doctor recommends."

Maldonado said she, too, has trouble sometimes containing her feelings when families are distraught or have trouble accepting that a patient may soon die. "Later in the day I say, 'Oh my God … can I vent?' I have to vent."

But Maldonado also noted that raw emotion from the families means she is doing her job well.

"When we get the tears and the reactions," she said, "we know we've rendered the message."

California Lawmaker Pulls Plug On Drug Price Transparency Bill

KFF Health News, August 18, 2016

The original bill required drug manufacturers to notify state agencies and health insurers within 60 days of federal approval of a new drug with a price tag of $10,000 or more per year or for one course of treatment and provide information justifying those prices.

This article first appeared August 17, 2016 on the Kaiser Health News website

By Ana B. Ibarra

After being approved by a key committee last week, a bill that would have required drug companies to justify treatment costs and price hikes was pulled by its author on Wednesday.

California state Sen. Ed Hernandez (D-West Covina) said that he introduced the bill "with the intention of shedding light on the reasons precipitating skyrocketing drug prices." But amendments by an Assembly committee last week make it difficult to accomplish this goal, he said in a statement.

"The goal was transparency, making sure drug companies played by the same rules as everyone else in the health care industry," he said.

The original bill required that drug manufacturers notify state agencies and health insurers within 60 days of federal approval of a new drug with a price tag of $10,000 or more per year or for one course of treatment and provide information justifying those prices. It also required these companies to provide notice before they increased the price of a drug by more than 10 percent. It was approved by the Senate in June.

But amendments by the Assembly Appropriations committee raised the reporting threshold for drug price increases to more than 25 percent. The amendments also removed the requirement for drug companies to provide justification for the price increases and delayed by a year when these notifications would have to go into effect.

"I would have preferred to see the Legislature tackle the need for pharmaceutical pricing transparency this year, but I respect Senator Hernández's decision," said Assemblywoman Lorena Gonzalez (D-San Diego), chair of the Assembly Appropriations committee. "I believe the amended version of SB 1010 [the bill] would have provided a first-in-the-nation framework this year that could have been built upon in the future."

Hernandez said he will continue to work closely with health advocates and community organizations until they "get it right."

"This is an issue that will not go away and the public demands answers," he added.

The bill had gathered support from patient, labor, education and business groups and was opposed primarily by the pharmaceutical industry. The opponents have said the bill places the responsibility solely on drug companies, ignoring that other organizations also affect drug prices, including wholesalers, distributors, health plans and other purchasers.

Some groups representing seniors and patients with chronic diseases had also expressed concerns about the legislation.

"The voters are with us and will be even more so in the future," said Anthony Wright, executive director of Health Access California, a Sacramento-based health care advocacy group. "Every new high-priced drug or unjustified price spike increases public attention and anger, not to mention contributes to rising health premiums."

Supporters referred to the bill as a solution to battling rising health care costs. Allowing insurers and state purchasers to know the cost of drugs at least 30 days in advance would enable them to better negotiate prices, supporters had said.

Key state drug purchasers include the California Public Employees' Retirement System and Medi-Cal, the state's version of the Medicaid program for low-income people.

Researchers have said that while drug price transparency measures alone, such as Hernandez's bill, would not bring health care costs down, they could help prevent drug companies from raising prices without explanation.

Similar proposals in other states have included requiring drug companies to report closely held research and development costs to government agencies. California joins other states where efforts have been stalled this year.

Hernandez's bill is separate from a ballot initiative on drug prices also garnering publicity this summer. That initiative, Proposition 61, would prohibit the state from paying more for prescription drugs than the lowest prices negotiated by the U.S. Department of Veterans Affairs.

License delays have plagued nursing boards across the nation in recent years in Georgia, Maryland and, more recently, Ohio.

Licensing Logjam For California Nurses

KFF Health News, August 18, 2016

License delays have plagued nursing boards across the nation in recent years in Georgia, Maryland and, more recently, Ohio, where thousands were reportedly waiting on backlogged license applications as of early August.

This article first appeared August 17, 2016 on the Kaiser Health News website

By Eryn Brown

Ivana Russo submitted her application for a California nursing license on April 22, nearly a month before she graduated from a nursing program at Brightwood College in San Diego. She expected it to take 10 to 12 weeks for the state to process her paperwork and authorize her to take the licensing exam.

As of early August, 15 weeks later, the licensing board still had not reviewed her file and could not tell her when it would. Russo called the agency, often, to ask about the status of her application. It was hard to get a staff member on the phone. When she did, she said, "Every time I got a different story."

State officials claim that hiring new nurses is a crucial workforce concern for California, yet at least 2,000 recent nursing graduates like Russo remain in licensing limbo, with their applications taking as long as 24 weeks for the Board of Registered Nursing to process.

Experienced nurses from other states who apply for California licenses also wait months for the go-ahead to work.

Even as labor experts worry the U.S. won't have enough nurses to care for an aging population, license delays have plagued nursing boards across the nation in recent years — in Georgia, Maryland and, more recently, Ohio, where thousands were reportedly waiting on backlogged license applications as of early August.

The current delay in California comes on the heels of a related slowdown in 2014 and is a major inconvenience for the nurses who want jobs and a hassle for the hospitals that want to hire them. And critics say at least some of the problem stems from the flawed $96 million implementation of a computer system called BreEZe which, as its name suggests, was intended to streamline professional licensing.

"We have positions for them, but we can’t let them in without licenses in hand."

Patricia McFarland, CEO of the Association of California Nurse Leaders, an advocacy group, described the computer system as poorly conceived and inefficiently deployed, citing it as a significant contributing factor in the delays. Moreover, she said, the licensing board doesn't have a big enough staff to handle the volume of license applications it receives.

