Project addresses readmission concerns by focusing on the frail

A new project is addressing the special concerns of frail elderly hospital patients in an attempt to help prevent lengthy hospital stays and readmissions for elderly folks, Anna Gorman of the Los Angeles Times reports.

Through the “frailty project” at Cedars-Sinai Medical Center, at-risk seniors are identified and, within 24 hours, assessed for “their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.”

Frail seniors … account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

Frailty is such an important component of getting older that it is a key concept in AHCJ’s Aging Core topic area, with background, statistics and links to studies and additional coverage of the topic.

Core Topics
Health Reform
Oral Health
Medical Studies
Other Topics

Gorman describes the experience of one patient as she is admitted, assessed through her answers to a series of questions and then a team comes up with a plan to address her risks. The plan for that patient included putting a yellow band on her wrist to indicate she’s at risk of falling, making sure she got uninterrupted sleep and reminding her frequently where she was.

Of course, the Affordable Care Act penalizes hospitals now for too many readmissions, something Kaiser Health News’ Jordan Rau has written about for AHCJ. Rau points out that “hospitals are doing a lot of interesting things to try to clamp down on readmission rates. It’s a nice window into many of the most important issues in health care, including cost, access and disparities.”

(Thanks to @judith_graham for pointing out this story.)

1 thought on “Project addresses readmission concerns by focusing on the frail

  1. Janice Lynch Schuster

    Thank you for posting this. Others might be interested in a recent study, published a few weeks ago in JAMA, in which quality improvement organizations worked with 14 communities to improve care transitions–and in doing so, reduced readmissions AND admissions among fee-for-service Medicare beneficiaries. My group, Altarum institute, developed a media toolkit to go with the report, and you can read it (and see videos with the authors), here:

    You might also be interested in my colleague’s take on the readmission calculation, which she believes is flawed. We wrote about that, here:

    Please feel free to contact me if you’d like more details or sources.

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