[Comprehensive Care Home Unit: reduction of hospital resources during influenza outbreaks]. / Unidad domiciliaria de atención integral: Reducción de recursos hospitalarios durante brotes de gripe.

OBJECTIVE: The Comprehensive Care Home Unit of the General Hospital of Villarrobledo is a unit formed by a geriatrician who sees people in nursing homes to improve their quality of care. The activity of the Unit has been analyzed, mainly with the objective of avoiding referral to the emergency room, avoiding hospital admissions, avoiding hospital readmissions and reducing the number of hospital admission days. METHODS: We retrospectively described the clinical activity of the Unit during the influenza outbreak of 2017 and 2018. We selected sociodemographical variables, functional assessment scales (Katz index, Barthel index and the Functional Ambulation Classification), and the Global Deterioration Scale. We registered mortality, type of treatment, oncological patients and patients with supplementary tests. The population was divided into four subgroups: hospital admission avoided, hospital re-admission avoided, referral to the emergency department avoided and reduction of admission days. The demographic characteristics were described, including the mode or mean of the variables. An economic report was made, and an analysis of cost per process according to the subgroups, means of Related Groups for the Diagnosis and degree of dependency measured by the Barthel index. RESULTS: We selected 112 patients, they had a mean age of 82.2 years, Katz G (34.8%), IB 28.8 (DE 34.9), FAC 0 (63.4%) and GDS 7 (22.3%). The most frequent disease seen was respiratory infection (63.2%), 71.4% received active treatment, 10.7% complementary tests were performed, 17.9% oncological and 17% mortality. Cost analysis: hospital readmission avoided (€ 4,128 per patient) and patients with total disability (BI 0-20, € 3,623 per patient) presented more economic saving. The economic savings were more than € 230,000. CONCLUSIONS: The contribution of the Unit during periods of influenza outbreak is cost saving because of reduced numbers of admissions, numbers of readmissions, days of admission and emergency room visits.

OBJETIVO: La Unidad Domiciliaria de Atención Integral (UDAI) del Hospital General de Villarrobledo está formada por un geriatra que atiende a las personas institucionalizadas para mejorar su calidad asistencial. Se analizó la actividad de la UDAI, principalmente en el objetivo de evitar ingresos y reingresos hospitalarios, evitar visitas a urgencias y facilitar el alta hospitalaria prematura. METODOS: Describimos de forma retrospectiva la actividad de la UDAI durante los brotes de gripe del 2017 y 2018. Aportamos variables sociodemográficas, escalas de valoración funcional (índice de Katz, índice de Barthel y la Escala de Valoración Funcional de la Marcha), y la Escala de Deterioro Global. Registramos mortalidad, tipo de tratamiento, pacientes oncológicos y pruebas complementarias. Se dividió la población en cuatro subgrupos: ingreso hospitalario evitado, reingreso hospitalario evitado, derivación a urgencias evitada y reducción días de ingreso. Se describieron las características demográficas, incluido la moda o media de las variables. Se realizó una memoria económica, y un análisis de coste por proceso según los subgrupos, medias de Grupos Relacionados por el Diagnóstico y grado de dependencia medido por el Índice de Barthel. RESULTADOS: Se seleccionaron 112 pacientes, presentaban una edad media de 82,2 años, Katz G (34,8%), IB 28,8 (DE 34,9), FAC 0 (63,4%) y GDS 7 (22,3%). La enfermedad más frecuente fue la infección respiratoria (63,4%), recibieron tratamiento activo un 71,4%, se realizaron pruebas complementarias en un 10,7%, oncológico 17,9% y exitus 17%. Análisis de costes: el reingreso hospitalario evitado (4.128 € por paciente) y los pacientes con discapacidad total (IB 0 ­ 20, 3.623 € por paciente) presentaron un mayor ahorro de costes. El ahorro económico fue de más de 230.000€. CONCLUSIONES: La contribución de la UDAI durante los periodos de brote de gripe supone un ahorro de costes basado en disminuciones de hospitalizaciones, disminución de reingresos, acortamiento de estancias hospitalarias y reducción de derivaciones a urgencias.

Merchants of Health: Shaping the Experience of Illness Among Older People.