"We can't license our graduates," McFarland lamented. "Nurses want to retire, they want to train the next generation. We have hospitals investing in residency programs and they can't start the new nurses they want to hire. At the end of the day, who's suffering? Our nurse graduates and our patients."

Veronica Harms, a spokeswoman for the nursing board and for the Department of Consumer Affairs that oversees it, said the department had resolved early glitches with the new computer system. But she acknowledged that the system is still labor-intensive and time consuming, and she agreed more staff is needed to speed the licensing process.

Harms said that the board's new executive officer, Joseph Morris, who started July 10, "has acknowledged the backlog of applications and is determined to work with [the department] in finding long-term solutions."

The nursing board is responsible for licensing the state's more than 417,000 registered nurses, or RNs. It conducts background checks, verifies educational bona fides and authorizes nurse graduates to take the National Council Licensure Examination, or NCLEX, which candidates must pass to get their nursing license. In fiscal year 2015-2016, the board issued 23,743 licenses, more than half to new nurses.

This year's delays are not the first at the board, which suffered a slowdown in 2014 after it and nine other state licensing agencies adopted the "off-the-shelf" BreEZe system. Once launched, the system malfunctioned, upending workflow and creating more tasks for staff.

A February 2015 report on the system by the California State Auditor concluded that the consumer affairs department "failed to adequately plan, staff and manage the project for developing BreEZe." The audit recommended that the nursing board analyze its application process to determine its need for additional resources.

But McFarland, of the nurse leaders' association, said the state audit was a "game of dodge ball" in which the consumer affairs department and state IT leaders refused to accept responsibility for a real fix.

The audit showed that most of the 10 state boards that implemented BreEze in 2014 were "generally dissatisfied" with it. All 10 were unhappy with the ;system's reporting capability, and eight of them said the system actually made their operations less efficient.

Today, BreEZe is used by 18 state boards, bureaus and committees, including the Medical Board of California, the Dental Board and the Board of Behavioral sciences.

The nursing board reports on its website which applications it is currently reviewing — but only by dates received, not by name. Applicants cannot click to find out where their individual applications stand in the process or how much longer they should expect to wait. And the website warns that "contacting the Board for application status while within these timeframes may cause processing delays."

As of Aug. 8, the board was processing applications filed between March 16 and March 31, according to the website. Nursing graduates said it seems to have been working on March applications for some time.

On July 27, Russo asked if showing up in person might help expedite her case. The worker on the phone said she didn't think so.

"I'd drive eight hours up to Sacramento if it meant I could move this forward even one week faster," Russo said. Promising offers come and go, she said, but she can't start a job until she has her license.

She said she had to withdraw or cancel interviews with a subsidiary of Rady Children's Hospital-San Diego and the Center for Discovery La Jolla, a residential treatment facility.

Other nursing grads are also feeling confused and frustrated as their job searches get mired in the state's licensing logjam.

Lara Golden, who recently earned a Master of Nursing degree from the University of Virginia, applied for her California license on April 13. She had postal receipts, but when she called the board in June they couldn't find her paperwork. So she flew from Virginia to California to submit a second set of fingerprints in person. Seven weeks and many phone calls later, Golden is still uncertain when her application will be reviewed.

Fremont resident Angel Li received her bachelor's degree in nursing from Washington State University in Spokane in May. She submitted an application to the nursing board on March 15. After hearing nothing for 12 weeks she, too, started calling the agency.

"I kept waiting and waiting and calling back, which is not an easy task," she said. "Sometimes they just hang up due to the high call volume."

In May, Li said she had a promising interview for a pediatrics position at a Southern California hospital. The manager wanted to hire her, but said she couldn't move ahead until Li had a license.

Golden is supposed to start a residency program at a UC hospital but fears she won't have her license in time.

"I have people calling me crying," said Kathy Harren, regional chief nursing officer at Providence Health and Services, Southern California. "We have positions for them, but we can't let them in without licenses in hand."

Nancy Blake, critical care services director at Children's Hospital Los Angeles, said that as of Aug. 9, 22 nurses out of the 57 her hospital has hired for its nursing residency program, which starts September 26, still had not been cleared by the nursing board to take the licensing exam. Under normal circumstances, only two or three candidates would not yet have taken the test by this point in the summer, she said.

Blake, who hit roadblocks while renewing her own license earlier this year, worries that young nurses will get discouraged — and that hospital staffing will suffer. "A lot of the boomers are retiring," she said. "I believe we're on the cusp of a nursing shortage."

A 2014 survey by the state nursing board acknowledged as much, reporting that nearly half of California's nurses were over 50 and that many younger nurses were having trouble getting work. It is "essential that recently graduated RNs find employment opportunities so they are prepared to take on the roles of retiring RNs," the report urged.

Susan Odegaard Turner, founder of Turner Healthcare Associates, a consultancy in Thousand Oaks, said California now has more of the newly trained nurses it needs but still has not solved the problem.

"We got more nurses. But now they can't get their license," Turner said. "This is a different kind of shortage. We've produced them, but they're not working."

Syncing Up Drug Refills: A Way To Get Patients To Take Their Medicine

Syncing Up Drug Refills: A Way To Get Patients To Take Their Medicine

KFF Health News, August 17, 2016

Patients whose prescription refills were aligned were more likely to follow their medication regimens. These findings come as more states pass laws that support the concept by requiring health insurance plans to cover partial refills of medication, and to charge pro-rated copays when they do so.

