Journal of Gerontological Nursing


Mildred O Hogstel, RN, C, PHD; Marsha Cox, RN, C, PHD, MBA



Older patients in acute care hospitals are at high risk for problems. Care of older persons is further jeopardized by a shortage of physicians and nurses interested and prepared in gerontology and geriatrics, as shown in a survey of hospitals and staff in one southwestern state.



Older patients in acute care hospitals are at high risk for problems. Care of older persons is further jeopardized by a shortage of physicians and nurses interested and prepared in gerontology and geriatrics, as shown in a survey of hospitals and staff in one southwestern state.

In the past, there was little interest and/or emphasis on the specialized problems, needs, and care of acutely ill hospitalized older patients. The primary focus in the care of older persons was on longterm care in the home, nursing home, and other similar community settings where the major consideration was care for chronic illnesses. Improving long-term care continues to be important, but acute care of older people is now receiving increasing interest because Medicare and private health insurance carriers mandate more outpatient treatment and surgery and shorter hospital stays, therefore, "those patients who remain in the hospital will be mostly older adults with multiple acute and chronic health problems" (Knapp, 1994, p. 7). These older patients are at high risk for complications, accidents, and other effects of acute care hospitalization. In a survey of family members of hospitalized elders, Bull and Jervis (1995) found problems related to admission, care in the emergency room, medication errors, discharge planning, and "rude or uncaring behaviors [of staff] and unwillingness to answer questions" (p. 22). Unfortunately, in many geographic areas acute care hospitals are not prepared to meet the needs of these older patients because they do not have the specialized types of units, equipment, supplies and/or the staff who have the knowledge and skills to give them the care needed.

Almost 6,000 people become age 65 every day (American Association of Retired Persons, 1994) and more than 200 become 100 every day (Schräge, 1989). Currently the fastest growing age group are those persons age 85 and over. By the year 2000, Atchley (1994) has predicted that the fastest growing age group will be persons age 95 and older. Therefore, hospitals need to focus more on the needs of their older patients.


Physical Facilities

The most common type of specialized unit in hospitals for persons age 65 and over is the Skilled Nursing Unit (SNU) or Skilled Nursing Inpatient Facility (SNIP). These types of units were developed in the 1980s as a direct result of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 that attempted to control Medicare costs by setting fees (prospective payment) based on patient diagnosis (Diagnostic Related Groups or DRGs) (Kovner, 1994). One effect of this law meant that patients were being discharged quicker and sicker to a home setting or were transferred to a nursing home. Many hospitals converted at least one area to a skilled nursing unit to provide nursing care and rehabilitation services (with a limited number of days covered by Medicare) and to help restore the patient's function and return to as much independence as possible (Mahoney, 1991). However, the number of skilled nursing beds in hospitals is not sufficient to meet the increasing demand (Michota, 1995). In addition to providing services to a growing population of older people, the units help maintain the hospital occupancy rates which were decreasing because of shorter hospital stays.

Financial Considerations for Hospital-Based Skilled Nursing Units

Hospitals also are benefited by offering other services specifically designed for the Medicare recipient. By offering a skilled nursing unit (SNU), the older patient who is discharged can be admitted to the SNU which has its own Medicare certification. The services offered by the hospital for acute care patients can be shared by the SNU. Therefore, such services as laboratory, radiology, physical therapy, occupational therapy, intravenous therapy, and education are readily available. Because of the method of Medicare cost reporting, the hospital can move resultant overhead costs to the SNU. SNU costs are cost-based, not DRGbased as are the acute care services in the hospital. Thus, the hospital can reap the DRG reimbursement from the patient's acute care admission, discharge the patient as quickly as possible, and admit her/him to the SNU. The personnel have ready access to the medical records and can share information about the patient, easily increasing continuity. Physicians are pleased with the addition of the SNU to the hospital because there is ease and convenience in visiting patients that the nursing home setting did not provide (Knapp, 1986).

Because the Health Care Financing Administration recognizes that the patients who are discharged to a hospital-based SNU generally require more intensive care than those discharged to a nursing home skilled nursing facility, the reimbursement rates have been greater. This advantage allows for better staffing levels in hospital-based SNUs than skilled care in nursing homes. Medicare helps pay for a maximum 100 days stay in a skilled nursing facility in each benefit period (a benefit period begins when the patient receives inpatient care and ends when the patient has not received hospital care, rehabilitation services or skilled nursing for 60 days). However, only the first 20 days are covered at 100% of the approved amount. The patient must pay $89.50 a day from the 21st to 100th day. Beyond 100 days the patient pays the entire amount (HCFA, 1995). The length of stay in a hospital SNU rarely exceeds the 20 days of maximum Medicare benefits.

