What do 140 nursing homes, retirement facilities and assisted living establishments within a 30 mile radius of Regions Hospital in Saint Paul, Minnesota have in common? They all have—posted in a prominent location—the phone number of Region’s GFP. (GFP stands for Geriatric Fracture Program, the bureaucratic-sounding name assigned, nationally, to a handful of hospital-based orthopedic care programs for the elderly.)
Dr. Peter A. ColeWhen a nursing home patient falls or otherwise sustains an injury, the staff calls, not an ambulance to take the patient to the hospital, but the Regions GFP number. In response a portable x-ray machine is dispatched to the nursing home, along with a nurse practitioner or an orthopedic physician’s assistant, both of whom have been trained in frontline medical care and orthopaedics. They do an onsite evaluation, take pictures, and discuss the situation with any one of nine orthopedic surgeons at Regions who cover the program. Then, as likely as not, right there in the nursing home, they will set the fracture, put a cast on the injury and leave the patient resting in his own bed.
Not for this patient is a harrowing ambulance transfer and emergency room work-up.
If the break turns out to be a fracture of the hip, an ambulance is called, but instead of taking the patient to the hospital’s emergency room, it takes the patient directly to the orthopedic floor of the hospital. Peter A. Cole, the orthopedic surgeon who conceived the program, says that now 60% of the elderly patients who used to be taken to the emergency room of Regions Hospital are now being successfully treated for their fractures at the nursing or residential home where they live.
Ten years ago Marc Swiontkowski, chairman of the University of Minnesota Orthopaedic Department, recruited Cole to build a program at Regions Hospital that could better address the volume of trauma cases that were coming in to this Level I trauma center. Cole dreamed of a trauma program that would care for patients from “infancy to grave.” To him that meant developing “bookend programs” for both pediatrics and geriatrics. It was not lost on Cole that the cares of fractures in the elderly was relegated to the most junior person on the staff, or to off-hour care after elective surgeries were completed. It was never anyone’s priority to take care of what some looked on as” inconveniences” that would come through the emergency room door.
As he looked ahead at the demographics, Cole realized that “an orthopedic tsunami was about to hit us.” To prepare for it he wanted a system in place so that when there were reams of elderly fracture patients coming in, the hospital would be able to take are of them. “We can’t simply be inconvenienced with every hip fracture that comes in the ER, ” he said. “Unfortunately that is what occurs in most hospitals. What was always treated as a relatively manageable inconvenience has become an unmanageable albatross to many hospitals because of the increasing numbers of patients.”
Dr. Julie SwitzerThe Regions-HealthPartners GFP got its start when Cole hired Julie Switzer, M.D., “a wonderful fracture surgeon, exceptional in treating broken bones, who loves to treat elderly patients”, he said, and Jay Noel. Noel is an orthopedic physician’s assistant who, Cole said, “is a real dynamo, willing to partner with me in initiatives, even to the extent that he carries a beeper 24 hours a day 365 days a year to go out to nursing homes and do consults.”
Switzer and Cole’s geriatric program now conducts more than 300 nursing home and assisted living consultations a year, in what he calls “a radical redefinition of the way we would traditionally address an orthopedic situation.” There is no charge to the nursing home for the service and the patients own health insurance pays for their medical care. Regions Hospital pays all of the costs of the service including the salaries of the staff people running the program. Cole estimates the cost savings to the insurance providers to be in the hundreds of thousands of dollars annually.
According to Cole, the program has raised the quality of care for the elderly. “It is an adverse situation, ” he says, “to take residents out of a nursing home and put them in a completely foreign environment, start them on a myriad of drugs for pain control and startle every sensory system they have with alarming stimuli. Many get confused, delirious. Patients become de-conditioned and this can lead to having to monitor patients more carefully to keep them from falling in the hospital, developing pneumonia and bed sores. They aspirate their food or don’t eat because they have lost their appetite, develop situational depression and spiral downward. Then there are the problems of transitions of care when you have a medical team, a cardiology team and an orthopaedic team—all of whom are working on a patient who easily could have had a simple treatment in the nursing home.”
Despite these benefits, Cole says the model, as it is now, is not repeatable. “I cannot take this program and sell it to my colleagues in other hospitals in other states, ” he said, “because it reduces the number of tests and procedures which the hospital can bill for to be reimbursed.” It works in Saint Paul because the program saves money for Health Partners, which owns the hospital. “We are saving a substantial cost of care for the health plan, ” he said.
Cole and Switzer are applying for a CMS (Centers for Medicare and Medicaid Services) Innovation Grant to help devise a workable financial model. “We must discover the exact value of this program. We want to be able to put a dollar value on every step of this model. What are the savings when patients avoid going to the ER, when post-operative patients can avoid going to the clinics, when patients are treated in nursing homes instead of coming to the hospital, when there are decreased lengths of stay because patients are admitted directly to Regions Hospital?”
According to Cole the staffs of the nursing homes and senior residences love the program. “They get a free consultative service and it is so much better for them to do it this way, ” he says. “Imagine all of the communication with families that needs to occur when patients are moved in and out of nursing homes, the logistical transfers of care, discharge orders, the medication sheets.”
Since the end of World War II, life expectancy rates have increased significantly in the U.S. and age-adjusted death rates have dropped for eight of the top ten diseases. The average American is living longer. As the overall U.S. population ages, demand for orthopedic services for the elderly will increase at a faster pace than the population growth rate. In fact, the growth rate in demand for orthopedic services will grow exponentially faster. For example, there are just under 6 million people 85 year of age or older today. By 2050 that number will triple. Yet the amount of orthopedic healthcare services this group will require will at least quintuple.
According to the United States Census Bureau, about 40 million, or just under 13% of Americans are currently age 65 and older. By 2050, however, that number is projected to expand to 88.5 million—roughly 20% of the country’s population. People 75 years old are becoming the United State’s fastest growing age group.
Cole and Switzer have become national leaders in a movement to create a sub-specialty within orthopedics, to be called Geriatric Orthopaedics. “Just as you have sports surgeons, and hand and spine surgeons, we want to recognize and develop a new specialty for geriatric surgeons with training programs, societies and journals—all the distinguishing elements of a subspecialty”, he said. It was in conversation with these other thought leaders that Cole learned that his team is the only one in the country doing this kind of outreach program for the elderly. “All of the other models are hospital based.” he said.