This article first appeared August 8, 2016 on the Kaiser Health News website

By Shefali Luthra

You have your red pill and your green pill. There's the one you take at breakfast, the one you take before bed and the one you have to take six hours after eating. All told, it is a lot to keep track of. And remembering the refills, all of which often happen at different times of the month, gets so complicated that sometimes you forget — and simply go without.

For the quarter of Americans with multiple ailments, this scenario is very familiar. It is also part of the reason, experts suggest, close to half of people with chronic conditions don't take their medications as directed by their doctors. This noncompliance costs the health care system hundreds of billions of dollars.

But a study published Monday in Health Affairs suggests a possible fix: syncing up prescription refill timelines for patients who take multiple medications.

"We have so many things going on and so many complexities in our daily lives that reducing one level of complexity, and getting rid of issues related to forgetfulness — that's a huge service," said Jalpa Doshi, an associate professor at the University of Pennsylvania's medical school, and the study's lead author.

Researchers began with a group of patients who were Medicare Advantage plan members, were taking medications for diabetes, hypertension or cardiac disease, and who participated in Humana's pharmacy mail-order service. They then randomly assigned 2,500 of them to an "intervention invitation group." Of those, 691 were reachable and agreed to enroll in this "pilot prescription synchronization program." A separate 695 were not contacted and made up a control group that continued to receive prescriptions as usual.

Patients whose prescription refills were aligned were more likely to follow their medication regimens, with overall rates of adherence increasing by 3 to 10 percentage points between September 2013 and December 2014. For those in the control group, adherence increased by only 1 to 5 percentage points. Improvement was greater for people who, at the start of the study, were already less likely to take medications correctly. For this group, syncing prescriptions boosted adherence by between 23 and 26 percentage points, as opposed to between 13 and 15 in the control group.

These findings come as more states pass laws that support the concept by requiring health insurance plans to cover partial refills of medication, and to charge pro-rated copays when they do so. Such measures make it possible for consumers and physicians to work together to make sure that prescription refill cycles match up.

That policy change can make a huge difference for people on multiple chronic prescriptions, Doshi said — a circumstance particularly common among elderly patients.

"If I'm an elderly person who needs care and support, I need someone to go to the pharmacy, or drive me. That in itself is a huge issue," she said. Even with mail-order prescriptions, remembering when individual ones end and making sure to keep them on schedule is a huge challenge. And if patients aren't getting their medications on the correct schedule, they can hardly take them as directed, she said.

Some independent researchers, however, were quick to point out that these findings are only a first step and that additional research is necessary. But if these results hold, the approach could help make a dent in unnecessary health expenses and keep chronically ill patients healthier.

They also cautioned against placing too much weight upon these findings. For instance, there's the self-selecting nature of people who had their prescriptions synced. Because they opted into the program, they may have been people already looking for ways to improve their medication habits, said Walid Gellad, co-director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. That could have inflated the improvement researchers found.

He added, though, that the practice seems promising.

"Intuitively, it would be great if you could get all the medications at the same time, rather than having to figure out when each one was due" for a refill, said Gellad, who wasn't involved with the study. "It's really patient-centered, and a good way to simplify things."

The study also doesn't link greater medication adherence to patients getting or staying healthier. That makes it hard to measure how much syncing prescriptions would really help consumers, noted Hayden Bosworth, a professor of medicine at Duke University.

But, that said, "with these particularly effective drugs — there's no question that if you take them, you're going to have benefits," he added. Bosworth also was not involved with the study.

Other research has strongly associated better adherence with improved patient health, said Niteesh Choudhry, a professor of medicine at Harvard Medical School, who was also not involved.

Meanwhile, it's still unclear how many patients actually want the service. In the study, only about 28 percent of customers opted to have their medications aligned. That could undermine the practice's potential.

The study's authors attributed that reluctance to what they call "status quo bias" — the idea that people are generally reluctant to deviate from a system they have in place.

Plus, the study only looked at Medicare Advantage patients who got mail-order prescriptions. That's a very specific group, said Choudhry. It's possible that when you extend out, the potential to benefit from prescription syncing changes.

And it's unclear who is most likely to benefit. This study looked at older patients, who are already more likely to adhere to their medications. More research should examine whether younger people — who are worse about taking their pills — could stand to gain from prescription syncing, Choudhry said.

No matter what, Bosworth said, the practice must be part of a larger strategy. Given how many people don't take their medications properly, there's no single silver bullet.

"Medication adherence is one of the largest public health problems we have," he said. "I don't think this is going to get us there, but it is part of the puzzle."

Medical Providers Try Uber, Lyft For Patients With Few Transportation Options

Medical Providers Try Uber, Lyft For Patients With Few Transportation Options

KFF Health News, August 17, 2016

This article first appeared August 17, 2016 on the Kaiser Health News website

By Zhai Yun Tan

While hospital efforts to use ride-hailing services are still small, providers think the potential for growth is large. In some cases, the cost is even covered by Medicaid and other insurance plans.

Edith Stowe, 83, waited patiently on a recent afternoon at the bus stop outside MedStar Washington Hospital Center in the District of Columbia. It's become routine for her, but that doesn't make it any easier.

Stowe, who lives about five miles from the hospital, comes into the medical center twice every three months to get checkups for chronic kidney failure. She doesn't own a car and relies on buses. During rush hour, buses are more frequent, and she can keep the commute to about 30 minutes. But when she has to come in the middle of the day, it takes her at least an hour to get in and another hour to get home.

"It's pretty good except for waiting during non-rush hours," she said. "When that happens I don't plan anything else for the day."

For people without access to private transportation, getting to medical appointments can be a challenge, especially if they have chronic conditions that require frequent appointments.

