My 89-year-old mother was recently sent to the hospital with an irregular heartbeat and a fracture that didn’t require surgery. She was placed under “observation” in the emergency room. I’m not sure I know what that means or what’s best for her in the hospital setting. — T.L., Pleasant Hill
Dear T.L.: This must have been an overwhelming situation for you and your mom. Having a loved one sent to a hospital under any circumstances can be scary. During this distressing time, it’s important to be aware of how observation care differs from other hospital admissions and what it might mean for your mom.
Hospitals and emergency departments are challenged with overcrowding, overutilization, escalating health care costs, and avoidable admissions. As a result, observation areas came into existence in the 1970s and have grown in number. These units are clinical areas in the emergency department where patients like your mom, who are not well enough to go home but not sick enough to be admitted, are observed. The period of time for observation is longer than an emergency visit, but shorter than an admission to the hospital.
More Medicare beneficiaries are entering hospitals as observation patients each year. The number rose 88 percent over the past six years to 1.8 million nationally in 2012, according to the Medicare Payment Advisory Commission. At the same time, Medicare hospital admissions stayed the same.
Observation care can prevent hospital admissions for some patients, which is actually a good thing. The longer someone is in the hospital, the greater the chance of contracting a hospital-acquired illness or infection. As a recent study in Annals of Internal Medicine showed, hospitals that reduce the length of stay also see reduced mortality and readmission rates.
Experts say that the most effective observation units have a dedicated staff that follows clearly defined protocols. If a high-risk patient comes into the emergency room with chest pain, it often makes sense to refer that person to an observation unit for repeat blood tests, EKGs and a stress test. Similarly, a patient with severe asthma who needs time and medication to get an attack under control might be sent to the observation unit for several hours. By monitoring and treating patients intensively upfront, observation unit staff can forestall problems and help people get better faster.
You should know, however, that observation care is considered by Medicare as an outpatient service. This means that observation patients such as your mom may end up with higher out-of-pocket expenses than if they were admitted. For example, observation patients are responsible for copayments for doctors’ fees and medication expenses that may be covered differently if someone is admitted as an inpatient. Observation patients are also not eligible for Medicare coverage if they require follow-up care in a nursing home, even if the doctor recommends it. (To be eligible for nursing home coverage under Medicare, patients must spend at least three consecutive days as an admitted patient.)
Despite the significant financial impact to patients, there aren’t clear standards around whether someone should be admitted as an inpatient or placed in observation care. According to the inspector general of the Department of Health and Human Services, admission practices vary wildly. A physician who has studied these practices says, “Some patients are admitted because they came in at the right time of day, not because they have more complicated medical problems.”
Starting in August, the Notice of Observation Treatment and Implication for Care Eligibility Act will require hospitals to provide written notification to patients 24 hours after receiving observation care, explaining why they have not been admitted to the hospital and the potential financial implications of this type of care.
Navigating the pros and cons of observation and inpatient care can be daunting. This may be a good time to retain the services of a professional such as a geriatric care manager. A care manager can advocate for your mom within the hospital to seek the best outcome for her particular situation. Knowledge and awareness will empower your mom and assure her of a safe transition back to her home.
Rita Clancy, LCSW, is director of adult services at Jewish Family & Community Services East Bay. Her columns appear regularly in J.’s Seniors sections. Have questions about your aging parents? Email firstname.lastname@example.org or call (510) 558-7800 ext. 257.