Elements of a Geriatric Competent Hospital

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Elements of a Geriatric Competent Hospital

• Nancy Erckenbrack
• Cindy Klug
• March, 2005

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Agenda

• Developing the process for a geriatric review.
• The elements of a geriatric competent system.
• Access
• Facilities
• Programs Services
• Clinical Indicators

• Implementing a geriatric review
• Findings from one Health System
• Impact of the review
• Whats next

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Developing the process for a geriatric review.

• Review of other organizations geriatric reviews
• AARP (Consumer Checkbook)
• Hospital inclusion criteria
• Hospitals in major metropolitan areas
• Hospital rating criteria
• Death rates
• Physician rating (surveyed physicians)
• Accreditation scores
• Training programs

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Developing the process for a geriatric review.

• Review of other organizations geriatric reviews
• US News and World Report
• Hospital Inclusion Criteria
• Council of Teaching Hospitals, or
• Medical School Affiliation, or
• A score of 9 or higher on the hospital wide
  technology index, and
• AHA Annual Survey, and
• Number of discharges

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Developing the process for a geriatric review.

• US News and World Report, continued
• Hospital Rating Criteria
• RNs to patient ratio
• Patient/Community Services (angioplasty, cardiac
  catheterization lab, cardiac intensive care,
  airborne infection, isolation room, ambulance
  services, case management, enabling services,
  linguistic/translation services, neonatal
  intensive care, pain management program, patient
  representative services, pediatric intensive
  care, rehabilitation care, sports medicine, and
  womens health center)

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Developing the process for a geriatric review.

• US News and World Report, continued
• Hospital Rating Criteria
• Geriatric Services (arthritis treatment centers,
  adult day care programs, patient representative
  services, geriatric services, meals on wheels,
  assisted living, and transportation to health
  facilities)
• Nurse Magnet Hospital Designation
• Hospice/Palliative Care

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Developing the process for a geriatric review.

• Expert panel input on key elements needed to
  qualify a hospital to be good in geriatric
  care.
• Included geriatric physicians throughout the
  country in both academic and community settings
• Members of the American Geriatric Society

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Developing the process for a geriatric review.

• List refined to manageable and doable by Center
  on Aging leadership council.
• Council is an interdisciplinary group of
  clinicians and support personnel.

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Elements of a Geriatric Competent Hospital
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Access

• Access to site by phone.
• Phone book listing
• Operator
• Physical Access to the site.
• Parking
• Public transportation
• Electronic access.
• Web site

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Facility

• Layout of site
• Easy to use directory
• Wheelchairs available
• Customer service available
• Easy access to public restrooms
• Lighting consistent throughout space
• Elevators and ramps available

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Programs and Services

• Discharge planning
• Discharge Assessment
• Needs assessment
• Prognosis
• Family capabilities
• Financial resources
• Patient/family goals
• Preferences for care (type and setting)
• Spiritual needs

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Programs and Services

• Discharge planning
• Discharge Plan
• Follow up care needed
• Treatment modalities needed
• Level of care needed
• Communication to physicians (primary care and
  specialty care)
• Communication to post acute provider
• Communication to family/patient
• Information about community resources
• Plan or written summary provided to physicians
• Plan or written summary provided to post acute
  providers

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Programs and Services

• Elder need inpatient resource teams
• Availability Description Elder specific
• Wound Care
• Incontinence Care
• Behavior management for cognitively impaired
  patients
• Pharmacy consults
• End of Life Care
• Pain management
• Ethics consult
• Pastoral Care
• Chemical Dependency
• Foot Care
• Elder need outpatient services

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Programs and Services

• Elder need outpatient services
• Anticoagulation
• Arthritis
• CHF
• Stroke
• End of Life
• Geriatric Assessment
• Geriatric specific programs (fall prevention,
  incontinence, dementia)
• Preadmission education
• Functional enhancement (exercise, tai chi)

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Clinical Indicators

• Functional screening
• screening with a validated tool
• Cognitive screening
• Screening with a validated tool
• Elder specific protocols
• Use of inappropriate medication
• Medications on Beers DO NOT USE list

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Data Collection

• Access and facility reviews conducted Elders In
  Action. This organization represents the
  interests of seniors in the Portland metropolitan
  area through volunteer-driven programs. Elder
  Friendly Business Certification is a licensed
  assessment program that uses specific guidelines,
  trained elder evaluators from a licensed aging
  agency to "shop" a business anonymously for a
  nominal fee. Evaluators review the effectiveness
  of telephone and customer service, building
  layout and access. This service is available in
  many communities in the U.S.
• www.eldersaction.org

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Data Collection

• Clinical indicators were obtained through a chart
  review conducted by RNs on 150 conveniently
  selected charts for inpatients age 65 during a
  six month period (January 2003-May 2003).
• Resource teams and outpatients services
  information obtained by interviewing staff and
  collecting available marketing materials.