Some hospitals and medical providers think that the hot-new technology in town — ride-hailing services such as Uber and Lyft — can address this problem by making the trips easier and, in some cases, it is even covered by Medicaid and other insurance plans. Partnerships between ride-hailing companies and hospitals are emerging around the country. While the efforts are still small, some hospitals and medical transportation providers think the potential for growth is large.

MedStar Health, a nonprofit health care system with hospitals in Maryland and the district, began a partnership with Uber in January that allows its patients who use Uber to access the ride service while on the hospital's website and set up reminders for appointments. Medicaid patients who may not have access to the Uber app can also arrange the ride by calling the hospital's patient advocates.

National MedTrans Network, a transportation system that provides non-emergency medical rides for patients and medical providers in a number of states, expanded its services through a partnership with Lyft last year in New York, California and Nevada.

Hackensack UMC, a hospital in New Jersey, the Sarasota Memorial Hospital in Florida, and Relatient, a health care communication company have also announced partnerships with Uber in the past year. Veyo, a San Diego startup, says it is offering a ride-hail-like technology for health care appointments in Idaho, Arizona, Texas, Colorado and California.

"We probably had 50 different systems across the country reach out to us and ask us 'How did you do it?'" said Michael Ruiz, chief digital officer for MedStar. "I would say that it has been a seismic shift for the people who have used the service and the places we've provided it."

Patients' costs for the services vary. For Medicaid patients, transportation for non-emergency medical visits are covered, although the extent of reimbursement depends on state rules. Traditional Medicare does not cover non-emergency medical transportation, although some private Medicare Advantage plans may offer some benefits. 

Getting To Your Doctor

When going to a medical appointment becomes a hassle, patients are likely to miss the visit, and that can help lead to untreated symptoms or worsening health.

"Transportation can make it difficult for people to see health care providers on a regular basis," said Ben Gerber, an associate professor of medicine at the University of Illinois at Chicago who has studied patient transportation issues. "It is important to see health care professionals regularly, especially for patients with diabetes or asthma."

In a 2013 analysis of 25 studies, Gerber and colleagues found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access. One of those studies showed that 82 percent of those who kept their appointments had access to cars, while 58 percent of those who did not keep appointments had that access. Another study reported bus users were twice as likely to skip on appointments compared to car users.

In addition to concerns about patients' health, those absences can also be expensive for medical institutions, which lose revenue from the missed appointment.

Hospitals and managed care organizations do offer a variety of options to assist with transportation for non-emergency medical appointments. Health centers often work with volunteer drivers to pick up and drop off patients.

Patients can call them ahead of time to arrange a ride, but these services generally require advance planning, which becomes a problem when the patient needs to go in for an unscheduled appointment or if the patient forgets to book ahead.

Some patients also end up calling 911 for non-emergency situations, potentially diverting resources that could be used for others with more pressing needs.

Timely Services 

The National Medtrans Network partnership with Lyft began after an incident in February 2015. One of its clients, an elderly woman, was left waiting for a ride to a hospital in New York in freezing weather for 30 minutes. The contracted provider failed to show up.

"It was almost a dangerous situation," said CEO Andrew Winakor. When his company was notified of the situation, officials immediately called a ride-hail service. The ride arrived within six minutes. Winakor said Medtrans officials realized they had to find a transportation option that could respond immediately to canceled rides.

But ride-hailing services do have some disadvantages. Wheel-chair friendly rides are still limited to a few cities. They also depend on the availability of drivers, which might be scarce in rural areas and low-income communities.

MedStar in Washington, dealt with the problem in one of its hospitals in rural Maryland, where there was a lack of Uber drivers, when a patient there had to travel to the flagship hospital in D.C. for an outpatient surgery at 6 a.m.

"Our social workers worked with the folks at Uber to be able to coordinate the ride to pick this patient up at 4:30 am, and coordinate the ride back," Ruiz said.

Buses, vans and local public transportation for people in wheelchairs come and go frequently in MedStar Washington Hospital Center's bus center. Stowe is satisfied with the transport options available. While she hasn't used Uber before, she said it is something she wouldn't mind trying especially when it gets cold outside.

"There are times when you come out and you really don't feel that well. If Uber is here, it'd be really nice to have it," said Stowe.

Fall Risk

Elderly Patients In The Hospital Need To Keep Moving

KFF Health News, August 16, 2016

Acute Care for Elders units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly. Research has shown that the units reduce readmissions.

This article first appeared August 16, 2016 on the Kaiser Health News website

By Anna Gorman

BIRMINGHAM, Ala. — Thelma Atkins ended up in the University of Alabama at Birmingham (UAB) Hospital-Highlands after a neighbor in her senior living center ran over her feet with a motorized scooter.

Terri Middlebrooks, a nurse at the hospital, tried to figure out how active the 92-year-old Atkins was before the incident. "Are you up and moving at home?" she asked.

"I can manage, but I have to have help sometimes," Atkins replied.

Atkins said she uses a walker to visit friends and to get to the communal dining room. But she's also fallen a few times in recent years.

"Don't quit walking here," Middlebrooks told her. "It's the most important thing you can do. … This bed is not your friend."

Middlebrooks is the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active.

The medical center's effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don't put a high priority on making them walk.

At UAB Hospital-Highlands' 26-bed geriatric unit, known as the Acute Care for Elders unit, or ACE, patients are encouraged to start moving as soon as they arrive. The unit is one of a few hundred around the U.S. that is attempting to provide better and more tailored care to geriatric patients.

The hospital opened the unit in 2008 with the recognition that the elderly population was growing and that many older patients didn't fare well in the hospital. ACE units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly.

Research has shown that the units shorten patients' stays in the hospital, reduce their likelihood of returning too soon after discharge and make it less likely they will be sent to a nursing home.

