The closing of St. Vincent's Hospital in New York City recently reminded me about some of the hazards of going into -- and coming out of -- the hospital. As an internist and geriatrician working (as well as a lifelong New Yorker), I got a bird's eye view as Saint Vincent's did god's work in caring for generations of some of the most vulnerable New Yorkers. I also got an all-too-close view of the fallout.
Shortly after Saint Vincent's closed, I cared for a patient who had had a surgical procedure there weeks earlier. She landed in another emergency room because there was no place else to go. She was then readmitted with a complication. But what we had here was not a surgical complication. No, what we had here -- to borrow a line from a favorite boomer movie -- was a colossal failure to communicate. Symptoms that could have been easily recognized and tended to a week earlier weren't, and a needless hospitalization resulted.
Now at this point you may be thinking that I'm being unfair. The poor lady had the bad luck of having her surgical procedure a week before the venerable New York institution that served her closed its doors after 150 years of operation, and there was simply no one to call when she got into difficulty. Who could have foreseen that? That could never happen if I were hospitalized at my local clean-as-a-whistle, financially solvent St. Elsewhere, right?
Sadly, the real eye-opening lesson is this: your local hospital doesn't have to be closing to put you at risk. Even if your hospital technically remains open, it might as well be closed after you go home.
One of the hottest new areas of aging research that could have a profound impact on your well being: care transitions. And here's the bottom line: The most vulnerable time in American health care is not necessarily during your hospitalization; it's actually when you move from the hospital to the next convalescence waypoint -- home, a rehab facility or just back to your doctor's office. Consider a few of the following sobering studies from the field of care transitions:
And we ain't just talking hospital discharge here: hospital admission is another ripe opportunity for problems. In one study, 54 percent of patients had a medication discrepancy upon their admission to the hospital with medicines they were taking at home. Many of these were potentially life threatening.
And who is at greatest risk of suffering the ill effects of care transition shenanigans? Older adults. As we age, we suffer disproportionately from care transitions problems. Why? Well for one thing, there's simply more to keep track of -- more medicines, more doctors and more medical problems.
Then there's our ever-growing sub-specialty culture: everybody seems to think that having one guy take care of your right thumb and another do the left is a great idea. But there's a whole person attached to those body parts. And yes, the increasing dearth of primary care doctors (who no longer follow you in the hospital and really know you, your medical problems and your family), is also a contributing factor.
And then there's the modern American Hospital, conceived of -- operationally and architecturally -- a hundred years ago, when the average patient was 25 and came to get their tonsils out, get a cast put on (and maybe stay overnight for it), or perhaps have a baby. Now these same hospitals are serving patients who are decades older on average, have between 5 and 10 chronic medical conditions, and a completely different cast of characters from the people who care for you when you're outside the walls of "the big house."
So if your anxiety level is appeased by knowing that your local community hospital is not likely to share the fate of venerable Saint Vincent's anytime soon, don't get too complacent. It might as well be closed, because in many American hospitals you're simply shooed from the windowsill after you've been nursed back to health (usually in 72 hours or less), and you're expected to "fly" on your own.
But there's also some good news. Many hospitals are developing innovative programs to improve post discharge continuity and communication. I'm fortunate enough to work in one, and I can tell you, it's worth the investment. All over the field, people are devising great strategies to teach patients and families how not to become a victim of care transitions, and in my next blog, I'll lay them out for you. In the mean time, remember one of our favorite aphorisms in geriatric medicine: The hospital is no place for sick people. And sick hospitals are definitely no place for sick people.
For more information on care transitions and other matter related to aging, please visit my web site: www.treatmenotmyage.com.
Follow Mark Lachs, M.D. on Twitter: www.twitter.com/DrMarkLachs
Richard C. Senelick, M.D.: Do TVs Belong In Doctor Waiting Rooms?
David Nichtern: Health Care and the Mandate for Compassion
Unfortunately, there are many complicating issues that get in the way. There is a critical shortage of primary care physicians and perhaps a greater critical shortage of those with specific geriatric training. There are major disconnects with reimbursement models that do not compensate appropriately for the time and effort required to help manage care handoffs. Electronic medical records are just now starting to take hold to help the flow of information, which is the lifeblood of better healthcare.
