Despite the fact that nearly half of the expenditures for health care for the elderly are for inpatient care in acute care hospitals, few studies have examined the complex needs of the acutely ill hospitalized elderly (Kovar, 1977). A high prevalence of functional disability in geriatric patients in acute care settings has been reported by Warshaw and others (Gillick, 1982; Mion, 1986; Warsaw, 1982). Findings in at least five research studies have shown that early discharge planning, multidisciplinary care, and a focus on functional abilities for older adults do reduce acute care hospital readmissions. The response to complex needs also enhances independence, improves morale, and increases the number of patients discharged to their homes (Applegate, 1983; Boyer, 1986; Collard, 1985; Lefton, 1983; Meissner, 1989; Rubenstein, 1984).
The purpose of this study was to identify the responsiveness of healthcare providers to the complex needs of patients 75 years of age and older. The specific acute care services addressed included early discharge planning, multidisciplinary care, and functional assessment.
The medical records of 101 patients 75 years of age and older who had lengths of stay (LOS) of 96 hours or longer were examined. Documentation of multidisciplinary care, early discharge planning begun within 4« hours of admission, and functional assessment within 48 hours was analyzed.
Living arrangements before admission and after discharge were noted. Review of the literature revealed evidence of a positive relationship between the services of functional assessment, multidisciplinary care and early discharge planning, and the discharge of patients to the home environment (El-Sherif, 1986; Golightly, 1984). Support services received, confusion exhibited over the LOS within the first 48 hours, polypharmacy over the length of stay, patient age, and medical diagnosis were also recorded because these were variables that can also influence the patient's chances of receiving the services being studied.
A convenience sample of 101 was selected by pulling the records of all patients meeting the criteria who were discharged from a 400-bed acute care hospital located in a Midwestern urban community between July 1988 and June 1989.
The research questions were:
* To what extent do adults age 75 years and older receive multidisciplinary care in the acute care hospital as reflected in written documentation on the medical record?
* How many patients 75 years of age and older have documentation of discharge planning assistance begun within 48 hours of their admission to the acute care hospital?
* How complete is the initial (within 48 hours of admission) functional assessment of patients 75 years of age and older as related in the medical record?
Definition of Terms
Multidisciplinary Care: Professional services that include dietary, physical therapy, occupational therapy, and discharge planning. In the facility where this study took place, discharge planning was completed either by nurse discharge planners who arrange for community services or by social workers who arrange for transfer to extended care facilities. The health professions of medicine and nursing were not included; medical and nursing care are routinely provided for all patients in this and most other acute care settings.
Discharge Planning: Any action noted in nursing notes or on the discharge planner's section of the medical record within the first 48 hours of admission or during the LOS that indicated support services for transition of the patient to home or an extended care facility.
Functional Assessment: Assessment of activities of daily living, including grooming, bathing, nutrition (amount of food taken), feeding, bowel and bladder elimination, mobility, ability to transfer, hearing, vision, and history of falls.
Polypharmacy: Use of seven or more drugs, including as-needed or over-the-counter preparations, within a 24-hour period.
Characteristics of Sample
The patient ages in the convenience sample (N = IOl) ranged from 75 to 99 with a mean of 81 and a mode of 77. The average LOS ranged from 3 to 57 days with a mean of 10.89 and a mode of 6. Consistent with previous studies, 37 (36.6%) of the subjects received seven or more drugs within a 24-hour period (Kroenke, 1990). Of these 37 patients, the mode was eight drugs with a range of 7 to 16 drugs per patient.
The patient's residence prior to admission was positively related to the site to which they were discharged (Table 1). All patients coming from an extended care facility were discharged to an extended care facility; 41 of the 69 patients admitted from home were discharged to their homes. Although not statistically significant.
it is important to note that 13 patients who were admitted from home were discharged to extended care. Data on living arrangements revealed that 19 (80%) of the subjects who lived with their spouse, 11 (75%) of the subjects who lived with children, and 11 (66%) of the patients who lived alone were dismissed to home.