In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.

Staff members try to disabuse patients of the idea that they are there to rest. "People walk in the door of a hospital and think it's OK to stay in a bed. It's not," said Middlebrooks.

Andres Viles, a nurse coordinator, said nurses at other hospitals are often so busy administering medications and tending to wounds that they don't make time to walk with their charges. The emphasis on patient mobility is "a culture change" for most hospitals, he said.

At UAB Hospital-Highlands, that shift took a lot of education. Staff members in the new unit attended workshops that included role playing and sensitivity training. The hospital also trained "geriatric scholars," who became advocates for addressing the particular physical and cognitive needs of seniors.

The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don't fall, often leave them in their beds.

"We are doing an awful lot to prevent falls, but there is a cost," said Heidi Wald, an associate professor at the University of Colorado School of Medicine. "The cost is decreased mobility."

Researchers said there are other explanations for the failure of hospitals to get elderly patients moving. They may not have enough staff, for example, or they may fear lawsuits.

Families won't sue if their mom gets weaker in the hospital, but they may if she falls, said Cynthia Brown, director of the Division of Gerontology, Geriatrics and Palliative Care at the UAB School of Medicine.

"Why would the hospital want to put themselves at risk for litigation or the CMS [Centers for Medicare and Medicaid Services] coming back and biting them?" she said.

Brown added that hospital staffers around the country generally do not consider walking with patients to be as important as their other duties. "It is just one more thing on a list of a whole lot of things," she said. "Often times, walking falls to the bottom."

It's also harder for patients to walk around if they are attached to IV lines or oxygen tanks, or if they take drugs that make them sleepy. Such medication or equipment is not always necessary.

The very layout of hospitals and the way they operate makes it too easy for patients to remain stationary. They can control their televisions by raising a finger, and they typically get their food in bed.

On average, hospitalized older patients spend just 43 minutes a day standing or walking, according to a study by Brown published in the Journal of the American Geriatrics Society. They are in bed more than 80 percent of their hospital stay, she found.

The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.

Immobility can also reduce patients' ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.

Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.

Instead of returning home to their normal lives, patients who can't walk when they leave the hospital are more likely to go into nursing homes, said Seth Landefeld, chairman of the Department of Medicine at the UAB School of Medicine.

"They don't bounce back," Landefeld said. "The pneumonia is better, but Aunt Mary is not walking and talking the same as before."

Landefeld said hospitals frequently take the "smart bomb" approach to illness. "We blow away the disease, but we leave a lot of collateral damage," he said.

Making sure hospitalized patients spend sufficient time out of their beds can save money, keep them mobile after they return home and improve their overall health. Researchers in Texas found that increasing the number of steps elderly patients took on their first and last days in the hospital reduced their risk of dying over the following two years. A study of pneumonia patients of all ages showed that walking early in their hospital stay shortened its duration, saving an average of $1,000 per patient.

The hospital hosts a twice-weekly session called "Move and Groove," designed to get older patients dancing. At a recent session, a music therapist played the piano as the patients held tambourines or bells and moved their feet to the beat. All of the patients used walkers. A few had oxygen tanks and most wore bracelets indicating they were at risk of falling.

Occupational therapist Linda Pilkerton said she doesn't give patients a choice of whether to participate.

"We don't ask them if they want to do an x-ray or if they want a CT scan," she said. "This is ordered by the doctor. If they don't get up and move, they start the death spiral."

After Atkins was admitted to the unit following the scooter mishap, Middlebrooks told her it would only take two days of lying in bed to lose muscle mass. "And if you lose muscle mass, you get weaker and you're more apt to fall," the nurse explained, adding that Atkins had done enough of that.

Atkins, who has a pacemaker and has had hip and hernia surgeries, said she has lived alone a long time and doesn't want to end up in a nursing home. As she pushed her walker down the hospital corridor, she acknowledged that she's gotten weaker as she's gotten older and that her arthritis makes it more difficult to shower and dress by herself.

But she said she's determined to keep walking — at home and in the hospital.

"I don't want to lose more independence," she said. "I've already lost a lot of it."

But even if patients spend a lot of time out of bed while they are in the hospital, it does not guarantee they will recover.

Willie Mae Rich, 86, came to the Alabama hospital this spring because her doctor was concerned about her heart. Rich knew her bones wouldn't withstand a fall, so she worried about walking around too much.

"I'll break up like peppermint candy," she said.

But the hospital staff didn't give her a choice. They urged her to eat meals while sitting in a chair, get herself dressed and get up as often as possible.

"The more time you spend out of this bed, the healthier you'll be," Viles told her.

Despite staying active in the hospital, Rich, a great-grandmother, became more sedentary over the next several weeks. Her daughter, Debra Rich-Horn, said her mother continued to walk when she first came home, but soon she could barely get out of bed.

In May, she passed away.

"Her heart was already at a bad stage," Rich-Horn said. "By the time [the hospital] got her, it was too late."

As States OK Medical Marijuana Laws, Doctors Struggle With Knowledge Gap

KFF Health News, August 15, 2016

States are beginning to require doctors to take continuing medical education courses that detail how marijuana interacts with the nervous system and other medications, as well as its side effects.

This article first appeared August 15, 2016 on the Kaiser Health News website

By Shefali Luthra

Medical marijuana has been legal in Maine for almost 20 years. But Farmington physician Jean Antonucci says she continues to feel unprepared when counseling sick patients about whether the drug could benefit them.

Will it help my glaucoma? Or my chronic pain? My chemotherapy's making me nauseous, and nothing's helped. Is cannabis the solution? Patients hope Antonucci, 62, can answer those questions. But she said she is still "completely in the dark."

