A summary of an actual case
Author: Peter Bechtel, President/CEO WellTrackONE Corporation, April 22, 2018
The following case study is based upon an actual incident of an elderly woman who experienced a broken hip. We will follow her through her journey leading up to the fall, after the fall and finally onto recovery.
This case summary will reveal the facts behind a case involving a senior Medicare patient (“Lucille”) who suffered a broken hip in the winter of 2018. Lucille is an 87-year old Caucasian woman living in a suburban area of a large metropolitan city in the Southeast. She lives with her 88-year old husband. Prior to the accident, both Lucille and her husband were active seniors who shared common interests such as travel, boating and dining out with family and friends.
In January of 2018, Lucille and her husband were relaxing in front of the fireplace in their living room when the phone rang. It was their son calling. Lucille’s husband spoke briefly to his son and then held the phone up for Lucille and said “Your son wants to speak with you.” Lucille had been staying warm with an afghan across her lap, resting quietly in her chair across from her husband. As she stood up, her toes stepped on the afghan and her feet were unable to move forward, but her body was already leaning in that direction. Lucille fell flat on the floor and fractured her right hip.
Flash Point: Most falls occur on the flat; falls on the stairs or in the bathroom are relatively rare. Old women tend to fall in the house, old men in the garden. In `care homes’, many falls occur on the way to or from the toilet. Only one in a hundred falls results in a hip fracture, but one-fifth cause serious injury. Of those who fall and lie on the floor for hours, half will be dead within six months1.
Before we transcend into Lucille’s trip to the emergency room, we will pause here to discuss the “preventive” aspects of fall risk.
Prevention
We believe that part of the problem with fall-related accidents is that there are few to no “preventive” aspects of fall risk commonly manifested upon the senior population. Here is a short list of action items that could be undertaken for this population both to save broken limbs but also to save billions of dollars in expensive treatment and after-care:
*Physicians should encourage their patients with two or more chronic conditions or risk factors to enroll in Chronic Care Management (CCM). Even if the physician does not have the capacity to handle the CCM requirements by him or herself, there are a number of third party companies (including WellTrackONE) who are capable of providing CCM services with nurses engaging with their patients on a full-time basis. This helps in so many ways to avoid falls because the nurse-counselor can help the patient think about falls around their home by drawing attention to common areas where falls occur. The nurse-counselor can also motivate the patient to install handrails, handgrips, and remove slippery rugs. But the nurse-counselor can also discuss past incidents of falls (such as Lucille’s experience) so the patient is ultra-aware of the risk and potential of falls like the one Lucille had.
*Risk-based organizations such as ACOs should consider assessing their attributed patients with an Annual Wellness Visit (such as the one WellTrackONE offers) and using that risk information given out by the AWV assessments to send home healthcare specialists INTO the patients’ homes to look for and help correct high-risk fall threats AND help patients strengthen their legs, hips, arms and shoulders through muscle-strengthening programs. While there is an obvious cost to this solution, the offsetting savings by NOT paying for a broken hip or leg is much greater than the home healthcare costs. For the general older population living in the community, evidence suggests that individualized home programs of muscle-strengthening and balance retraining, complex multidisciplinary, multifactorial, health/environmental risk factor screening and intervention, home hazard assessment and modification, and medication review and adjustment can all reduce the incidence of falls2.
Hospital selection
Lucille was in great pain on the floor of her living room and of course, her husband did the most reasonable thing by calling 911 for assistance and then immediately calling his daughter. The emergency operator immediately dispatched an ambulance to their house.
Flash Point: The ambulance company will generally take the patient to the nearest hospital unless directed by the patient or their family (non-life threatening situations). This can cause a cascade of problems if the patient’s PCP is NOT affiliated with that hospital. As part of a Chronic Care Management program, CCM nurses are trained to constantly remind patients that they need to direct ambulances to THEIR hospital where THEIR PCP has privileges.
The ambulance took Lucille to an unfamiliar hospital because the drivers were not given alternative instructions. As a result, Lucille was assigned to a foreign hospital with a primary care hospitalist who knew nothing of Lucille’s past medical history, which was very complicated.
Coordination of Care
As it turns out, Lucille is a cancer survivor and is undergoing a clinical trial with a special drug regimen for lung cancer. This aggressive regimen is working for Lucille and her PCP monitors her condition on a regular basis. Lucille previously survived lung cancer and has had surgery on one lung.
Lucille endured the standard protocol of hospital treatment for a broken hip, including:
*Ambulance ride
*Emergency Room triage (with 4 hours in pain waiting)
*Admission
*Radiology
*Vitals/Labs
*Medication reconciliation (verbally, from Lucille)
*O/R scheduling
*O/R
*Recovery
New developments/problems
While in the hospital, Lucille was diagnosed with Afib, which apparently is common among patients of this age group. At this point, there was administered another battery of tests, EKGs, remote heart monitors, medications and other procedures ordered by the cardiologist. Lucille’s hospitalist changed every 12 hours. Yes, 12 hours. Lucille never saw the same hospitalist twice during her entire stay.
Meanwhile, Lucille contracted pneumonia. Given the nature of her lungs and her pulmonology and oncology history, this was a serious problem that needed very intricate monitoring and care. Lucille was still being monitored by the random hospitalists, but now that included the cardiologist, pulmonologist, orthopaedic surgeon and oncologist. Her Family Physician had not been brought into the loop at this point because he was not affiliated with the hospital.
