Texas hospitals face challenges and opportunities as the number of Americans ages 65 and older continues to surge.
By the mid-2030s, the United States will be home to 77 million people ages 65 and older —the first time in the nation’s history that older Americans will outnumber children. Texas — as it does on many trends — is leading the way when it comes to the population of older adults.
The latest data show Texas has the nation’s third-largest population of older adults, and it’s growing at a faster rate than the national population. By 2030, older Texans will number 5.9 million or nearly one-fifth of the state’s population. Overall this is good news — people are living longer and healthier lives.
On the flip side, growing older often comes with chronic, complex and costly health problems. This means older people typically use health care services at much higher rates than other age groups. National data show older adults already make up about 40% of hospital patients on a typical day, and about 25% of older adults discharged from an emergency room return to a hospital within a month.
Such data and predictions are hardly news for hospitals and health systems. Across the state, many hospitals are already deeply entrenched in efforts to get ready for the surge of older Americans, from opening units specially designed to care for elderly patients to home-visiting programs that help older people manage their conditions and avoid the hospital altogether. The challenge — like so many others in health care — is doing it all in a way that yields better outcomes and greater value while still containing costs.
“We’ve known this was coming for decades, and we have a lot more work to do,” said Craig D. Rubin, M.D., professor and division chief for geriatric medicine at UT Southwestern Medical Center in Dallas. “But a lot of what we’re talking about in terms of providing optimal care for older patients isn’t high-tech — lots of these are structural and systems changes.”
Karen Kendrick, RN, vice president of clinical initiatives at the Texas Hospital Association, identified geriatric care as an area that presents both challenges and opportunities for Texas hospitals. “Older adults have unique needs and deserve a health system that provides the highest quality of care. The care must be tailored for them and delivered in a way that preserves their independence and dignity,” said Kendrick.
‘Break down the silos and train everybody’
UT Southwestern has several efforts already in place to improve care and value for older patients, such as a house call program for high-risk patients and targeted assessments to reduce age-related surgery complications. But its most far-reaching effort is focused on expanding access to quality care for older Texans despite current and projected shortages of geriatricians.
The effort is known as SAGE — or the Southwestern Aging and Geriatrics Program — and is designed to address the sizeable and growing gap between the rising demand for geriatric care and a shortage of practicing geriatricians. It began about 10 years ago, Rubin said, when UT Southwestern’s medical school received the first of two four-year “game-changing” grants.
With the new funds, the school began integrating geriatrics education across its existing curricula and interprofessional training, with an ultimate goal of graduating physicians and providers who understand aging and the conditions and risks that come with it. Today, the curricula changes mean that across UT Southwestern’s care continuum, older patients engage with providers who understand their needs, can tailor care to avoid age-related risks like delirium, and who know how to partner with patients and caregivers to reduce the risk of readmission. “These efforts have completely transformed the culture of our institution,” Rubin said.
In fact, last year — thanks, in part, to the system’s integrated approach to geriatric care — its Medicare accountable care organization was among the country’s biggest cost savers.
“We wanted to improve training across the board to reach every student and really change our culture in terms of elevating geriatrics as an important discipline,” Rubin said. “ Our approach is to break down the silos and train everybody.”
To the east, Aanand Naik, M.D., associate professor and chief of geriatric medicine at Baylor College of Medicine, is leading similar workforce efforts. In July, the college’s department of medicine was awarded a grant from the federal Health Resources and Services Administration to launch the South East Texas Geriatric Workforce Enhancement Program, one of a few dozen such programs around the country. The program, which Naik co-directs, includes a long list of area partners, such as medical, pharmacy and nursing schools, health systems and hospitals, and community organizations that serve older Texans.
“The future of elder care is interprofessional, which better reflects the real-life way people get care,” said Naik, who’s also a geriatrician at Houston’s Michael E. DeBakey VA Medical Center and chief of the Geriatrics Section at Baylor College of Medicine.
For example, the South East Texas GWEP partners with local senior service organizations to train family caregivers on dementia, works with Meals on Wheels to educate volunteers on signs of abuse and neglect, and teams up with federally qualified health centers to disseminate best practices in elder care. Overall, the grant-funded program zeroes in on five focus areas that Medicare is using to help shift systems from a fee-for service model to value-based care: dementia caregiving and support; advanced care planning; reducing 30-day hospital readmissions; assessing for high-risk opioid use; and reducing and preventing falls, which remain a leading cause of injury-related death among older people.
“It’s a numbers gap,” Naik said. “We simply don’t have enough geriatricians who can see every patient. There are just not enough health professionals specialized in elder care. So, we have to take the knowledge we have and disseminate it out to as many primary care and specialty clinicians, caregivers and family members as possible.”
In southeast Texas, UT Health has long been a leader in improving care for older patients. It was the first to use telemedicine to screen for elder abuse, and its affiliated teaching hospital, Memorial Hermann, was among the first in Texas to have an emergency department accredited in geriatrics care. Then earlier this year, its geriatrics clinic in the Houston suburb of Bellaire — the UT Physicians Center for Healthy Aging — became the very first in the state to be designated an Age-Friendly Health System.
The designation is an initiative of the Institute for Healthcare Improvement and John A. Hartford Foundation — with support from the American Hospital Association — that launched in 2017 with a goal of helping at least 20% of U.S. hospitals and health systems become age-friendly by 2020.
“There are simple, evidence-based changes that any hospital can put in place to improve care for older patients that aren’t expensive and have a high return on investment,” said Carmel Dyer, M.D., who helped lead efforts to earn the clinic’s age-friendly designation and serves as executive director of the Consortium on Aging at the UT Health Science Center at Houston. “In general, good geriatric care tends to be low-tech, but high-touch.”
Earning the designation means the clinic ensures all older patients are cared for using a framework known as the “4 Ms”: what matters, medication, mentation and mobility. In other words, getting to know an older patient’s goals and preferences; ensuring medication doesn’t interfere with mobility and mentation; preventing and managing delirium, dementia and depression across care settings; and making sure older adults can be safely mobile.
Dyer, also a professor of geriatrics and palliative medicine at the university’s McGovern Medical School, said the designation is particularly effective because it helps drive improvement at the system level, which means the changes are much more likely to stick regardless of turnover in the workforce.
“If we don’t act, costs will continue to escalate as a higher percentage of the population becomes older and frailer,” she said. “But if we can target care and prevent harm, we can reduce costs while helping people live longer and healthier, rather than older and sicker.”