Antonucci doesn't know whether marijuana is the right way to treat an ailment, what amount is an appropriate dose, or whether a patient should smoke it, eat it, rub it through an oil or vaporize it. Like most doctors, she was never trained to have these discussions. And, because the topic still is not usually covered in medical school, seasoned doctors, as well as younger ones, often consider themselves ill-equipped.

Even though she tries to keep up with the scientific literature, Antonucci said, "it's very difficult to support patients but not know what you're saying."

As the number of states allowing medical marijuana grows — the total has reached 25 plus the District of Columbia — some are working to address this knowledge gap with physician training programs. States are beginning to require doctors to take continuing medical education courses that detail how marijuana interacts with the nervous system and other medications, as well as its side effects.

Though laws vary, they have common themes. They usually set up a process by which states establish marijuana dispensaries, where patients with qualifying medical conditions can obtain the drug. The conditions are specified on a state-approved list. And the role of doctors is often to certify that patients have one of those ailments. But many say that, without knowing cannabis' health effects, even writing a certification makes them uncomfortable.

"We just don't know what we don't know. And that's a concern," said Wanda Filer, president of the American Academy of Family Physicians and a practicing doctor in Pennsylvania.

This medical uncertainty is complicated by confusion over how to navigate often contradictory laws. While states generally involve physicians in the process by which patients obtain marijuana, national drug policies have traditionally had a chilling effect on these conversations.

The Federation of State Medical Boards has tried to add clarity. In an Aug. 9 JAMA editorial, leaders noted that federal law technically prohibits prescribing marijuana, and tasks states that allow it for medical use to "implement strong and effective … enforcement systems to address any threat those laws could pose to public safety, public health, and other interests." If state regulation is deemed insufficient, the federal government can step in.

That's why many doctors say they feel caught in the middle, not completely sure of where the line is now drawn between legal medical practice and what could get them in trouble.

In New York, which legalized marijuana for medicinal purposes in 2014, the state health department rolled out a certification program last October. (The state's medical marijuana program itself launched in January 2016.) The course, which lasts about four hours and costs $249, is part of a larger physician registration process. So far, the state estimates 656 physicians have completed the required steps. Other states have contacted New York's Department of Health to learn how the training works.

Pennsylvania and Ohio are also developing similar programs. Meanwhile in Massachusetts, doctors who wish to participate in the state medical marijuana program are required to take courses approved by the American Medical Association. Maryland doesn't require training but encourages it through its Medical Cannabis Commission website, a policy also followed in some other states.

Physicians appear to welcome such direction. A 2013 study in Colorado, for instance, found more than 80 percent of family doctors thought physicians needed medical training before recommending marijuana.

But some advocates worry that doctors may find these requirements onerous and opt out, which would in turn thwart patients' access to the now-legal therapy, said Ellen Smith, a board member of the U.S. Pain Foundation, which favors expanded access to medical cannabis.

"It's very difficult to support patients but not know what you're saying."

Education is essential, given the complexity of how marijuana interacts with the body and how little physicians know, said Stephen Corn, an associate professor of anesthesiology, perioperative and pain medicine at Harvard Medical School. Corn also co-founded The Answer Page, a medical information website that provides educational content to the New York program, as well as a similar Florida initiative. The company, one of a few groups to offer teachings on medical marijuana, is also bidding to supply information for the Pennsylvania program, Corn said.

"You need a multi-hour course to learn where the medical cannabis works within the body," Corn said. "As a patient, would you want a doctor blindly recommending something without knowing how it's going to interact with your other medications? What to expect from it? What not to expect?"

But many say the science is too weak to answer these questions.

One reason: the federal Drug Enforcement Agency classifies marijuana as a schedule I drug, the same level as heroin. This classification makes it more difficult for researchers to gain access to the drug and to gain approval for human subjects to participate in studies. The White House rejected a petition this past week to reclassify the drug in a less strict category, though federal authorities say they will start letting more facilities grow marijuana for the purpose of research. (Currently, only the University of Mississippi can produce it, which advocates say limits study.)

From a medical standpoint, the lack of information is troubling, Filer said.

"Typically, when we're going to prescribe something, you've got data that shows safety and efficacy," she said. With marijuana, the body of research doesn't match what many doctors are used to for prescription drugs.

Still, Corn said, doctors appear pleased with the state training sessions. More than 80 percent of New York doctors who have taken his course said they changed their practice in response to what they learned.

But even now, whenever Corn speaks with doctors about medical marijuana, people ask him how they can learn more about the drug's medical properties and about legal risks. Those two concerns, he said, likely reduce the number of doctors comfortable with and willing to discuss marijuana's place in medicine, even if it's allowed in their states.

Though others say this circumstance is starting to ease, doctors like Jean Antonucci in Maine continue to struggle to figure out how marijuana can fit into safe and compassionate medicine. "You just try and be careful — and learn as much as you can about a patient, and try to do no harm," she said.

Ron Schwarz is a patient in a special ward known as the Acute Care for Elders unit, or ACE, at Zuckerberg San Francisco General Hospital and Trauma Center.

Elderly Hospital Patients Arrive Sick, Often Leave Disabled

KFF Health News, August 10, 2016

 

About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.

This article first appeared August 9, 2016 on the Kaiser Health News website

By Anna Gorman | Photos by Heidi de Marco

SAN FRANCISCO — Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then, in March, a bad fall landed her in the hospital.

Doctors cared for her wounds and treated her pneumonia. But Prochazka, 75, didn't sleep or eat well at Zuckerberg San Francisco General Hospital and Trauma Center. She became confused and agitated and ultimately contracted a serious stomach infection. After more than three weeks in the hospital and three more in a rehabilitation facility, she emerged far weaker than before, shaky and unable to think clearly.

