Get ready for the aging of America

The baby boomers are growing older, and this means a tremendous influx of senior citizens with significant healthcare needs. Case managers are going to be needed more than ever to manage the care of this huge population, but they also need to understand the special needs of senior citizens and take them into consideration as they tailor care plans. In this issue of Case Management Advisor, we look at how managing care for seniors differs from managing care for younger patients. We'll look at how a geriatric fracture care program cuts hospital lengths of stays by 2.1 days, how home visits to high-risk seniors after discharge resulted in a 195% return on investment, and give details on a telephonic case management program that eases the transition from hospital to home.

Educate yourself to manage care for a growing senior population

Opportunities, challenges abound for case managers

As the baby boomers reach retirement age, the senior population in this country is growing by leaps and bounds.

By 2030, the United States will have an estimated 72.1 million older adults, representing a growth of almost 20% says Anthony J. Balsamo, MD, orthopedic surgeon and director of the Geriatric Fracture Care Program at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA.

An increasing number of people are going to need help managing chronic diseases, accessing community resources, and navigating the complicated healthcare system. This change brings opportunities for case managers, but it also means challenges in providing the kind of care coordination that the senior population needs.

"Healthcare spending already consumes more than 17% of the gross national product. We've got to provide evidence-based cost-effective medical care for this large generation of seniors who are coming along and the care has to be coordinated to get them in and out of the hospital and living safely in the community as rapidly possible," Balsamo says.

The needs of the elderly are different from those of younger patients, and the entire process of care is different for them, says Moreen Donahue, DNP, RN, chief nurse executive and senior vice president of patient care services at Danbury (CT) Hospital. After receiving a federal grant, Danbury Hospital developed a family-centered geriatric nursing care curriculum to give its nurses and case managers the skills and competencies to care for its growing elderly population. "Many nurses completed their training before the nursing curriculum included geriatrics and providing care for the elderly as a specific population," Donahue says. "This course offers our nurses and case managers an opportunity to increase their knowledge in caring for an increasing population of older patients."

As they develop a care plan for the elderly, case managers must understand the specific needs and limitations of their patients and take them into account when creating a discharge plan. Elderly patients might experience failing eyesight, loss of hearing, and problems with their balance. Many have cognitive issues and physical mobility problems. Being away from the home setting and in the hospital is disorienting for them. "Case managers need the expertise to plan for an appropriate level of care for seniors and to help their families make the best decisions," Donahue says.

Because elderly patients often have trouble comprehending and retaining information, case managers should involve the family in plan of care and the discharge instructions, Donahue advises. Often this involvement means that hospital case managers need to do more frequent rounding and be available when the family can be there. They can make sure the patient understands the medication regimen. "When they work with older patients, case managers have to become more flexible in meeting the needs of the patient and family members," Donahue says.

Many times when the elderly have an acute event that results in a hospital admission, their next level of care is different from the level of care before hospitalization. Often the elderly person needs additional assistance after discharge and telephonic care coordination interventions to make sure they adhere to their treatment plan.

Seniors who are living at home often need more support than younger patients to ensure that they can continue to live safely in the community, adds Diana Lehman, RN, BSN, CHIE, director of case management for Independence Blue Cross in Philadelphia. "The Medicare population tends to have more comorbidities than commercial members, and their condition is complicated by complex polypharmacy issues. They are often confused about their medication and need help in following their treatment plans. They are overwhelmed by all the instructions they get in the hospital and often need assistance with transportation to physician visits," she says.

Because of the unique needs of the senior population, case managers and social workers at Independence Blue Cross work exclusively with Medicare patients and carry a smaller caseload than case managers who work with the commercial population. "The frequency and intensity of interventions is greater with the Medicare population. They need more community resources than younger patients, and our case managers often have in-depth discussions about their medication regimen and how to follow their treatment plan, Lehman adds.

Case managers need to understand how the events that result in hospitalization could have affected the senior's physical mobility and cognition, and they should take that issue into consideration when they create a discharge plan, Donahue says. "Lengths of stay are getting shorter and shorter. This means case managers must have the expertise be able to quickly assess the specific needs of the elderly and get a plan in place to address those needs," she says.

Older patients might experience reactions to drugs that don't affect younger patients, Balsamo says. For example, older patients taking hydromorphone for pain management might become groggy and disoriented, with an increased risk of falls. If they have to stay in bed because of the disorientation, they can lose muscle tone and develop pressure ulcers, prolonging or impeding their recovery.

If elderly patients are being discharged back to home, especially when they live alone, case managers should educate them and their family members about the importance of good lighting, remove scatter rugs to prevent falls, and install hand rails in the bathroom, says Patti Dorgan, LCSW, ACSW, director of direct services for the Pima Council on Aging in Tucson, AZ.

In situations in which the seniors' family members live in a different state, case managers often need to provide a great deal of support to the senior and his or her family, Dorgan says. "The whole healthcare system is difficult to navigate, particularly for seniors. Most seniors and their family members don't know the whole range of community resources that are available to them," she says.

The Pima Council on Aging offers workshops for caregivers in which they teach them medical advocacy, how to take charge of their loved one's care, and how to navigate the system to find their elderly relatives the care they need, Dorgan says. The organization has a caregiver support program, staffed by social workers who help families access community services. If appropriate, they refer the families to a caregiver specialist who provides individual care coordination.

"We educate the families on the options available and help them decide what options will work best for their loved ones," Dorgan says. "Many seniors don't want to ask for help, particularly the generation that grew up during the Depression. They look on it as government assistance. There are a lot of wonderful programs available to help them with their daily needs, but they need help in accessing them."