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Invited Commentary
Health Care Reform
September 28, 2009

Improvement of Hospital Care of Elderly Patients: Thinking Outside the (Hospital) Box: Comment on "Hospital at Home for Elderly Patients With Acute Decompensation of Chronic Heart Failure"

Arch Intern Med. 2009;169(17):1576-1577. doi:10.1001/archinternmed.2009.268

As the population ages, the number of older patients hospitalized with functional debility and exacerbations of chronic illnesses increases. For these patients, traditional hospital care frequently results in adverse outcomes, such as delirium, infections, and functional decline, which increase the risk to these patients of functional dependency, institutionalization, and dying. For example, more than a third of hospitalized patients older than 70 years are discharged with worse functional status than their baseline status. Half these patients acquire their new impairments during their hospitalization, despite the stabilization of their acute illness.1 Suboptimal transitions in care at the time of hospital discharge (eg, poor medication reconciliation, failure to communicate to subsequent physicians the care plan and patient care preferences, or missed follow-up visits) also lead to adverse outcomes and frequent subsequent hospital admissions.2,3 Several alternatives to traditional hospital care have been shown to address these problems and improve outcomes for older patients. These models focus on improving care of elderly patients in the hospital by the use of patient-centered, interdisciplinary team care with a geriatric focus on rehabilitation of the patient, limitation of adverse medication effects, and reduction of cognitive and functional impairment. Examples of inpatient alternatives to traditional hospital care include the Geriatric Evaluation and Management (GEM) program through the US Department of Veterans Affairs, the Acute Care for Elders (ACE) units, and the Hospital Elder Life Program (HELP). The GEM program was launched in 1976 at Veterans Affairs medical centers to provide interdisciplinary multidimensional evaluations for elderly patients in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. ACE units use interdisciplinary geriatric teams to care for elderly patients on a restructured hospital ward designed specifically to provide a physical environment that reduces hazards of hospitalization and isolation and promotes functional independence. HELP integrates interdisciplinary geriatric teams into standard hospital units by the provision of specific interventions for 6 common risk factors for cognitive and functional impairment.

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