Three (15%) of those patients living alone received support services. Three (18%) of those patients living with children received support services, and eight (24%) of those living with spouses received services. Eighty-seven (86%) of the subjects studied received no support services on discharge.
DATA ANALYSIS AND FINDINGS
The first research question was: to what extent did adults aged 75 years of age and older receive multidisciplinary care? Of the 101 patients, 36 (35.6%) received no multidisciplinary services. Forty-six (45.5%) of the patients received at least one service; 36 of these were dietary screens. Two services were provided to 15 adults (14.9%) and three services were provided to 4 adults (4%).
The multidisciplinary service of discharge planning was addressed separately. Physical therapy services were provided to 21 (20.8%) adults in the sample. Sixteen (76%) of the patients receiving physical therapy had either a neurological or orthopedic primary medical diagnosis. The remaining 5 (23.6%) had a secondary diagnosis in these same two categories. Only six (5.9%) of the adulte in the sample received occupational therapy.
The second research question was: how many patients 75 years of age and older had documentation of discharge planning assistance begun within 48 hours of their admission to the acute care hospital? Twentyfive (25%) adults in the sample had documented discharge planning within 48 hours of their admission; 33 (33%) received discharge planning later in their hospital stay; and 43 (42.6%) patients received no discharge planning at all. Twenty-nine percent of the discharge planning consisted only of arrangements for transfer to an extended care facility.
Patients' Resilience Prior to Admission Related to Discharge Site
The third research question was: how complete was the initial functional assessment of patients 75 years of age and older as documented in the medical record within 48 hours of admission? Assessments on each individual ranged from 4 to 11 functional activities, with a mode of 9. Only one patient was assessed for all 11 functions (Table 2).
Sixty-seven (66.3%) of the subjects in this study were assessed as being totally oriented throughout their hospital stay. Another 20 (19.8%) were oriented at times. Only 10 (9.9%) were confused. One patient was comatose. The remainder were described as lethargic.
Multidisciplinary care was provided to a relatively small number of the sample population studied: 64 received multidisciplinary services, and 36 of these were dietary screens. The benefits of multiple health-care disciplines working together to address the many complex problems of older people, especially when they become acutely ill, have been documented frequently in the gerontologicai literature (Bourret, 1986; LekanRutledge, 1988; Reilly, 1990). The varied perspectives of each discipline seem to provide a broader scope to the problem-solving process.
The patients receiving physical therapy or occupational therapy services all had either orthopedic or neurological diagnoses. This selective type of therapy illustrates the probable lack of recognition among acute care providers of the benefits these services can provide to older patients regardless of their medical diagnosis. Underuse of these services may also be related to the cost of these services and the belief that hospitals will not be reimbursed for them.
T A B L E 2 .; . -:
The dearth of multidisciplinary care conferences in this, and many other, institutions may partially explain the absence of dietary, physical therapy, and occupational therapy consultations. The present shortage of staff and higher acuity of patients has limited the time available for these conferences. They have been almost totally replaced by informal, sporadic communication between the nurse and the providers of these services concerning only those needs that are critical to patient safety. Nursing in the acute setting seems to have become crisis oriented and task focused. This focus is a deterrent to holistic access to care. One wonders how many significant health and home care planning needs were left unmet in the 43% of patients who fell through the cracks by receiving no discharge planning.
The data collected on documented functional assessment may not reflect the actual activities. The chart forms used in this particular acute care setting facilitated the nurses' documentation by providing a checklist for functional assessment; the forms include 10 of the 11 functional activities for which data were analyzed. Grooming was not included on the checklist and was documented in only 2% of the subjects' patient records.
