6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.
Revisit Daily Goals
Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.
To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.
“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”
In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)
It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”
Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.
Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.
“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.
Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”