A RANDOMIZED TRIAL OF CARE IN A HOSPITAL MEDICAL UNIT ESPECIALLY DESIGNED TO IMPROVE THE FUNCTIONAL OUTCOMES OF ACUTELY ILL OLDER PATIENTS

Background. Older persons who are hospitalized for acute illnesses oft en lose their independence and are discharged to institutions for long -term care. Methods. We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; the se patients were randomly assigned to receive usual care or to be care d for in a special unit designed to help older persons maintain or ach ieve independence in self-care activities. The key elements of this pr ogram were a specially prepared environment (with, for example, unclut tered hallways, large clocks and calendars, and handrails); patient-ce ntered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning w ith the goal of returning the patient to his or her home; and intensiv e review of medical care to minimize the adverse effects of procedures and medications, The main outcome we measured was the change from adm ission to discharge in the number of five basic activities of dairy li ving (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently. Re sults. Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in t he intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual-care group, 40 (13 percent ) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P=0.009), The difference bet ween the groups remained significant (P=0.04) in a multivariable model in which we controlled for potentially confounding base-line characte ristics of the patients. Lengths of stay and hospital charges were sim ilar in the two groups. Fewer patients assigned to the intervention gr oup were discharged to long-term care institutions (43 patients [14 pe rcent], as compared with 67 patients [22 percent] in the usual-care gr oup; P=0.01). Among the 493 patients discharged to private homes, simi lar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge. C onclusions. Specific changes in the provision of acute hospital care c an improve the ability of a heterogeneous group of acutely ill older p atients to perform basic activities of daily living at the time of dis charge from the hospital and can reduce the frequency of discharge to institutions for long-term care.