White Coat, Black Art·DR. GOLDMAN'S BLOG

The trouble with hospitalized seniors

A staggering number of hospitalized seniors are readmitted shortly after discharge from hospital. @NightshiftMD says a study suggests important gaps in health care.
Up to one third of Nova Scotians are caring for an ill loved one (CBC)

Doctors have begun to grapple with a new problem related to the country's aging demographic.

A growing number of older patients are readmitted to hospital shortly after discharge. A study just published in the Canadian Medical Association Journal (CMAJ) uncovers a big gap in health care.

  Hospital readmissions are a huge and growing problem in Canada. Researchers from Alberta and Ontario looked at more than 700,000 Ontario patients over the age of 65 with an average age of just over 78 years of age.

Overall, 88,000 or 12 per cent of the patients had to be readmitted to hospital within 30 days of being discharged. Forty per cent of the patients had five or more chronic medical conditions. The big ones included arthritis, Type 2 diabetes, heart disease, anxiety, depression or cancer.

Frail seniors with chronic conditions

As an ER physician on the front lines, I see this all the time. It used to be once a shift. Now, it feels like I'm seeing three or four patients per shift who have returned to the ER after having been admitted and discharged from the hospital where I work.

Typically, they are frail seniors with dementia and other chronic medical conditions.

It's easier to identify patients discharged from our hospital who are brought back to our ER. Not infrequently, when an ambulance is summoned, the patient is taken to a different hospital from the one where they were admitted.

Sometimes, I see a patient who was discharged from another hospital before being brought to ours. It becomes essential to track down records from the other hospital to try and figure out why they've been taken to the hospital the second time.

Why is this happening more often? There are many reasons. Some patients are readmitted to hospital because they have a condition that was missed the first time.

The study suggests a significant gap in home care provided to seniors when they're discharged from hospital. (CBC News)

Some patients have trouble getting new prescriptions filled. Or, they have difficulty figuring out to take their medications. Some don't get timely followup with their family doctor or specialist.

Gap in home care

The study in CMAJ uncovered a new factor associated with hospital readmissions: inadequate home care.

Patients who were discharged to their homes with home care provided by the system were the most likely to need readmission. They also had the longest stays in hospital. Patients who were living in a nursing home prior to the first admission were also more likely to be admitted a second time.

Patients who were admitted from home and who were discharged to a nursing home were less likely to need readmission. As well, patients who came from home and who were sent home without needing home care were also unlikely to need readmission.

The study suggests a significant gap in home care provided to seniors when they're discharged from hospital. There are limits to the type of care provided at home. And even when the level of home care is adequate, frequently, there is no communication between the agency that provides the care and the patient's family doctor.

The reason why patients who live in nursing homes may be getting readmitted is that the hospital is sending patients back to the nursing home prematurely. Or, the doctors at the hospital may be expecting the nursing home to provide more followup care than they are able or equipped to provide. The problem may be a mismatch of expectations. 

I think the system can do a much better job of predicting which patients are most likely to be readmitted.

Knowing that patients sent home with home care services are at risk means those patients should be observed more closely for signs of deterioration. The system should also target patients with five or more chronic conditions like heart disease and diabetes for even closer monitoring.

Once they know who to keep an eye on, one solution is better and more comprehensive home care services.

All of this costs money. When you factor in the cost of readmission and waiting for a nursing home bed to become available, I think it's money well spent.


Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.


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