For all of the craziness surrounding health care reform and the insurance industry, a few positive notes are reflected in the current emphases on primary care, medical home, chronic disease management and accountable care initiatives. While we don’t know how all of this will play out, it is comforting to know that professionals like you are out there as helping us navigate these dangerous waters. And by the way, your new book, Treat Me, Not My Age is outstanding!
People are a conglomeration of systems that interact with one another. Separating each of those systems out into segmented, individualized care providers cannot address the complex nature and workings of disease in the human body. This medical culture is definitely a result and condition of the for-profit model of medicine.
A study published in the April 22/29 issue of the Journal of the American Medical Association, found that continuity of care was lacking among Medicare patients. Only about one-third of those hospitalized were seen by their own physician while there. We’ve discussed the move to have all health records online as soon as possible. It will certainly help, but in the meantime, don’t assume that somebody else is looking out for your loved one while they’re not in that provider’s office or facility [...]
http://silverbuzzcafe.com/?p=214
Some of the blame has to fall on the nature of the older patient. This is what went on at an eye doctor appointment recently. Doc trying to find out if patient was in compliance to 92-year-old: How did you use the glaucoma drops? Patient: Exactly like I was supposed to. Doc" How many drops, how many times a day? Patient: Just what you told me. Doc: So, can you tell me how often you put them in? Patient: I do what I'm supposed to. Period!
The doctor never found out if her glaucoma was worse because she didn't use the medicine correctly, or because the medicine just was not working for her. So, she changed the medicine to one that only had to be used once a day. Easier for my neighbor to do.
This is why I go with my elderly neighbors to their doctor's appointments and surgeries. I ask questions, make sure my neighbors understand, make charts of their medications for them, get them to physical therapy, schedule the next appointment, etc. I can't, however, be there to see that they take each dose or drop correctly.
Doctors have their work cut out for them with the elderly.
After a heart attack, the last thing I wanted to do was leave the hospital… This was the most anxiety I had ever dealt with in my life; the hospital felt like the only safe place on the world….
Insurance will pay up to about four days after a heart attack, but they push for quick discharge… There was no one from the hospital who did any follow-up at all…
You would think that insurance companies would pay for transitional care and follow-up since it would them re-admission costs.
Thank you again for addressing this important health topic.
No doubt, trauma centers saved the lives of the most traumatized patients, ... tens of miles from their injuries and homes, ... and left their local hospitals less experienced in the complications which occur not simply from trauma, ... but routine surgery and medical cases as well. Regionalization of pediatrics to a few specialty hospitals has left ER's and the hospitals where they are located, unqualified to assess, let alone adequately treat pediatric emergencies including asthma and severe allergies. The recent epidemic of Whooping cough and associated deaths in California come to mind, ... after the recent scare of H1N1.
Even in hospital "enterprises" which include acute and rehab facilities, ... the reimbursement regulations, particularly for the elderly, cause the patients in the sister rehab centers, ... to linger too long with avoidable complications, infections, ... No better than if they had been transferred to the Moon!
Care providers with who I have worked around the world are equally dedicated. What distinguishes the best health care systems in the world is the absence of barriers to care and information.
Never more information! Never less communication!
And what is even more apparent is that the medical community has carte blanche when it comes to billing you - the bills are outrageous and there is never ever any discussion about it. I think every hospital business and medical office should have a published set of prices handed to the patient before hand.
As it is now once you enter through those doors it's a total free for all on charges. I had one foot MRI done in a hospital setting that cost $2700. - the doctor wasn't able to read it - so back again and another $2700. charge - mean while the outpatient diagnostic office down the street was charginf $700. for the same MRI. The entire medical community seems to have a license to steal.
I stopped using my insurance because I found out that the rates are cheaper if you go in as someone without insurance - if you have a high deductible as I do you get screwed twice.
So, while there certainly is a big failure to communicate - there is no failure to overcharge, overcharge, overcharge.
http://www.doctorbob.com/colon_effect.html
This particular article is about colonoscopies. But check out other articles on the web site as well.