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The Evolution and Devolution of Hospital Care by Jerald Winakur, MD, MACP, CMD

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The Evolution and Devolution of Hospital Care by Jerald Winakur, MD, MACP, CMD INSIDE: Starts on Page 4 Hospitals April 2020 • VOLUME 21, NO. 3 www.CaringfortheAges.com FREE ONLINE ACCESS An Official Publication of The Evolution and Devolution of Hospital Care By Jerald Winakur, MD, MACP, CMD entered medical school in 1969. IN THIS ISSUE I Through a quirk of fate, I found my- self part of an experimental program in medical education, the “Clinical Pro- gram,” as it was called. It was an off- the-wall endeavor, but I was forged by it. From my first day of medical school — before I had taken classes in anatomy or physiology, pathology or pharmacol- ogy — I was placed into clinical clerk- ships that traditional students do not enter until their third year of training. And since I knew nothing of the culture of medicine, its doctors or hospitals, my sole identification was with my patients. That first day I duly reported for my as- signed clerkship: general surgery at the Looking Ahead, Philadelphia General Hospital (PGH). with Confidence PGH, a city-financed facility for the The immediate past president underserved, had evolved from “Old and the executive director Blockley,” established in 1732 as an of AMDA – The Society almshouse for the poor, the sick, the The author caring for a long-time patient during one of her many hospital for Post-Acute and Long- elderly, and the insane. William Osler, stays. Term Care Medicine sum up the Father of Internal Medicine, during recent accomplishments and his time at Penn (1884–1888) regularly dim, gray light. Hand-cranked hospi- hub of nursing activity. Nurses, aids, and initiatives in progress and made rounds there. Historians consider tal beds lined two long opposing walls, trainees worked 24/7 in the ward with share plans for the future. 3 Old Blockley to be the first hospital in with a painted metal nightstand by each the patients. what would become the United States. one. Folding partitions would be placed I remember that the patients, if they PDPM and Hospitals The surgery ward at PGH was a around a bed when necessary, such as were well enough, would socialize with Vital partners of post-acute huge open space with large windows during examinations, therapeutic min- each other, assist each other, and often and long-term care facilities, all around, though by 1969 they were istrations, or a patient’s death. At each hospitals are affected by the covered in deep grime and only let in end of the ward was a large table, the See EVOLUTION • page 8 patient driven payment model in many ways. 7 Nursing Home Abuse How to “ACHIEVE” Better Transitions Abuse in nursing homes can By James E. Lett, II, MD, CMDR take many forms and have many causes, but it always requires a response. 14 his is the epoch of Value Based Pay- These measures purport to determine are created, approved, shaped, defined, Tments (VBP). Some in the medical the adequacy or quality of our clinical and prioritized from sources such as community consider them wonderful, care. Further, just how well we clini- the Centers for Medicare & Medicaid Medical Director and while others may feel they are evil. Re- cians perform on these measurements Services, the Joint Commission, the the Survey Process gardless of our feelings, they are here to determines whether we are paid and how National Association for Healthcare Medical directors play a vital stay for the foreseeable future. Within much. All this is now ingrained into our Quality (NAHQ), the National Quality role before, during, and after that VBP framework, the true financial practice lives. Forum (NQF), and many others. the survey. 16 determinants and the components of our Quality measures, including those “report card” are reportable measures. judging “success” in care transitions, See TRANSITIONS • page 9 Join the only medical specialty society representing practitioners working in the various post-acute and long-term care settings. Visit paltc.org/membership to learn more! 2 CARING FOR THE AGES APRIL 2020 CARING COLLABORATIVE By Elizabeth Galik, PHD, CRNP, and Richard Stefanacci, DO, MGH, MBA, AGSF, CMD Caring Collaborative for Friendly Institutions and Communities ypically our patients come out of methods of delivering skilled profes- consulting service comprising nurses, The cornerstone of the Age-Friendly Ta hospitalization worse than when sional services. It is designed from the geriatricians, pharmacists, case manag- Health System (https://www.johnahart- they went in, whether that be with de- ground up to look and feel like a real ers, and physical therapists to improve ford.org/age-friendly-health-systems- lirium, a decline in function, nosocomial home. Food is cooked on the prem- the comprehensive assessment and initiative) includes the 4Ms: addressing infections, polypharmacy, or medical er- ises, and medical equipment is often plan of care for older adults in ED what matters (choice and goals of care), rors. Despite