Nurses completed assessments only to the extent that the necessary data to complete the flow sheet were available. Additional assessment information was seldom documented on the narrative record. For example, in assessing bladder elimination, the question of continence was always asked. However, defining characteristics and etiologies could not be discovered from a review of the record. It is the investigators' belief that acute care settings in general have promoted a medical model of assessment, which is lacking in functional parameters. For example, assessments are made for the respiratory and cardiac systems, but the ability to walk to the end of the hall is not documented. It is possible that nurses who work in a strong medical model environment are unaware of or are not encouraged to define characteristics that would facilitate the appropriate diagnosis of functional problems. Also, the time limitations to fully document care may influence adequate assessment of patient care by reviewing records.
Hearing and visual deficits are prevalent among this population. The potentially negative impact of these deficits on hospitalized older people is widely documented (Kopac, 1983; Spellbring, 1988). Clearly, hearing and vision assessments are of primary importance. For 55.4% of this sample, hearing function was not addressed in the chart. Vision was assessed for two thirds of the sample. Clinical questions are prompted when these data are reviewed: Are nurses lacking assessment skills? Are they lacking the time to assess and document? Is there a prior focus on the disease process that precludes functional ability so that it becomes a secondary issue?
Once patients in the 75 and older age group fall, they frequently fall again (Tinetti, 1989; Wolf-Klein, 1988). The importance of assessing for this risk factor cannot be overstated. Yet, 35.6% of the population studied had no documentation regarding history of falls. This is all the more troublesome because this assessment parameter has a prominent place on the initial nursing assessment form in the institution where this study took place. Healthcare institutions are continually developing prevention strategies to decrease patient falls. Emphasis on a detailed admission assessment would facilitate this.
Additional data were collected to determine if the benefits frequently ascribed to multidisciplinary care, early discharge planning, and functional assessment were occurring in the institution studied. Were patients admitted from home able to return to their homes? Did their previous living arrangements have any impact on this? What was the usual level of support services provided to these patients?
The majority of patients admitted from nome did return to their homes. Yet, 13% did not. Data indicated that patients' chances of being discharged to home were best if they lived with a spouse, and somewhat less if they lived with children. People living alone had the least chance of being discharged back to their home setting.
Returning to home often entails the need for support services. Documentation indicated that few of the subjects studied received these services. This has significant implications at a time when many patients are being dismissed from acute care hospitals still quite acutely ill after increasingly shorter hospital stays.
A lack of social services increases the feeling among older adults that they are abandoned by the healthcare system. Data from this study indicates that those patients who are most in need of support services after discharge were least likely to get these services. For example, subjects living with spouses were most likely to receive support services, whereas patients living alone were least likely to receive these services.
It has been the experience of both investigators that patients' spouses frequently act as patient BdVOCaIeSx demanding support services when patients themselves are too sick to do so. Many support services have no charge, but some services are costly and the patient may not be reimbursed if skilled care criteria are not met. Other services have long waiting lists that limit their availability. The above circumstances plus the very real lack of discharge planning and discharge planning personnel in many institutions compromise patient access to vital support services. In the documentation reviewed for this study, only one case of refusal of offered services was noted.
The significance of this data lies in the fact that the elderly are frequent users of hospital services. They also have longer lengths of stay than any other age group (Mion, 1986). Identifying and filling gaps in care provided to this age group might provide substantial cost savings to an overburdened health-care system. It would almost certainly improve care and decrease complications.
Professional nurses' roles as patient/family advocates and coordinators of holistic care puts them in the vanguard of change. Great potential exists for facilitating the collaborative provision of care. Acute care specialized gerontology units and special multidisciplinary assessment teams are two increasingly common strategies that health-care providers are using. Both encourage attitudinal and knowledge changes in caregivers, as well as provide a better focus for care.
Perhaps the greatest challenge is education. More knowledgeable physicians, nurses, social workers, and families, to name a few, might result in a narrowing of these service gaps with healthier, happier older adults as the final outcome.
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Patients' Resilience Prior to Admission Related to Discharge Site
T A B L E 2 .; . -: