Challenges for acute care geriatric inpatient units under the present Medicare prospective payment system

Geriatric assessment for the rheumatologist

The population of industrialized countries is aging rapidly. Rheumatologic disorders are the most common illnesses causing functional disability in the elderly and medications for rheumatologic disorders are among the most frequently prescribed. As the population of patients seen by rheumatologists ages, it is important for the rheumatologist to understand the techniques of geriatric assessment that are useful in understanding and treating this special population. This article reviews practical ways to assess function, cognition, affect, directives, and end-of-life care in elderly populations. The article concludes with a "Top Ten" list of geriatric principles for rheumatology fellows to learn.

Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective

OBJECTIVE

To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care.

DESIGN

A randomized controlled study.

PARTICIPANTS

A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).

MEASURES

The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.

RESULTS

The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.

CONCLUSION

Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.

A university-affiliated community hospital inpatient geriatrics program functioning in an administrative and educational capacity

OBJECTIVE

To demonstrate an unusual form of inpatient geriatric assessment with unique outcomes.

DESIGN

A prospective evaluation of patients admitted to a community hospital-based inpatient geriatrics unit utilizing traditional members of the assessment team along with educational assessment of nurses and satisfaction profiles of patients and/or families.

SETTING

A non-profit community hospital in Northeast Washington, DC.

PARTICIPANTS

All patients older than age 62 admitted to the 42-bed Geriatric Unit during a 4 1/2 year time period.

MEASUREMENTS

Number of total and category recommendations taken by attending physicians from the Inpatient Geriatric Assessment Team, periodic evaluation of unit nurses' geriatric knowledge base and certification, and patient satisfaction through periodic surveys.

RESULTS

More than 4500 patients have been evaluated during the past 4 1/2 years. The number of recommendations taken by attending physicians has averaged 31.3 to 50.7% during four consecutive chart reviews involving the first 25 consecutive patients for the month each performed every six months (n = 100). The average age of patients evaluated was 77.2 (minimum of 62 and maximum of 97); 67% were females and 33% males. The average number of recommendations communicated per patient was 4.1, and the average number adhered to 1.6/patient. The overall knowledge base and certification in geriatric nursing has increased significantly over a 2.5-year period. Composite monthly unit patient satisfaction survey scores increased as well.

CONCLUSIONS

The program is unique in its development, limitations, and outcomes. Other than the cost of limited geriatric nurse practitioner and faculty salary support, the program has been implemented using only current hospital department personnel. The role of the assessment team is to educate attending nurses and staff physicians. It has not yet been possible to measure objective outcomes. However, the current program also serves the purpose of introducing a new medical program to a community hospital in a nonthreatening way and offers opportunities for research. In addition, the program offers further opportunity for expansion and change.

Improving malnutrition documentation enhances reimbursement

Diagnosis coding for malnutrition can positively affect hospital reimbursements. Our goal was to quantify the possible increase in reimbursements when the diagnosis of malnutrition was identified and appropriately coded. A sample of 234 cases representing 14% of Medicare patients seen from March 1991 through February 1992 at Allenmore Hospital in Tacoma, Wash, was retrospectively reviewed. Malnutrition diagnoses (using ICD-9-CM codes) were assessed according to established criteria. Ninety-four cases (39.7%) met the criteria for malnutrition. Seven demonstrated increased reimbursement, totaling $12,326 for the sample. Length of hospital stay was significantly longer in the malnourished group (P = .001). The results indicated a need for an improved system of documenting and coding malnutrition diagnoses for improved identification and reimbursement enhancement purposes. An example of criteria used for each malnutrition ICD-9-CM diagnosis code and a policy defining the criteria usage are shown. A nutrition assessment form, which includes each malnutrition ICD-9-CM code title for enhanced interdisciplinary communication leading to improved coding of malnutrition diagnoses, is also shown. We conclude that effective identification of malnutrition leading to enhanced reimbursement strengthens the leadership potential of hospital dietitians and improves hospital revenues. Additionally, we suggest that such a system initiates a process that may lead to improved, cost-effective treatment of persons identified as being malnourished and provide a foundation for surviving within the future health care reform environment.