With increased longevity comes an increasing number of sensory-impaired seniors needing health care services. Trinity Health is among health providers exploring better ways to accommodate the special needs and requirements of these patients.
The system now boasts a dozen hospitals with senior-friendly emergency rooms, and more are in the works.In addition to a senior ER opened in 2008, its Holy Cross Hospital in Silver Spring, Md., has a Senior Surgery Center launched in 2009 and an Acute Care for the Elderly, or ACE, unit, opened last July. The hospital, a leader in senior-centric services, is on the hunt for ways to operationalize its senior-centric approach throughout its facility.
"We are gradually spreading this throughout the hospital," Bonnie Mahon, senior director for medicine and senior services at Holy Cross, said of the specialized focus on seniors.
Holy Cross' innovative, evidence-based approach to senior care will be the subject of an Innovation Forum session at the 2012 Catholic Health Assembly, June 3-5 in Philadelphia.
Mahon will lead the assembly session "Addressing the Specific Needs of Seniors in the Acute Care Environment" together with Margaret Penoza, director of growth and strategic leadership for Trinity Health.
Age boom
Dr. William Thomas, a geriatrician who has been advising Trinity Health on better models of care for elderly patients, said hospitals need to transform themselves, both physically and in staff training, to better serve the special needs of the growing number of older patients. He founded Eden Alternative, a not-for-profit in Rochester, N.Y., to consult on quality of life issues with nursing homes and other long-term care institutions.
"The center of gravity in medical care now relates to older people, but we still have systems that were designed for younger people," said Thomas — his observation is directed at inpatient and outpatient care. "In 2006, America tipped from primarily doing acute care to doing more chronic care. This requires different systems and, especially, different thinking."
Senior ER
At Holy Cross, nurses examine incoming emergency patients 65 years or older to decide whether they would be best served by the Senior Emergency Center or whether the seriousness of their respective conditions calls for treatment in the regular acute care emergency department. Holy Cross' senior ER has an atmosphere and approach designed to comfort and protect patients whose advanced age may make them more vulnerable and anxious, particularly when they already are stressed by the pain or the advanced illness that necessitated their trips to the ER.
To lesson fall risks in the unit, soft lighting is used to ease glare from wooden floors. For comfort and calm, warm blankets take the chill off stiff joints and muscles; thick mattresses protect fragile skin; and a determination to tamp down noise lessens the potential for confusion and upset.
Preserving independence
The original ACE unit concept was developed more than a decade ago by geriatricians at Cleveland's Case Western Reserve University. They wanted to abate the loss of independent physical functioning that can occur when seniors, particularly frail seniors, are hospitalized.
Researchers know that spending the day alone in a hospital room can be disorienting to frail elderly patients, and too much sedentary time can lead to muscle atrophy and permanent loss of physical function. Hospitalization can cause an elderly patient to lose the capacity to independently perform tasks of daily living. In ACE programs such as the one at Holy Cross, clinicians encourage elderly patients to get out of bed as soon as they are able and to make use of an activity room to meet and socialize with others.
"We want to get the patients involved and keep them moving," Mahon said. "Too many senior patients in nursing units sit in chairs all day. Getting them to have their meals together, maybe listening to music, keeps them more active. We don't want their cognitive status and health to decline while they're in the hospital."
When deciding whether a patient is a candidate for the ACE inpatient program, staff looks for frailty factors including skin problems, incontinence, cognitive impairment, inadequate hydration and nutrition, and fall risk. Mahon said someone who still plays tennis at age 90 may not need to be assigned to the special geriatric unit. ACE usually serves about 30 patients any given day on the hospital's fifth floor medical unit. The ACE program, led by a nurse practitioner, is a collaborative that includes physical therapists, pharmacists, social workers and registered dieticians.
Patience is a key ingredient in patient interactions. "You have to take more time with seniors. You can't rush them," Mahon said.
Senior surgery
Rooms in the Senior Surgery Center are quiet and roomier than the regular surgical areas so families can more comfortably stay with patients. There are recliners for patients to relax after outpatient procedures. Older patients may recover more slowly than younger ones, so in senior surgery, patients are not hurried. The hospital makes the Senior Surgery Center an option for patients 55 years or older, Mahon said. (The emergency center and ACE program keep to the age 65 threshold.)
With all the programs, nursing and medical staff receive special training in treating older patients. And a staff nurse follows up to check patient progress after discharge.
Leading practices
Mahon said teams from other Trinity Health hospitals and other systems as far away as Japan have toured Holy Cross to observe its senior programs.
Penoza said she has been working with Thomas to spread the methods and designs used at Holy Cross to Trinity Health's 46 other hospitals in eight states. Penoza said six more emergency departments are considering opening senior ERs this year.
She said a group of doctors and nurses from Trinity Health have developed guidelines for senior ERs. During the assembly presentation, she will describe how other Trinity Health hospitals have modified the basic Holy Cross model for senior services to fit their different resources and needs. Penoza said she believes "there is a relationship between senior ERs and (reduced) readmissions," and a team is now working to collect data on that purported correlation.
Saint Joseph Mercy Health System in Michigan, a member of Trinity Health, established senior ERs at eight emergency departments between July 2010 and February 2011. Joanne Grosh, director of senior services at Saint Joseph Mercy Health System, said most of the facilities have discrete senior emergency centers adjacent to their regular ERs, but smaller emergency departments have adapted the guidelines in all emergency department bays and rooms.
For example, Chelsea Community Hospital in Chelsea, Mich., west of Ann Arbor, refitted its entire six-bed emergency department based on the senior ER guidelines developed by Trinity Health.
Grosh said Saint Joseph Mercy Health System is committed to staff training with the NICHE (Nurses Improving Care for Healthsystem Elders) program established by New York University, an improvement that Trinity Health is promoting throughout the system. At St. Joseph Mercy Hospital in Ann Arbor, said Grosh, the goal is to have 25 percent of the nurses qualify as geriatric resource nurses. Each of the other Trinity Health hospitals engaged with the program has similar goals.
Grosh said the need for skilled geriatric care is growing, not only because hospitals treat more elderly people, but also because many patients suffer from memory loss or other cognitive problems.
"We need to develop evidence-based systems that help them," Grosh said.