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Sudeep Gill

Thu, 07/28/2016 - 01:38

Dear Stephen, This is a compelling blog post. I'm one of several department members who practices largely outside of KGH (at St. Mary's of the Lake Hospital, which will move to the Providence Care Hospital in 2017). However, many of our patients come directly from KGH to either the inpatient geriatric rehabilitation unit or the outpatient Seniors' Day Rehabilitation program (SDR; formerly "Day Hospital"). Other specialized streams are managed by our colleagues in Physical Medicine and Rehabilitation (e.g. rehabilitation for individuals following stroke, orthopedic surgery, spinal cord injury, or acquired brain injury). These programs have an important role to play in helping to improve outcomes for older individuals, and we hope their involvement here helps in some way to address the vexing and complex ALC issue. For example, a meta-analysis of randomized trials of inpatient geriatric rehabilitation shows it improves function, lowers LTC admissions, and reduces mortality (Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;340:c1718, http://www.bmj.com/content/340/bmj.c1718). Similar to the "opportunity cost" argument made in the blog post about use of acute care beds, a significant part of our role on the geriatrics consult service is trying to select individuals with the greatest potential to benefit from rehabilitation services (http://www.ncbi.nlm.nih.gov/pubmed/9106937?dopt=Abstract). The "opportunity cost" exists at SMOL as well because ALC is not only an issue at KGH but also at SMOL (and MHS too). We wanted to highlight a few points related to the blog post: First, ALC relates in part to an aging population. However, the blog post rightly touches on other important contributors including poverty. Patient and family income likely influences many of the challenging dilemmas we all face. There are very few individuals who could afford the full $1100 daily cost for a patient to stay in an acute care bed. Many individuals cannot even afford the costs of a retirement home (which often run $3000 per month or more, and do not usually include any assistance with basic daily tasks such as dressing, bathing, etc). Nursing home (AKA LTC) beds are subsidized in Ontario, so often cost less than retirement home beds. However, the LTC application process takes time, LTC eligibility is determined by CCAC, and LTC beds are in limited supply in our LHIN as highlighted in the post. Second, another important contributor to ALC rates that may be uncomfortable to recognize is improvements in medical technology. Improved care for patients with critical illnesses, e.g. acute coronary syndrome, severe aortic stenosis (TAVR), acute stroke (rapid endovascular intervention), etc, have led to uncomfortable situations in which patients who would have once died now survive but are left with physical and/or cognitive deficits. The ability to manage (and pay for) the impact of these deficits on day-to-day life in the long-term has not kept pace with management of acute issues in many cases. Many of the affected individuals will require long-term assisted living, and some become "hospital dependent" (Reuben DB, Tinetti ME. The hospital-dependent patient. N Engl J Med 2014; 370:694-697, DOI: 10.1056/NEJMp1315568, http://www.nejm.org/doi/full/10.1056/NEJMp1315568#ref1: " Usually, hospital-dependent patients are not recognizable as such at the time of the first admission. During almost all index admissions, the patient, family members, and clinicians assume that the patient will be restored to usual health. This optimism is generally justified, since none of the many prognostic indicators are accurate enough to predict the trajectory of an individual patient. Hospital-dependent patients are readmitted not because of inadequate hospital discharge, care transitions, or post-hospital care, but because their medical problems cannot be managed outside the hospital. The amount of medical and instrumental support that can be mounted is simply not enough. It is tempting to conclude that these patients are discharged to the wrong location and that they should be sent to skilled nursing facilities (SNFs), but most SNFs cannot or do not provide the needed level of treatment and support for them, and the readmission rates from SNFs are similar to those from home. These patients are often relieved to be back in the hospital because they feel more secure than they do at home or in nursing facilities. Many have established relationships with hospital staff and clinicians who remember them from prior admissions, and these familiar faces provide reassurance. ") Third, the focus of the post is on acute care hospitals. It is worth pointing out that ALC is also an issue in rehabilitation hospitals and mental health care facilities (e.g. SMOL and MHS, soon to be at one site in the new Providence Care Hospital). Fourth, the post highlights the increasing pressures at KGH to get patients admitted and discharged as quickly and efficiently as possible, with reduced LOS at KGH ("Indeed, while ALC populations and ALC LOS have mushroomed, the LOS for all other patients has shrunk to below the provincial average and is now ~5 days. This improvement in LOS has occurred despite a dramatic rise in admission numbers. For example on the Medicine service at KGH our admissions have increased from ~3000/year in 2012 to over 5000/year in 2015."). Unfortunately, one potential contributor to the ballooning number of admissions (beyond population growth and aging) is the readmission rate. The 30-day readmission rate in many jurisdictions is 20%, and this number is likely climbing as the population of frail elderly individuals increases. Like ALC itself, it has been difficult to identify effective strategies to reduce readmission rates. One strategy that might help reduce preventable readmissions is more robust and responsive home care, which has been a clear focus for the MOHLTC . Finally, becoming designated an "ALC patient" can lead to frustration for everyone involved including patients and their families, physicians and nurses and our allied health colleagues, and hospital administrators. Sometimes this frustration can boil over into inadvertent ageism directed toward physically frail and cognitive impaired older individuals. This pattern has echoes in the past, such as the troubling term GOMER from Samuel Shem's House of God (https://en.wikipedia.org/wiki/GOMER). If you google the term gomer, one of several unflattering definitions is: "(used mainly by doctors) a troublesome patient, especially an elderly or homeless one". It is important not to fall into this ageist trap, and to remember the individual behind every ALC case who you can help. Thank you for highlighting this very important issue, Sudeep

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Sudeep Gill
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