She had to stop working and wasn't able to drive for months. And now, she's considering a move to Maine to be closer to relatives for support.

"It's a big, big change," said her stepdaughter, Kitty Gilbert, soon after Prochazka returned home. "I am hopeful that she will regain a lot of what she lost, but I am not sure."

Many elderly patients like Prochazka deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.

As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

"The older you are, the worse the hospital is for you," said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. "A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more."

Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.

Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.

San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, the staff tests patients' memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.

"Bed rest is really, really bad," said the medical director of the ACE unit, Edgar Pierluissi. "It sets off an explosive chain of events that are very detrimental to people's health."

Such units are still rare — there are only about 200 around the country. And even where they exist, not every senior is admitted, in part because space is limited.

Prochazka said the constant checks by hospital staff made it hard for her to get a good night's sleep during her stay in the hospital. The night before, she said, she pulled the covers over her head in order to be left alone. (Heidi de Marco/KHN)

Prochazka went to the emergency room first, then intensive care. She was transferred to ACE about a week later. The staff weaned her off some of her medications and got her up and walking. They also limited the disorienting nighttime checks. Prochazka said she got "the first good night of sleep I have had."

But for her, the move might have been too late.

"She will not leave here where she started," Pierluissi said several days before Prochazka was discharged. "She is going to be weaker and unable to do the things you really need to do to live independently."

Not A Priority

How hospitals handle the old — and very old — is a pressing problem. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. Patients over 65 already make up more than one-third of all discharges, according to the federal government, and nearly 13 million seniors are hospitalized each year. And they stay longer than younger patients.

Many seniors are already suspended precariously between independent living and reliance on others. They are weakened by multiple chronic diseases and medications.

One bad hospitalization can tip them over the edge, and they may never recover, said Melissa Mattison, chief of the hospital medicine unit at Massachusetts General Hospital.

"It is like putting Humpty Dumpty back together again," said Mattison, who wrote a 2013 report detailing the risks elderly patients face in the hospital.

Yet the unique needs of older patients are not a priority for most hospitals, Covinsky said. Doctors and other hospital staff focus so intensely on treating injuries or acute illnesses — like pneumonia or an exacerbation of heart disease — that they can overlook nearly all other aspects of caring for the patients, he noted.

In addition, hospitals face few consequences if elderly patients become more impaired or less functional during their stays. The federal government penalizes hospitals when patients fall, get preventable infections or return to the hospital within 30 days of their discharge. But hospitals aren't held accountable if patients lose their memories or their ability to walk.  As a result, most don't measure those things.

"If you don't measure it, you can't fix it," Covinsky said.

Improving care for older patients requires an investment that hospital administrators are not always willing to make, experts said. Some argue, however, that the investment pays off — not just for older people but for hospitals themselves as well as for a country intent on controlling health care spending.

Though research on the financial impact of problematic hospital care for the elderly has been limited, a 2010 report by the Department of Health and Human Services' Office of Inspector General found that more than a quarter of hospitalized Medicare beneficiaries had suffered an "adverse event," or harm as a result of medical care.

Those events, such as bed sores or oxygen deficiency, cost Medicare about $4.4 billion annually, according to the report. Physicians who reviewed the incidents determined that 44 percent could have been prevented.

In addition to outright mistakes, poor or inadequate treatment in hospitals leads to needless medical spending on extended hospital visits, readmissions, in-home caregivers and nursing home care. Nursing home stays cost about $85,000 a year. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality.

"If you don't feed a patient, if you don't mobilize a patient, you have just made it far more likely they will go to a skilled nursing [facility], and that's expensive," said Robert Palmer, director of the geriatrics and gerontology center at Eastern Virginia Medical School and one of the brains behind the idea of ACE units.

ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 Health Affairs study, Palmer and other researchers found that hospital units for the elderly saved about $1,000 per patient visit.

A Different Life 

After coming home, Prochazka said she felt weak. It took weeks of walking her labradoodle, Gino, to regain strength.

Her stepdaughter, Gilbert, said Prochazka has started to improve. "We knew she was getting better when she was getting ornery," she said.

But Prochazka, who is highly educated, still has some short-term memory loss, Gilbert said.

Prochazka knows that her life after hospitalization is different than before — she will have to depend more on others. It's not an easy adjustment, she said.

"I have been somebody who has always been both mentally and physically active," she said. "Before I fell … I was respected for what I have and what I did and all of a sudden, I'm not."

She said her time at San Francisco General was frustrating. Getting the infection just as she was starting to recover was especially hard, she said. "I felt like I had been dealt a blow I really didn't need."

For other patients, being admitted proactively to the special geriatric unit can stave off such precipitous declines.

Rosenda Esquivel, 80, spent 18 days at San Francisco General, much of it in the unit, this spring. She suffered no noticeable setbacks, physical or mental, during her time in the hospital, according to Annelie Nilsson, a clinical nurse specialist in the unit.

Esquivel, an animated woman who used to work as a home caregiver, was admitted with intense arthritic pain and, while hospitalized, underwent a procedure to address an abnormal heartbeat.

Soon after her arrival, Pierluissi, the ACE unit medical director, speaking to Esquivel in her native Spanish, sought to determine how independent she was at home. He learned that a friend helped take care of her but that she took pride in cooking and cleaning for herself.

The doctor noticed that Esquivel needed help to get up from a chair but that she could get around with a walker. Her memory, though, wasn't too strong. A few minutes after hearing three words — "honesty," "baseball" and "flower" — she could only recall one of them.