efforts to treat older adults tucked away in wall closets. Skilled nurs- observation units (Acad Emerg Med mentation, mobility, and medications in place and avoid hospitalization, 35% ing assistants manage the residents’ care 2018;25:76–82). (Healthc [Amst] 2018;6[1]:4–6). A pilot to 40% of all hospital admissions include with support from nurses and therapists Comprehensive guidelines for geri- test of the Age-Friendly Health System individuals who are 65 years of age and but without the extra supervisory and atric EDs have been developed by model of care is underway in five hos- older. administrative layers — a reversal of the the American College of Emergency pital systems across the country, and Over the past decade, the focus of traditional nursing home model. Physicians (ACEP) in collaboration additional cohorts are planned. More policy makers and providers has shifted Of course, efforts can be made by with the American Geriatrics Society, information can be found at the IHI site across a multitude of initiatives that all LTC facilities to transform institu- Emergency Nurses Association, and (http://www.ihi.org/Engage/Initiatives/ have impacted the care of older adults as tional settings to be more home-like the Society for Academic Emergency Age-Friendly-Health-Systems/). they move through complicated health and friendly for older adults without Medicine (Ann Emerg Med 2014;63:e7– Addressing the 4Ms is certainly not systems. Some of these initiatives have undergoing a full Green House trans- 25). Consumers will recognize the envi- new to PALTC collaborative teams. included improving care transitions, formation. John E. Morely, MB, BCh, ronmental and equipment modifications This gives us an opportunity to serve preventing 30-day hospital readmis- of the Saint Louis University School in geriatric EDs, such as pressure-reliev- as experts, educators, and mentors for sion, increasing the use of emergency of Medicine in Missouri detailed this ing mattresses, no-skid flooring, and hospital systems. department (ED) observational stays, transformation in his discussion on the chairs with armrests. The guidelines also and responding to value-based payment design of nursing homes of the future (J emphasize the importance of geriatric Dementia-Friendly America models. The response of some hospital Am Med Dir Assoc 2013;14:227–229). interdisciplinary teams, adequate staffing Even as changes are transforming our systems to these initiatives has been to And while SNFs have been undergo- ratios and education, and policies and LTC institutions, EDs, and health sys- create preferred networks of skilled nurs- ing these transitions for several decades, protocols that address the assessment tems, similar changes are occurring in ing facilities. The need for faster, better, our other settings are just getting up to and management of geriatric syndromes. our communities. Dementia-Friendly and cheaper has tested relationships and speed. Quality improvement initiatives, geriat- America (DFA) is a national network of collaboration among hospitals and post- ric prescribing principles, targeted care communities, organizations, and indi- acute and long-term care settings, as each Geriatric Emergency Departments of falls, delirium, and dementia, and viduals who are seeking to ensure that group works to care for more medically Older adults comprise 25% to 50% of palliative care are key components of communities across the United States are complex older adults. all individuals admitted to the ED. They the geriatric ED — it sounds a lot like equipped to support people living with Although it is easy to blame recent have longer ED stays and use 50% more PALTC. dementia and their caregivers. Dementia- policy changes and hospital providers, laboratory and imaging services than With support from the John A. friendly communities encourage people we wanted to step out of our PALTC their younger counterparts (Ann Emerg Hartford Foundation and West Health, living with dementia to remain in their silo to recognize how hospitals and other Med 2014;63:e7–25). And despite their the ACEP offers a geriatric ED accredi- communities, supporting their ability to settings outside of LTC have adapted to high use of services, many older adults tation program. Since 2018, over 130 engage and thrive in day-to-day living. the new environment. They have been and their families are dissatisfied with the hospital EDs have completed the accred- The DFA movement, which began in promoting geriatric care principles and ED experience. itation process. We encourage you to September 2015 after the White House using collaborative teams to better meet While the use of specialized geriatric explore the guidelines, resources, and Conference on Aging, is based on ACT the needs of their older patients. EDs isn’t new, we are seeing more of accreditation process at https://www. on Alzheimer’s, Minnesota’s successful them, with more research to support acep.org/geda/. If your local hospital is statewide initiative. DFA launched in Friendly LTC their use.
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