Other Specialized Hospital Units and Programs

Additionally, some hospitals have inpatient geropsychiatric units. Many of the older people on these units also have medical problems, so this type of unit is especially important because most psychiatric hospitals do not have the physical facilities or staff to care for older patients with physical as well as psychiatric or mental problems (Wagner, 1995).

Other hospitals have specialized geriatric medical acute care units, but these are primarily found in large hospitals associated with medical schools. In order to financially support geriatric medical acute care units, a large older population must be served by the institution. Additionally, geriatricians and other specialists with knowledge of geriatrics must be available.

The Deaconess Eldercare Service inpatient geriatric assessment and care coordination program developed at the New England Deaconess Hospital in Boston, Massachusetts is a good model for the care of hospitalized elders. This model used an ideal gerontology-trained interdisciplinary staff approach in selecting, assessing, planning, coordinating, discharging, and following up on the care of "patients age 65 and older who are at high risk for complicated hospital stays and possible poor outcomes" (Delis, Stanley, & Yesner, 1995, p. 227).

There are also large numbers of older patients in special care units (cardiovascular and respiratory), orthopedic units, oncology units, and rehabilitation units, but it is not known how well the personnel in these units are specifically prepared to meet the special needs of older patients and their families. Nurses in these units have expert knowledge and skills in their specialties but often are not aware of the other needs of older patients based on their functional status (e.g., communication and mobility) and the presenee of other multiple chronic health problems such as sensory deficits, arthritis, depression, osteoporosis, and side effects caused by a multiple medication regimen.

Some of the equipment, supplies, and building designs that are effective for older persons are low examining tables with soft pads that are raised on both sides, straight back chairs with padded arm rests, elevated toilet seats, low beds, walk-in showers with built-in seats, large number calendars and clocks clearly visible in patient rooms, large-print clear admission forms including information about informed consent and durable power of attorney for health care, and clear, specific discharge instructions. Skilled nursing units have to be designed to include space for communal dining, recreation facilities, and rehabilitation equipment and supplies.


Hospitals are offering other special services for older persons as a marketing strategy, so that they will become familiar with the hospital and choose it for treatment and /or hospitalisation when the need arises. Some of these services are wellness education and exercise classes designed for their age group, billfold-size computer cards containing a complete medical history, Medicare HMOs, and senior clubs that provide social and travel activities and waive the Medicare Part A deductible for a small annual fee if hospitalization is needed. Marketing departments in some hospitals have been creative in devising these strategies in an attempt to woo older patients to help fill their empty beds. According to Friedman (1994, p. 26), "the national occupancy rate was 62% in mid-1993."

Even though there may be financial incentives for some hospitals to enter the acute care geriatric market, the concerns for quality must be paramount. In order for information about quality issues to be available to the public, voluntary accreditors such as the Joint Commission for the Accreditation of Healthcare Organization QCAHO) and public regulators such as the Health Care Financing Administration are supporting the preparation of "report cards" on organizations and providers (Jost, 1994; Oberman, 1994).


Nurses - There is a critical shortage of registered nurses in hospitals with interest and preparation in the specialized care of older persons. In the United States in 1995 there were 13,009 registered nurses (out of about 2.2 million), certified by the American Nurses' Credentialing Center (ANCC) in one of the three areas of gerontological certification: generalist (10,633), clinical specialist (628), and nurse practitioner (1,748). In the state of the survey, there were only 403 (out of a total 142,200) nurses certified in areas of gerontological expertise in 1995 (ANCC, 1995). Of course, it is not known how many of these certified nurses are employed in acute care hospitals or how many gerontological prepared nurses are not ANCC-certified. It could be assumed that most of the nurse practitioners are employed in outpatient clinics and other community settings, clinical specialists (the fewest) in hospital settings, and generalists in hospital or nursing home settings. There has been progress in increasing the number of experts in gerontological nursing. There are now 64 graduate nursing education programs in the United States that offer advanced preparation in gerontological nursing (Gueldner et al., 1995). Undergraduate nursing schools are adding gerontological nursing courses for their students, although only 14% have a required course (Gueldner et al., 1995).