Pierluissi came up with a plan for her time in the hospital: Get Esquivel's pain under control. Make sure she walks three or four times a day. Arrange for her to have a caregiver at home to remind her to take her diabetes and blood pressure medications.

Then, release her as fast as possible.

"The less time she spends here, the better," Pierluissi said.

California Doctors And Hospitals Tussle Over Role Of Nurse-Midwives

California Doctors And Hospitals Tussle Over Role Of Nurse-Midwives

KFF Health News, August 9, 2016

The California Hospital Association and the California Medical Association, which represents doctors, agree that nurse-midwives have the training and qualifications to practice without physician supervision. But they differ sharply over whether hospitals should be able to employ midwives directly.

This article first appeared August 8, 2016 on the Kaiser Health News website

By Anna Gorman

A California bill that would allow certified nurse-midwives to practice independently is pitting the state's doctors against its hospitals, even though both sides support the main goal of the legislation.

The California Hospital Association and the California Medical Association, which represents doctors, agree that nurse-midwives have the training and qualifications to practice without physician supervision.

But they differ sharply over whether hospitals should be able to employ midwives directly — a dispute the certified nurse-midwives fear could derail the proposed law.

"We are very much caught in the middle," said Linda Walsh, president of the California Nurse-Midwives Association.

The bill would override an existing law that requires certified nurse-midwives to practice under the supervision of medical doctors. California is one of only six states that requires full supervision. Several other states mandate other forms of collaboration, such as in prescribing medications.

The American College of Nurse-Midwives has been chipping away for decades at state laws that require physician supervision, and it has finally passed the tipping point nationally, said Jesse Bushman, director of federal government affairs for the organization. Nurse-midwives aren't seeking permission to go off and do whatever they want without consulting anyone, Bushman said. "They're just asking to be able to do what they are trained to do."

In states where nurse-midwives can practice independently, there is more access to care, he said, citing a recent report published by the George Washington University's Jacobs Institute of Women's Health.

There are more than 11,200 nurse-midwives around the nation, including about 1,200 in California. They provide maternity care, family planning services and other primary care for women.

In 2013, California eliminated the physician supervision requirement for licensed midwives, who require significantly less training than nurse-midwives. Unlike licensed midwives, certified nurse-midwives must become registered nurses and obtain a graduate degree in midwifery. They primarily deliver babies in hospitals, while licensed midwives usually work in homes or birth centers.

Walsh said her association is trying to make it easier for certified nurse-midwives to practice around the state, especially in areas where there may not be any obstetricians. It can be challenging to find physicians willing to oversee nurse-midwives, because of the responsibility and liability involved, she said.

"We have an access issue in California," Walsh said. "Yet we have this supervisory language that prevents an increase in access for the people who need it most."

Lisa Catterall, who works in a hospital-based midwifery practice at Feather River Hospital in Paradise, Calif., said getting physician supervision is not easy. For one thing, some nurse-midwives have to pay extra malpractice insurance in addition to paying doctors for their supervision. Even with the supervision, the doctors are not required to be present to oversee the care, added Catterall, who delivers about 100 babies a year and sees patients from throughout the rural region north of Sacramento where her hospital is located.

The debate between the doctors and the hospitals centers on the state's prohibition of what's known as the "corporate practice of medicine." California does not allow corporations, including hospitals, to hire physicians, though there are several exceptions. The intent of the ban is to avoid undue corporate influence on doctors' medical judgment and patient care. Under current law, hospitals can hire nurse-midwives, though many don't.

One of the bill's co-authors, Assemblywoman Autumn Burke, recently withdrew an amendment that would have mirrored the law applying to doctors by barring hospitals from hiring nurse-midwives. With that provision withdrawn, the California Medical Association now opposes the legislation and the California Hospital Association supports it.

The physicians' group believes that the health care decisions of nurse-midwives employed directly by hospitals could be influenced by their administrators, and it says it will only back the bill if the amendment is reinstated.

Patients should have the same consumer protections whether they see a nurse-midwife or a doctor, said Juan Thomas, a lobbyist with the medical association. "It should be a level playing field," he said. "We believe very strongly that the corporate practice of medicine bar language provides an important layer of patient protection."

The California Hospital Association, meanwhile, won't support the bill if the amendment is reinstated. The association believes hospitals need to retain the freedom to hire nurse-midwives.

A ban on hiring would make it more difficult for nurse-midwives to work in hospitals, forcing them into roundabout contracts that are "unduly cumbersome, unduly burdensome and unnecessary," said Jackie Garman, a vice president of the hospital association.

In addition, Garman said, some nurse-midwives are already employed by hospitals. "What happens to them?" she asked.

The nonprofit Pacific Business Group on Health recently announced its support of the midwife bill, saying it would help expand women's choices in pregnancy care and lead to better maternal health. In the spring, the group had sponsored a roundtable with more than 30 organizations from around California to discuss increasing access to nurse-midwives.

"It is really hard to argue with the evidence about the value that midwives offer pregnant women," said Brynn Rubinstein, the group's senior manager for transforming maternity care. "They are delivering more patient-friendly care, yielding better outcomes and saving money for purchasers," she said. "But they are not always easy to find."

Research shows that patients of certified nurse-midwives have fewer cesarean deliveries and lower epidural rates.

Assemblywoman Burke's office is continuing to talk to representatives of both the physicians and the hospitals to try and find a solution to the contentious issue of whether hospitals should be allowed to hire nurse-midwives, said Allison Ruff, a senior aide to Burke.

"For both of them, it is an issue they don't want to compromise on," she said. "The bill became a pawn in the fight between the hospitals and the physicians. It still is."

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