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Navigating a Hospital Stay: A Changing Health Care Era Requires a New Approach to Older Patients

Sara Merwin, MPH November 26, 2018
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Being hospitalized can be a stressful and confusing experience for anyone—all the more so for older people. After all, almost everything about how medicine is practiced in the US and the developed world has changed over the past 20 years. There has been a proliferation of new tests, new technology, new medications and new specialties.

Thanks to these improvements, along with better nutrition and preventive care, people are living longer. But this extension in life expectancy can come with more medical problems. We need a new approach to hospitalization that reflects this new era.

The Changing Relationship Between Doctors, Patients and Caregivers

In previous times, the hierarchy of the clinical encounter was clear. Physicians were at the top; patients at the bottom. One did not challenge the knowledge and advice of the doctor. But in the complex world of modern health care, a paradigm shift is required. To optimize the patient experience, there must be a partnership between doctor and patient.

For people of older generations, that old way of thinking can be a habit that is very hard to break. We can help our elderly patients by encouraging them to engage an advocate who is equipped to gather information and pose relevant medical questions.

A caregiver, often someone younger, can step up as an advocate. According to AARP, one quarter of family caregivers are millennials. This bodes well for our elders, for millennials are emboldened, tech-savvy and not fearful of speaking up.

Or, in the absence of a suitable friend or family member, a patient navigator can provide support. The emergence of this profession is partly in response to the longevity market and promises to bring great value to all stakeholders.

Patients Still Need to Plan for Admissions

As health care systems integrate the electronic medical record interface between outpatient care and acute care, there will be less of a need to pre-gather health information. Until that utopian goal is realized, we must help our patients prepare for admissions, particularly at the critical entry point – the emergency department.

To eliminate delays, repeated queries and unnecessary work-ups, the patient or caregiver should assemble a “go-packet.” The packet includes list of current medications, a history of conditions and surgeries, and contact information for primary care physicians and specialists. Advance directives and health care power of attorney documents should be included. This packet can be kept in a wallet, by the front door or stored electronically in a smart phone.

In Fast-Moving Hospitals, Everyone Benefits When Patients Are Informed

For better or for worse, efficiency is the byword for running a successful health care facility. Many patients are anxious and confused about processes and personnel since they lack the resources to understand and integrate what is happening. My colleague and I wrote “The Informed Patient: A Complete Guide to a Hospital Stay” to meet this need. The book offers an insider’s glimpse into the world of the hospital, with details, tips and explanations designed to demystify many aspects of an admission for patients.

We believe that people who are prepared and informed will have fewer questions and less anxiety. This in turn makes for a better relationship with the health care providers, who have a multitude of responsibilities and time constraints. We encourage hospitalized patients and caregivers to organize questions in advance of the doctor’s visit, and to prepare by learning about their diagnosis, potential procedures and tests.

Older Patients Need Different and Special Support

Older patients often have a particular set of needs that may require a modified environment and management approach in the hospital. Increasingly there is an awareness of the aging individual’s special needs in the hospital.

ACE (acute care of the elderly) units have been created in response to changing demographics. Also, adding geriatricians on the care team can be a game-changer, with their expertise and insights gleaned through training and practice.

Even when these boons are not present, health care professionals can work with families to accommodate patients’ needs. This is especially important for people at risk for heightened confusion or delirium, a common condition in hospitalized older adults.

We suggest that families rotate visits for an increased presence. This allows them to continually reorient the patient, communicate directly with the provider team, and ensure that assistive devices like glasses or hearing aids are within reach. When a family member or caregiver cannot be present, an elderly patient can be moved closer to the nursing station for more vigilance.

Every Story Is Different

Much of hospital medicine is based on established protocols, so we need to step back to see the big picture. For all patients, the primacy of values, preference and priorities is central. It is important to identify in advance patients’ wishes—and to derive a consensus among family members. These highly personal decisions require information from providers about realistic options and objectives. By taking into consideration the specific wishes of patients and families, we can help preserve their humanity and dignity.

Sara Merwin, MPH

Sara Merwin MPH is a clinical and health services researcher. She received her MPH degree in epidemiology from the Columbia University Mailman School of Public Health. Most recently she was the Director of Clinical Research in the Department of Orthopaedic Surgery at the Montefiore Medical Center, Assistant Professor of Research in Orthopaedic Surgery and Associate in Medicine at the Albert Einstein College of Medicine. Her career and research focus has included patient and professional education and communication. She has published in and presents nationally and internationally on research topics and quality improvement research.

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