According to Fulmer and Mezey (1994, p. 126), "little has been done to create models of geriatric nursing in hospitals" and "nurses employed by hospitals by and large have little exposure to the principles of geriatric nursing." One of the few ventures to address nursing care of older patients is the Nurses Improving Care to the Hospitalized Elderly (NICHE) Project. Five acute care models have been studied. These include: a) the geriatric nurse specialist (GNS) model which uses the geriatric nurse specialist to plan and implement strategies to deal with defined geriatric problems; b) the acute care of elderly patients (ACE) model which uses a team approach to address common problems of older persons; c) the geriatric resource nurse (GRN) model which incorporates the use of the primary care nurse as well as other resources such as the GNS and geriatrician to deliver a unit-based, nurse-centered program; d) the comprehensive discharge planning (CDP) model which enhances continuity of care and minimizes readmissions by establishing individualized protocols implemented by the GNS; and, e) the case management (CM) model which is a multidiscip Unary approach using outcome-oriented patient care protocols (NICHE Project Faculty, 1994). The geriatric nurse specialists are increasingly needed in acute care hospitals to teach and guide other nurses in the care of older patients and their families. There are differences in the care of older persons that many nurses have not been exposed to in their educational programs such as differences in assessment techniques and findings (Lueckenotte, 1994), vital signs (Hogstel, 1994), laboratory data (Garner, 1989), medication dosage and side effects (Knebl & Graitzer, 1994), communication needs (Browning, 1994), and cardiovascular/respiratory reactions to major physical Stressors such as surgery, trauma, and infection (Hogstel & Taylor-Martof, 1994).

Physicians - There is also a critical shortage of geriatricians in this country. The Nira; York Times reported that the reasons for this problem are a reluctance of doctors to deal with aging and death, low reimbursement for their services, and an inadequate number of qualified role models, both in academia and practice (Geriatric doctor, 1994). According to Dr. Robert Butler, head of the geriatrics department at Mount Sinai Medical College in New York City, "Older people in this country, particularly those 75 and older, unless they have unusual primary-care physicians, are at great risk for poor health care and an earlier death" (Geriatric doctor, 1994, p. 10).

There are about 500 fellowshiptrained (two years in length) geriatricians in the United States, with about 50 or 60 fellows completing programs each year. Although a physician could be board certified as a geriatrician by examination only in the past, now only fellowship graduates may take the examination for board certification 0ahnigen, 1995). According to the Board of Medical Examiners for the state of the survey (June 6, 1995), there are only 38 (out of 31,501) licensed physicians with a self-reported primary specialty in geriatric medicine. It is not known how many have a subspecialty in geriatric medicine because this information is not reported.

Physicians in some areas who do have formal preparation in geriatric medicine are often overloaded. For example, in one geographic area with a medical school and a population of 1 .2 million residents, there are only eight physicians (out of a total 2,200) with formal preparation in geriatric medicine. One of the geriatricians is not accepting new patients and there is a waiting time of 4 weeks for three others. In 1992, persons age 65 and over averaged more contacts with their physicians (11 per year) man those less than 65 (5 per year) (American Association of Retired Persons, 1994). They also may require more time because they often do not have the classical symptoms of disease and, therefore, diagnosis is more difficult.

Communication also may take longer. The low reimbursement from Medicare is another factor in limiting their geriatric practice. In fact, it is sometimes difficult for older persons to find any new physician, especially an internist. One individual on Medicare and in a Health Maintenance Organization (HMO) recently called 20 physicians, none of whom were accepting new patients who were either on Medicare or in an HMO. In another group practice, only one of the seven physicians was accepting new patients on Medicare.

Ageism - Because of this lack of health care providers with special preparation in the care of older persons, ageism (or a negative view of older people) is still prevalent in the health care delivery system in 1995. Ageism was noted to be one factor in the poor care of hospitalized elders as reported by family members in the study by BuU and Jervis (1995). Older patients are often not respected (called "honey", "dearie", or "gramps"), sick dependent older patients are often treated like children ("that's a good boy"), and the lives of the very old are often not considered worth the extra time and care they need ("slow code"). These personal and other environmental factors (i.e., multiple medications, unnecessary physical restraints, and lack of adequate communication) can cause increased dependency and feelings of hopelessness and helplessness (Michota, 1995). In order to counter ageism and the resultant lack of quality care for older people, senior sensitivity programs are being incorporated into hospital education programs.