Importance of family involvement
Fortunately for Lucille, her family was rallying around her in all directions and taking a very direct position in her care. In fact, if it had not been for her family’s involvement, Lucille’s outcome may have been very different. Communication between the patient, family and clinicians is a critical component of high-quality, safe care and the foundation of partners between the patient, family and clinicians3.
Lucille’s mental state degraded during her stay in the hospital. As most physicians who are experienced with the geriatric population know, mental acuity degradation is very common in seniors who stay in the hospital. A study in the journal Neurology which followed 1870 seniors over the age of 65 for 12 years and periodically tested their cognitive ability found that hospital stays actually may start a downward spiral in elderly patients’ cognitive ability4.
Had it not been for the family involvement, we believe Lucille’s mental state may have eroded much faster and to a deeper level. Fortunately, her family was there with her constantly, but to a great degree this is a rarity among elderly hospital patients who do not have an active family involvement.
Post-Discharge
Lucille wound up staying in the hospital/SNF for a total of 22 days – about 15 days longer than normal for a fractured hip. Her surgery was successful, her pneumonia contained and her Afib still prevalent.
When she was discharged, her family made sure she was adequately transported home and had made arrangements for her bedroom to be on a lower floor of the house. Lucille’s husband installed handrails in certain areas of the house to help her navigate the steps.
Lucille was NOT put under any kind of Transition Care Management (TCM) program. We regard this as one of the major mistakes made in Lucille’s care while at the hospital. Every hospital is a stakeholder in the after care of the patient once discharged and this hospital failed to move the patient to a TCM status with a navigator helping her and the family.
The scenario after discharge was as follows:
*Lucille was still in a state of cognitive degradation;
*She was showing signs of depression;
*She was on new medications and was taking her oncology medication before she left the hospital;
*She continued to take medications prescribed PRIOR to the fall, but there was no coordination of care nor reconciliation of medications that include the full extent of post-discharge medications;
*Her Family Physician was aware of her condition only due to family members outreaching to him. He had not been “in the loop” while she was in the hospital;
*There was no clear and well-managed physical therapy management program put into place to help her with her recovery;
At home, Lucille’s B/P started falling and the family was advised by a home healthcare agency worker to “call an ambulance” to take her back to the hospital. The cardiologist phone triage unit confirmed, but no follow-up by the cardiologist office was given. By this time, the family contacted her Family Physician for urgent review of medications due to lack of support from the hospital-based cardiology service unit. Lucille’s Family Physician was on task to oversee the situation with Lucille’s health and he ordered a change of medications which helped Lucille’s B/P stabilize.
Again, thanks to the family and Lucille’s PCP, disaster was averted. The hospital seemed to lose interest in Lucille once she was discharged. This presents a very dangerous situation when a patient is discharged without a solid plan of treatment and care and the hospital was exposing themselves to potential liability as well as re-admission penalties by NOT putting Lucille into a TCM plan of care.
Flash Point: The hospital put Lucille in grave danger by discharging her without a care coordinator or navigator assigned to manage her health for the next 30 days. At this point, Lucille’s medications were askew, the rehab agency was not scheduled properly and Lucille’s hospitalist was now out of the picture.
Cost
Lucille’s family shared with us redacted copies of her invoices from the hospital. The total BEFORE discharge was $218,456. We have not seen the invoices post-discharge, including rehab, home healthcare, supplies, follow-up doctor’s visits, additional medications, follow-up radiology, etc. Our suspicion is that the total bill will be in excess of $350,000 with all accounts closed. Each year, over 300,000 older people – those 65 and older – are hospitalized for hip fractures5. As the Medicare population doubles by 2025 to over 100 million patients, this could double the number of hip fractures to 600,000. That acceleration could easily cost the US taxpayers $210,000,000,000 (Two Hundred and Ten Billion Dollars!).
Summary and Recommendations
Clearly, the small price to pay for prevention is the key to containing the cost, mortality and morbidity of falls and fractures. We advocate that physicians make a conscious effort to enroll their patients with 2 or more chronic diseases or risk factors – especially with risk of fall – in Chronic Care Management. We also recommend that hospitals engage their post-discharge patients in Transition Care Management services at all times.
Flash Point: (1) Chronic Care Management and (2) Transition Care Management will help prevent falls and cost overruns due to fall incidents.
Lucille today
Lucille is making great progress in recovery today (3 months after her accident). She has regained her mental acuity and is walking with a walker and/or cane with about 75% recovery to this point. Her food intake has improved, she is back to a normal weight and there are fewer signs of depression. Her Family Physician is once again managing her health and doing a great job keeping track of Lucille. Lucille has had follow-up visits with the pulmonologist, oncologist and cardiologist. Again, thanks to her family, this recovery was possible. We fear that had the family NOT been involved, Lucille’s condition would have been substantially worse.
References
1.Falls in Older People: Risk Factors and Strategies for Prevention. Stephen R Lord, Catherine Sherrington, Hylton B Menz. Cambridge: Cambridge University Press, 2000. [249 pp; ISBN 0-521-58964-9 (p/b); £29.95 (US $49.95)]
2. Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev . 2003(4):CD000340. [PubMed]
3. Communicating to Improve Quality. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy2/index.html
5. Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov. Accessed 5 August 2016.