Despite nearly universal health-care coverage for older Americans, the quality of care for the sickest and frailest remains sub-optimal. Understanding why requires analysis of the medical ecosystem. This paper considers the role of four of the principal actors in this system: physicians, hospitals, drug companies, and Medicare. Physicians spend more time in the office addressing diabetes and hypertension than they do evaluating falls and impaired cognition because of their training and their interests. Hospital administrators affect the hospital experience by investing in procedural specialties at the expense of low-tech, high-touch care. Pharmaceutical companies affect the medications older patients take by direct-to-consumer advertising and marketing to physicians. Medicare affects the patient's experience by prospective payment for hospitals, resulting in the burgeoning of post-acute care to accommodate early hospital discharges. Determining how to improve the quality of care for older people requires identifying a lever that affects the entire system. Medicare is uniquely positioned to serve this role. Reforming Medicare by introducing cost-effectiveness criteria for reimbursement of expensive devices, by instituting requirements that medical resident training programs include exposure to multidisciplinary team care, and by introducing a new benefit package for the frail elderly could improve American geriatric care.

Organizing Eldercare for Geographic Communities.

The dramatically increasing prevalence of elderly persons disabled by conditions associated with aging could motivate reexamination of service delivery and financing for this population, seeking quality, reliability, and efficiency. Research and innovation have established many components of effective reforms, such as patient-directed care planning, encouragement of volunteer networks and family caregiving, mobilizing services to the home, adhering to patient goals and priorities, limiting poly-pharmacy, reducing the risk of falls, and providing adequate support services for people with disabilities. However, none have become widespread and rarely, if ever, are all of the evidence-based improvements available to a particular disabled elder. This essay argues that reform for disabled elders should be anchored in geographic communities, with a new organizational entity having responsibility for measuring performance and implementing improvements. This entity would use data and public input to set priorities, test improvement strategies, and take steps to assure adequate workforce and service supply. In this MediCaring Community, sustaining finances could come from local taxes or capturing the savings in Medicare that arise with optimal comprehensive services. Generating a new structure to monitor and manage eldercare services for a geographic community would be readily accomplished in some communities and would be worth testing.

Joint geriatric and psychiatric wards: a review of the literature.

Joint geriatric/psychiatric wards are a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. A literature search using Medline, PsycINFO, Embase and CINAHL between 1980 and 2010 was carried out for information about joint wards for older people. Thirteen relevant papers were identified. These wards share common characteristics and there is evidence that they may reduce length of stay and be cost-effective, but there are no high-quality randomised controlled trials. Further research is needed, particularly regarding cost-effectiveness.

Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study.

BACKGROUND: The question of whether to withhold artificial nutrition and hydration (ANH) from severely cognitively impaired older adults has remained nearly unexplored in Japan, where provision of ANH is considered standard care. The objective of this study was to identify and analyze factors related to the decision to provide ANH through percutaneous endoscopic gastrostomy (PEG) in older Japanese adults with severe cognitive impairment. METHODS: Retrospective, in-depth interviews with thirty physicians experienced in the care of older, bed-ridden, non-communicative patients with severe cognitive impairment. Interview content included questions about factors influencing the decision to provide or withhold ANH, concerns and dilemmas concerning ANH and the choice of PEG feeding as an ANH method. The process of data collection and analysis followed the Grounded Theory approach. RESULTS: Data analysis identified five factors that influence Japanese physicians' decision to provide ANH through PEG tubes: (1) the national health insurance system that allows elderly patients to become long-term hospital in-patients; (2) legal barriers with regard to limiting treatment, including the risk of prosecution; (3) emotional barriers, especially abhorrence of death by 'starvation'; (4) cultural values that promote family-oriented end-of-life decision making; and (5) reimbursement-related factors involved in the choice of PEG. However, a small number of physicians did offer patients' families the option of withholding ANH. These physicians shared certain characteristics, such as a different perception of ANH and repeated communication with families concerning end-of-life care. These qualities were found to reduce some of the effects of the factors that favor provision of ANH. CONCLUSION: The framework of Japan's medical-legal system unintentionally provides many physicians an incentive to routinely offer ANH for this patient group through PEG tubes. It seems apparent that end-of-life education should be provided to medical providers in Japan to change the automatic assumption that ANH must be provided.

ACE units take a wholistic, team approach to meet the needs of an aging America. A fresh model for gerontology.

Even in their senior years, baby boomers will pose an enormous challenge to hospitals, which must find new ways to provide comprehensive, quality geriatric care. A number of hospitals have established ACE units, which take a wholistic, team approach to treating older patients, and appear to improve outcomes, satisfaction and maybe the bottom line.

In defense of a department of geriatrics.

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.