Ih an attempt to determine to what extent special units, services, and staff were available exclusively for the benefit of patients age 65 and older in hospitals in a large southwestern state, a short survey form was mailed to 99 hospitals in the summer of 1994. There are approximately 500 hospitals in aie state, even though it had the most hospital closures (118) from 1980 through 1992 (Friedman, 1994). The accidental stratified sample selected was based on geographic location, size, and ownership. Pediatrie hospitals, psychiatric hospitals, and Veterans Administration hospitals were excluded. All hospitals selected were accredited by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) or the American Ostéopathie Association (AOA).


Thirty-seven hospitals (37%) representing all designated areas of the state responded to the survey. The size of the sample ranged from a bed capacity of 49 to 923. The average occupancy of the hospitals ranged from 18 to 879 patients. Sixty-six percent of the hospitals had an average occupancy of 250 or less. The largest percentage (62%) of hospitals were classified as private not-for-profit. In 48% of the hospitals greater than 50% of the patients were age 65 and older. The services offered for older persons are found in Table 1. Responses from 20 (54%) of the hospitals indicated that there were plans to expand geriatric services. Five (14%) of the hospitals planned on having a skilled nursing unit in 1995, three (8%) planned on having a geropsychiatric unit, two (5%) were starting home health services for the older patients, one was building a nursing home in the hospital complex, one planned hospice services specifically for the older patient, and one planned a rehabilitation unit.

Many of the geriatricians but fewer advanced practice nurses in gerontology (clinical nurse specialists and nurse practitioners) in the state were accounted for by the hospitáis that responded. Hospitals surveyed reported 26 geriatricians (38 in the state) on their medical staffs and 14 gerontological advanced practice nurses (125 in the state according to the Board of Nurse Examiners, June 7, 1995) on their staffs. When hospital managers were asked to list their immediate plans for programs and services for persons age 65 and older, one listed the addition of a geriatrician and one listed the addition of gerontological nurses. One hospital representative stated that several nurses were scheduled to take the ANCC certification examination in gerontological nursing. Five hospitals listed advanced practice nurses on their lists of resources they would like to have to give the best possible care to their patients age 65 and older.


TABLE 1Services for Older Patients


Services for Older Patients


TABLE 2Services/Programs Ottered in Addition to fnpatieiit Services


Services/Programs Ottered in Addition to fnpatieiit Services

The list of other services and programs offered (in addition to specific inpatient services) offers insight into trends in geriatric services (Table 2). Hospitals are reaching out to the older person, offering innovative programs and services. The older patient continues to be a major consumer of acute care services and long-term care services. There is mutual benefit as older persons receive programs and services designed specifically to meet their needs and hospitals find new customers for health-related services. Some of the newfound interest in geriatrics is based on financial concerns as hospitals struggle to find ways to grow but others attribute the interest to the baby boomers struggling with aging parents (Gray, 1994).


Acute care providers need to recruit staff prepared in the fields of geriatrics and gerontology to provide effective quality programs and services appropriate for older people. The need to focus on quality care, including care coordination by an interdisciplinary team with gerontological and geriatric expertise and effective discharge planning is essential.

Besides adding necessary staff with this kind of special preparations, hospitals should provide more staff development inservice programs and workshops in the area of gerontological nursing. Interested nurses could enroll in gerontological nurse practitioner programs on a part-time basis and others could pursue continuing education needed to receive American Nurses Credentialing Center certification in one of the three areas of gerontological nursing.

Medical and nursing students should note that there will be varied opportunities in the care of older persons in the future, but probably more in settings where wellness and health promotion are the focus (Gueldner et al., 1995) rather than in the acute care hospital. Outpatient clinics, day surgery and treatment centers, adult day care centers and a multitude of new residential care centers will be looking for nurses with special preparation in the care of older adults (Gray, 1994).


There are severe shortages of physicians and nurses with education and expertise in geriatrics. These shortages have contributed in part to the lack of specialized care for older persons in acute care hospitals. However, as the need for specialized care is becoming more pronounced and known, health care agencies and educational facilities are responding. There are now more than 60 masters degree nursing programs offering gerontology as a specialty. The survey of hospitals in one southwestern state indicated that while there are few geriatricians and gerontological nurses, hospitals are trying to recruit these experts.

Many hospitals are expanding and improving their programs and services for persons age 65 and older. The financial benefits of establishing skilled nursing units, geriatric medical units, and geropsychiatric units within the hospital setting are evident. Hospitals are offering more services to attract the group of people who use hospital services the most.


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Services for Older Patients


Services/Programs Ottered in Addition to fnpatieiit Services


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