As the Population Ages, Patient Transitions Become More Diverse

The aging of America is even more dramatic than many health-care professionals might guess. From 1970 to 2006, the median age of Americans rose from 28.1 years to 36.4, according to the U.S. Census Bureau. But the age distribution of hospital inpatients changed even faster over that period, with the average rising from 40.7 years to 52.5, according to the 2006 National Hospital Discharge Survey.

“The population is aging and Medicare beneficiaries will double to 80 million,” says Eric Rackow, M.D., CEO of geriatric care-management firm SeniorBridge and former president of New York University Hospitals. Meanwhile, “hospital and nursing-home beds are shrinking because treatment is offered outside those institutions, especially at home.”

These variations in utilization across the continuum of care are driven by the population age shift, as well as by medical advances. But our health-care infrastructure hasn’t kept up. “The system was designed for acute care,” says Dr. Rackow. “But as the population has aged, we’re living in a world of chronic illness.”

While hospital length of stay is decreasing, transitions of care continue upward. Total hospital discharges increased by 14 percent from 1997 to 2007, similar to that decade’s population increase of 11 percent, according to HCUP Facts and Figures. But during the same period of time, discharges to home-health care shot up 55 percent, while discharges to long-term care and other facilities rose 32 percent.

Boomers and the Very Old Dominate Growth in Discharges.
The changes in average American ages are striking, but they don’t tell the whole story.

HCUP discharge data from 1997 to 2007 grouped by hospital inpatients’ age shows a bimodal distribution; the graph looks like a two-humped camel. As baby boomers moved into and through middle age, the population of the 45- to 64-year-old bracket jumped 36 percent, while that age group’s hospital discharges leapt 41 percent over the decade. While 65- to 84-year-olds saw only single-digit increases over the same 10 years, advances in medical care drove up the 85-and-older population 41 percent as their hospital discharges rose 25 percent.

Those 70 million boomers now personify the median 52-year-old hospital patient. But in the coming decades, as they enter old age, boomers will require more complex care and transitions. So for discharge planners, health-care reform that emphasizes primary care can’t come too soon. When older patients present in the optimal setting of primary care, they are more likely to have a smooth trip through the health system and enjoy better outcomes.

“It’s harder to get discharge-relevant information from a geriatric patient when they’re in the ER,” says Lori Jacobson, a discharge planner with New York Presbyterian/Weill Cornell and Mt. Sinai hospitals. “Patients’ ability to participate in discharge planning can deteriorate because they may become delirious in the ER waiting for a bed for 20 hours or longer.”

Hospital, SNF Beds Decline as Other Care Settings Emerge.
The headlines about hospital utilization are unequivocal: admissions up, beds down. Community-hospital admissions have risen gradually, from 32.4 million in 1999 to 35.8 million in 2008, according to the American Hospital Association’s annual survey of hospitals. Meanwhile hospital beds declined from 1.21 million in 1990 to 945,000 in 2007, according to the National Center for Health Statistics’ Health, United States, 2009 report.

Over the same period, alternative facilities took up a substantial portion of the demand for services once supplied by hospitals. Home-health agencies rose from 5,730 to 9,024; comprehensive outpatient rehabilitation facilities nearly tripled, from 186 to 539; and hospices jumped from 825 to 3,255, according to the report.

SNFs have seen their population diversify and lose high-functioning elderly people to alternative living arrangements. “We’re seeing nursing home beds go down as assisted-living facilities grow,” says Anne Tumlinson, a vice president at Avalere Health, a Washington, D.C., consulting firm.

Although alternative care settings are seeing rapid growth, quality care can still be in short supply. “New York City has a very limited number of good rehab facilities,” says Jacobson. “People are living longer and staying longer at rehabs.”

Reimbursement Changes May Roil Trends in Elder Care.
But as the wave of aging propels more and more elderly into the belly of the health-care system, a reimbursement trend may give hospitals incentives to direct more of their own resources toward positive patient outcomes.

 “Penalties for readmissions are in policymakers’ crosshairs,” says Tumlinson. “This could motivate hospitals to both keep patients for a couple more days and give them more home health care. The discharge planning function is going to be very important as payment reform initiatives start to take hold.”

Well-designed financial incentives may indeed spur hospitals to align their interests more closely with those of their elderly patients, says Dr. Rackow. “If you bundle the first 30 days after discharge into the hospital payment, the hospital will have to make sure the process is efficient and safe and doesn’t have patients bouncing back.”

But states may stage their own countertrend, motivated by historic budget shortfalls. Putting a sharp pencil to their skyrocketing Medicaid expenses, some states could reverse some of the movement toward alternative care settings.

“Missouri is cutting in half its allowance of Medicaid home-care hours,” says Robert Cimasi, president of Health Capital Consultants in St. Louis. “Having outside care-management firms come in and cut hours of care will increase the demand for long-term care and SNF beds. With today’s long-distance families, there’s a lot of reasons to believe we’re going to need more long-term skilled-nursing beds.”