An 83-year-old veteran of battles with chronic disease who has been a long-time patient of mine recently faced colorectal cancer surgery. His recovery, complicated by the new reality of living with an ostomy bag, has been murky and fraught with challenges.
Skilled surgeons have done their part; the wound heals, bowels work. His oncologist, the architect of his chemotherapy, awaits a follow-up in weeks. His primary care physician, though adept with his chronic conditions, has been sidelined by his own cancer treatments and remains unaware of the patient's current state and medications. This gap leaves the man's immediate postsurgical care without a clear steward.
As a geriatrician at Harvard Medical School with special expertise in geriatric surgery, I have seen firsthand how critical coordinated postsurgical care is for older adults. My research and clinical work, including nationally recognized leadership in geriatric surgery, often intersects with cases like this patient's, for whom the transition from hospital to home care requires meticulous follow-up.
Home from the hospital, the patient navigates through unfamiliarity: pain, poor appetite, and new drugs. His family, supportive yet unprepared, feels anxious about managing his altered state.
Barely coping with his heart failure and diabetes amid these changes, and experiencing confusion and decline, he was readmitted to the hospital 10 days after discharge. This readmission highlights the shortcomings of a healthcare system in this country that excels in acute intervention but stumbles in the continuum of care.
This scenario is a reality for many older adults, who are vulnerable due to the complexities of aging physiology, multiple comorbidities, and the effects of high-risk medications after major surgery. Inside the hospital, the care may seem well-structured, but it proves inadequate in the unpredictable environment of everyday life after discharge. Our fragmented system fails to address the whole person, leaving a significant gap in care when continuity is critically needed.
This disjointed nature of the US healthcare system is costing families and patients dearly, not just in the quality of human life but also financially, with an estimated annual toll of $180 million due to readmissions after colorectal surgeries in older patients alone.
Research published recently in JAMA Network Open indicates that nearly 1 in 8 older adults (12%) who undergo surgery are readmitted to the hospital within 30 days, and more than one quarter (28%) are readmitted within 6 months.
Research shows up to 80% of patients do not remember the information provided to them at surgical discharge, and among those who do, 50% recall the information incorrectly. This gap is not just a lapse in care but a critical failure that affects the lives of older patients.
The risk is even higher in patients who are frail or who have dementia, with frail patients readmitted at a rate of about 37% within 6 months and patients with dementia at a rate of 39%. These readmission rates significantly impact a senior's independence and function, highlighting the need for comprehensive pre- and postsurgical care planning.
The US Census Bureau reports there are nearly 60 million people over age 65 years in this country. According to the Centers for Disease Control and Prevention , many of these individuals have multiple chronic conditions and have trouble caring for themselves.
The costs and outcomes are even worse when comparing patients across different races and ethnicities. For instance, Black and Hispanic older adults often receive less effective care and face more significant barriers in the healthcare system compared with their White counterparts. The Kaiser Family Foundation reports these disparities lead to higher rates of complications and readmissions.
These facts are a clarion call for urgent reform. Bridging the chasm between hospital discharge and home recovery in this vulnerable population requires valuing and incentivizing proactive and preventive care as much as cutting-edge technology and acute crisis-driven approaches such as interventional medicine. Preventive care, often neglected, must receive equal recognition and financial incentives.
The proactive approach works. The Optimization of Senior Care and Recovery (OSCAR) program, which I developed, brings geriatrics-focused care and a proactive approach through multidisciplinary care as part of routine surgery care following colorectal surgery.
This program emphasizes geriatrics care in collaboration with surgeons, through comprehensive assessment and care of high-risk, older patients following colorectal surgery. It focuses on optimizing their medications, comorbidities, nutrition, mobility, and cognition to prevent complications. The OSCAR program showed a 15% decrease in transfers to intensive care units and heart rhythm problems and significantly reduced the risk for confusion in older and sicker patients while saving up to $17,000 per case.
Engaging a multidisciplinary team of healthcare professionals — including surgeons, geriatricians, primary care physicians, nurses, social workers, therapists, and nutritionists — as soon as surgery is decided for a patient ensures the goals of postdischarge care will be concrete and prioritizes what matters most to the patient, which differs for every patient based on what they hope to achieve from the surgery.
Evaluating a patient's mental, cognitive, mood, functional, and nutritional status before surgery provides a baseline to tailor postdischarge plans and set realistic recovery goals.
Integrating geriatrics care into surgical teams addresses unique challenges, such as cognitive dysfunction and malnutrition, that can be preemptively diagnosed and managed before those issues result in any complications like delayed wound healing due to malnutrition. Similarly, understanding a patient's social support system and anticipated postdischarge needs before surgery allows the alignment of resources and local programs to provide necessary support, preventing issues like inadequate self-care and nutrition due insufficient social support following discharge.
Educating patients and caregivers with tailored, easy-to-understand, culturally adapted materials and dedicated sessions for discussing postdischarge care improves outcomes.
Keeping the primary care physician informed about the patient's surgical and medical course, medication changes throughout the perioperative period, and potential issues that need follow-up ensures any emerging issues are promptly addressed following discharge, which is crucial given the multiple comorbidities and high-risk medications older patients often have.
Coaching and mentoring patients and families clarifies their roles and expectations before, during, and after surgery. Additionally, establishing two-way, functional communication systems between healthcare providers, with standards and checklists through shared electronic health records and scheduled postdischarge follow-ups, could significantly enhance overall care.
Bridging the gap between postsurgery hospital discharge and home recovery has never been more important. With an exponentially growing aging population and rising surgical rates in this vulnerable group, the need for effective, continuous care is more urgent than ever. The success of this endeavor hinges on valuing and incentivizing a proactive approach and preventive care to ensure older adults receive the comprehensive support they need to thrive after surgery.
Note: This article originally appeared on Medscape.
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