Edgar Pierluissi

Hospitalization-Associated Disability: “She Was Probably Able to Ambulate, but I’m Not Sure”

In older patients, acute medical illness that requires hospitalization is a sentinel event that often precipitates disability. This results in the subsequent inability to live independently and complete basic activities of daily living (ADLs). This hospitalization-associated disability occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated. In this article, we describe risk factors and risk stratification tools that identify older adults at highest risk of hospitalization-associated disability. We describe hospital processes that may promote hospitalization-associated disability and models of care that have been developed to prevent it. Since recognition of functional status problems is an essential prerequisite to preventing and managing disability, we also describe a pragmatic approach toward functional status assessment in the hospital focused on evaluation of ADLs, mobility, and cognition. Based on studies of acute geriatric units, we describe interventions hospitals and clinicians can consider to prevent hospitalization-associated disability in patients. Finally, we describe approaches clinicians can implement to improve the quality of life of older adults who develop hospitalization-associated disability and that of their caregivers.

A Clinical Index to Stratify Hospitalized Older Adults According to Risk for New-Onset Disability

BACKGROUND: Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new‐onset disability may improve care. Thus, this studys objective was to develop and validate a clinical index to determine, at admission, risk for new‐onset disability among older, hospitalized adults at discharge.

“Missing Pieces”—Functional, Social, and Environmental Barriers to Recovery for Vulnerable Older Adults Transitioning from Hospital to Home

To describe barriers to recovery at home for vulnerable older adults after leaving the hospital.

Support From Hospital to Home for Elders: A Randomized Trial

BACKGROUND Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success. OBJECTIVE To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital. DESIGN Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532). SETTING Publicly funded urban hospital in Northern California. PATIENTS Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese). INTERVENTION Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner. MEASUREMENTS Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals. RESULTS There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days). LIMITATIONS This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered. CONCLUSION A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population. PRIMARY FUNDING SOURCE Gordon and Betty Moore Foundation.

Attitudes and Expectations Regarding Exercise in the Hospital of Hospitalized Older Adults: A Qualitative Study

To describe expectations of, and perceived motivators and barriers to, in‐hospital exercise of hospitalized older adults.

Depressive symptoms after hospitalization in older adults: function and mortality outcomes.

To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes.

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

BACKGROUND After hospital discharge, patients are at risk for medication errors, missed test results, adverse events, and readmissions. Handoff communication between the inpatient and outpatient settings is primarily accomplished with the discharge summary. However, critical information can often be missing, such as the date of the first postdischarge follow-up visit, a complete and accurate list of discharge medications, and follow-up recommendations. There have been no studies focusing on identifying and implementing a parsimonious, clinically relevant, inpatient-to-outpatient discharge handoff tool within a fully integrated electronic medical record (EMR) system. A concise, written, electronic handoff communication tool was created to address this gap. METHODS Using inpatient and outpatient provider stakeholder input, a standard, succinct, and clinically relevant handoff tool was designed and implemented within the Veterans Affairs EMR. Retrospective chart review at 3 and 15 months after the handoff tool rollout in December 2010 was conducted to monitor handoff uptake and outcomes. RESULTS At 15 months after implementation, 86% (129/150) of patients had a completed handoff at the time of discharge. More handoff notes were available in the EMR within 24 hours of discharge than discharge summaries (100% versus 77%, p < .0001). There was no difference between those patients with or without a handoff in the number of emergency department visits or readmissions. DISCUSSION A standardized clinically relevant discharge handoff tool had high user uptake and sustainability and improved timeliness of communication of information between the hospital and outpatient setting. Even within a fully integrated EMR system, simple and efficient handoffs between inpatient and outpatient providers may fulfill a communication gap at the time of discharge.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

To determine the prevalence of preadmission functional disability in late‐middle‐aged and older safety‐net inpatients and to identify characteristics associated with functional disability by age.

A Pharmacist‐Led Program to Evaluate and Reduce Polypharmacy and Potentially Inappropriate Prescribing in Older HIV‐Positive Patients

The goal of this pharmacist‐led study was to utilize two validated instruments, Beers Criteria and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), to assess potentially inappropriate prescribing (PIP) in older patients infected with the human immunodeficiency virus (HIV) and evaluate pharmacist interventions.

Specialty Care Access in the Safety Net—the Role of Public Hospitals and Health Systems

Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access. Based on our findings, we propose a framework for assessing and improving specialty care access with a focus on population health planning.