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Findings from one Health System

• Hospital A 50 bed community hospital
• Hospital B 450 bed tertiary, teaching community
  hospital
• Hospital C 500 bed tertiary, teaching
  community hospital

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Hospital A Access - Strengths

• Able to find phone number in white and yellow
  pages.
• Hospital operator knowledgeable, friendly and
  helpful.
• Good signage to indicate entry.
• Entrance to facility on flat ground.
• Can enter second floor from ground level
  entrance.
• Wheelchairs and seating by entrance door.

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Hospital A Access Areas Needing Improvement

• Need more handicapped parking spaces.
• Long walk uphill from public transportation.
• Long walk from entrance to admitting desk.

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Hospital A Access - Recommendations

• Add more handicapped parking.
• Transportation service from bus stop to hospital.

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Hospital BFacility - Strengths

• Maps available.
• Staff and volunteers are very helpful.
• Lots of places to sit along the way.
• Rover to transport people.
• Good signage.
• Good lighting.

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Hospital B Facility Areas Needing Improvement

• Some ramps too steep.
• Not enough room in handicap stalls in bathroom
  (main floor).
• Rover only available on first floor.

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Hospital BFacility - Recommendations

• Use consumers with mobility issues to review
  design elements such as public restrooms and
  wheelchair ramps to assure meets consumers needs
  in addition to meeting ADA standards.
• Prepare own checklist to include in next Elder
  Friendly review.

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Hospital C Programs and Services - Strengths

• 88 of patients had a discharge plan in place.
  For 54 of patients discharge planning began
  prior to or on the day of admission.
• Inpatient resources available for wound care,
  incontinence care, management of confusion,
  pharmacy consults, end of life, ethics, pain
  management and pastoral care.
• Outpatient services available for
  anticoagulation, end of life, geriatric
  assessment, fall prevention, and exercise.

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Hospital C Programs and Services Areas Needing
Improvement

• Only 27 of patients had all seven elements of a
  discharge assessment completed.
• Only 30 of patients had all nine elements of a
  discharge plan completed.
• Geriatric consults not available for inpatients.
• Resources seen as formal and informal programs.
• Services distinguished as offered on site vs.
  regional.

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Hospital C Programs and Services - Recommendations

• Develop a standard discharge process and plan
  which includes the critical elements to meet
  older patient and family needs.
• Support NICHE teams with geriatric physician to
  participate in rounding.
• Resource book for older adults by topic areas
  including services available inpatient and
  outpatient. Useful for patient, family and staff.

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Hospital CClinical Indicators - Strengths

• 92 of patients had functional status evaluated
  via the CAD.
• 92 of patients had cognitive status evaluated
  via the CAD.
• Only 8 (5) patients received drugs classified as
  inappropriate for the elderly.

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Hospital C Clinical Indicators Areas Needing
Improvement

• No patients were given a standardized cognitive
  assessment.
• No patients were given a standardized assessment
  of functional status.
• Only 6 patients (4) had elder specific
  guidelines or protocols in place.
• Five patients received Demerol.

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Hospital C Clinical Indicators - Recommendations

• Develop and implement a geriatric standard of
  care or add geriatric criteria to current
  standards (NICHE).
• Implement the use of standardized assessment
  tools for evaluating cognition and function.
• Support continued implementation of management of
  confusion protocol.

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Hospital A Elements of a Geriatric Competent
Hospital 4.0
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Hospital B Elements of a Geriatric Competent
Hospital 4.1
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Hospital C Elements of a Geriatric Competent
Hospital 4.3
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Impact of Review

• Changes made, especially around facility issues
• Change in reporting structure of discharge
  planning
• Standardization of nursing policies and protocols
• Regular meetings of senior care programs
• Development of internal senior programs guide
• Development of common clinical outcome measures

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Whats Next

• Conduct second evaluation with modifications
• Disseminate findings
• Compare to other interested hospitals