Discharge decision making for hospitalized older adults can be a complicated process involving functional assessments, capacity evaluation, and coordination of resources. Providers may feel pressured to recommend that an older adult with complex care needs be discharged to a skilled nursing facility rather than home, potentially contradicting the patientʼs wishes. This can lead to a professional and ethical dilemma for providers, who value patient autonomy and shared decision making. We describe a discharge decision‐making framework focused on interprofessional evaluation and management, longitudinal follow‐up, and education and support for patients and families. By gathering and synthesizing information, eliciting goals and preferences, and identifying community resources, the healthcare team can help maximize independence for vulnerable older adults. J Am Geriatr Soc 68:859–866, 2020
Accurate and timely transmission of medical records between skilled nursing facilities and acute care settings has been logistically problematic. Often people are sent to the hospital with a packet of paper records, which is easily misplaced. The COVID-19 pandemic has further magnified this problem by the possibility of viral transmission via fomites. To protect themselves, staff and providers were donning personal protective equipment to review paper records, which was time-consuming and wasteful. We describe an innovative process developed by a team of hospital leadership, members of a local collaborative of skilled nursing facilities, and leadership of this collaborative group, to address this problem. Many possible solutions were suggested and reviewed. We describe the reasons for selecting our final document transfer process and how it was implemented. The critical success factors are also delineated. Other health systems and collaborative groups of skilled nursing facilities may benefit from implementing similar processes.
Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested.
Background Geriatric collaborative care models improve postoperative outcomes for older adults. However, there are limited data exploring how preoperative geriatric assessment may affect surgical cancellations. Methods This is a single-center retrospective cohort analysis. Patients enrolled in the Perioperative Optimization of Senior Health (POSH) program from 2011 to 2016 were included. POSH is a collaborative care model between geriatrics, surgery, and anesthesiology. Baseline demographic and medical data were collected during the POSH preop appointment. Patients who attended a POSH pre-op visit but did not have surgery were identified, and a chart review was performed to identify reasons for surgical cancellation. Baseline characteristics of patients who did and did not undergo surgery were compared. Results Of 449 eligible POSH referrals within the study period, 33 (7.3%) did not proceed to surgery; cancellation rates within the POSH program were lower than institutional cancellation rates for adults over age 65 who did not participate in POSH. Patients who did not have surgery were significantly older, more likely to have functional limitations, and had higher rates of several comorbidities compared with those who proceeded to surgery (P \ 0.05). Reasons for surgical cancellations included a similar number of patient-and provider-driven causes. Conclusions Many reasons for surgical cancellation were related to potentially modifiable factors, such as changes in goals of care or concerns about rehabilitation, emphasizing the importance of shared decision-making in elective surgery for older adults. These results highlight the important role geriatric collaborative care can offer to older adults with complex needs.
BACKGROUND/OBJECTIVES Acute hospitalization may be an ideal opportunity to introduce palliative care to dementia patients, who may benefit from symptom management and goals of care discussions. We know little about patients who receive inpatient palliative care consultations (IPCCs). DESIGN Retrospective analysis using electronic medical record. SETTING Tertiary academic medical center and affiliated community hospital. PARTICIPANTS Patients with dementia by International Classification of Diseases diagnosis, 65 years or older, hospitalized between July 1, 2015, and December 31, 2015. MEASUREMENTS We used χ2 and t‐test/Mann‐Whitney U test to compare characteristics (living arrangement, advanced dementia markers, diagnoses of delirium and dementia with behavior disturbance, and admitting diagnosis) and outcomes (change in code status, length of stay [LOS], discharge disposition, and discharge medications for symptom management) of patients who did and did not receive IPCC. Patients were matched on sex, age, and race. RESULTS Among 927 hospitalized patients with dementia, 17% received IPCC (N = 157). Patients who received IPCC were more likely to be admitted from a nursing facility (35.7% vs 12.7%; P < .0001), experience delirium (71.3% vs 57.3%; P = .01), have behavior disturbance (23.6% vs 13.4%; P = .02), have a pressure ulcer at admission (26.1% vs 11.5%; P = .001), have hypernatremia (12.7% vs 3.2%; P = .002), and be bedbound (20.4% vs 3.2%; P < .000). Patients who received IPCC had a longer LOS (median = 5.9 vs 4.3 days; P = .004) and were more likely to be discharged to hospice (56% vs 3.1%; P < .0001). Patients with IPCC were more likely to have a discharge code status of do not attempt resuscitation (89% vs 46%). There was no significant difference in comfort medications at discharge between groups. CONCLUSIONS Patients who received IPCC had evidence of more advanced dementia. These patients were more likely to change their code status and enroll in hospice. IPCC may be useful to prioritize patient‐centered care and discuss what matters most to patients and families.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
334 Leonard St
Brooklyn, NY 11211
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.