Asan Medical Center (AMC) takes the most proactive approach to deal with the aging of hospitalized patients.
In September 2020, AMC recognized the need to address the needs of elderly patients through continuous discussions after medical professionals who had frequent contact with them voluntarily formed the “Senior Patient Committee.”
The committee later led to the “Senior Patient Management Team.” In August 2023, SMC announced it would begin providing specialized care for elderly patients from hospitalization to discharge.
Checking patient's status based on the 'clinical frailty scale' upon hospitalization
The core of AMC's elderly patient management system is to quickly identify problems that worsen patients’ condition as soon as they are admitted to the hospital, apart from the treatment of the disease, and prepare customized responses for each patient when classifying high-risk elderly patients.
To this end, AMC conducts a “Clinical Frailty Scale (CFS)” assessment for all hospitalized patients and identifies "high-risk" patients who need intensive support.
CFS was developed in Canada in 2005 to measure frailty by quickly observing a patient's mobility and ability to perform daily activities. CFS scores range from 1 to 9, with a score of 5 or higher considered high-risk regardless of condition.
A score of 1 means very healthy, 2 means healthy, 3 means good healthcare, and 4 means very mild frailty, and patients have had no major problems up to this point.
The problem begins with a score of 5, which indicates mild frailty, characterized by slowed behavior and the need for assistance in performing instrumental daily activities that are somewhat difficult. Patients with mild frailty will gradually find it difficult to shop, walk outdoors alone, prepare meals, and perform household chores.
A score of 6 indicates moderate frailty and requires assistance with all outdoor activities and household chores. Indoors, they are often unable to climb stairs, bathe, etc., on their own and may need some assistance with dressing. A score of 7 is severe frailty, meaning you are completely dependent on others for physical or cognitive reasons, but your condition is stable, and you are not at high risk of death within six months.
A score of 8 is extremely frail and has a short life expectancy, is completely dependent on others for daily activities, has difficulty recovering from even minor illnesses, and a score of 9 is terminally ill.
AMC looked at 311 patients with a score of 5 or less and 180 patients with a score of 5 or more according to the CFS classification.
It found that patients with a score of 5 or less had 0 percent pressure sore, 0.3 percent delirium, 0.3 percent falls, 2.3 percent emergency room visits, 0.32 percent readmissions within 30 days, and 0 percent deaths.
In contrast, patients with a score of 5 or higher had 5.6 percent of bedsore, 14.4 percent of delirium, 1.1 percent of falls, 10.6 percent of ER visits, 7.85 percent of readmissions in 30 days, and 3.3 percent of deaths.
Second confirmation is made by AMC’s unique '4M' classification method
AMC has been implementing the CFS classification for 14 wards in the hospital since May 2021 and has been applying it to all wards since Nov. 21, 2023.
It is only after the CFS classification that the Senior Patient Management Team moves. Dedicated nurses from the Senior Patient Management Team evaluate the "4M" unmet factors for patients with a CFS score of 5 or higher.
4M is a concept introduced by AMC to manage elderly patients. It categorizes the complex problems that elderly patients may encounter during treatment into (what) Matters, Medication, Mentation, and Mobility.
Within 24 hours of admission, the nurses on the ward measure the CFS of all inpatients, and if they are classified as high-risk with a score of 5 or more, the senior patient management team will visit them to assess them based on the 4Ms.
The 4M-based survey is conducted as an interview to determine if the patient has difficulty taking medications, using the restroom, and eating, among other factors contributing to the patient's condition.
For example, if the 4M assessment determines a problem with eating, it is shared with the department in charge to help the patient with hospital meals and other matters. If risk factors, like delirium, are detected, the patient and guardian are educated. If it is determined that there is a problem with rehabilitation, early rehabilitation begins.
Classifying and managing high-risk elderly patients reduces mortality rates
AMC has been doing this for years, and it's paying off. According to the hospital, the program has reduced the mortality rate of patients with CFS scores of 5 or higher by 71 percent, and the rate of emergency room revisits after discharge by 52 percent. Other benefits include fewer hospitalization days and fewer falls.
"Since the establishment of modern medicine, hospitals have been focusing on quality improvement rather than quantity growth. They have been trying to reduce complications, falls, and pressure ulcers. Still, they are not reducing them well," said Professor Jang Il-young of the Department of Geriatrics, who heads the Senior Patient Management Team. "As a hospital, we tell our staff to 'manage better,' but if it doesn't work even after several years of repetition. It should be seen as a problem of method, not effort."
Jang explained that elderly patients are difficult to care for, and even if hospital workers do the same things as normal patients, these patients don't get better.
“Then medical workers think, 'What should I do?' As a result of that thought, AMC created 4M," he said.
Professor Jang went on to say, "If you can't take care of all patients, the key to managing elderly patients at AMC is to screen and approach high-risk elderly patients with CFS and provide them with what they need specifically through the 4M analysis."
AMC manages 30% of newly hospitalized patients as high-risk elderly patients
A captain leads AMC’s Senior Patient Management Team, which consists of dedicated nurses, pharmacists, physical therapists, rehabilitation therapists, and social workers. The team members are not full-time but work in their respective departments and combine their work with the Senior Patient Management Team.
However, there is a consensus within the hospital that the Senior Patient Management Team members prioritize their work when a senior patient management team task arises.
"We have been able to gain cooperation since September 2020, when internal staff voluntarily gathered to discuss issues related to elderly patients," Professor Jang said. "It was not easy, but it is a necessary part of efficient use of resources."
In this way, the Senior Patient Management Team manages about 30 percent of hospitalized patients as high-risk seniors with a staff of about 10 people. Daily, the team manages about 15 patients as they are discharged and new patients are added.
The departments that are mainly managed are urology, orthopedics, cardiology, and respiratory medicine, with a high proportion of elderly patients. AMC has a policy of increasing the number of departments managed by the Senior Patient Management Team, predicting that it will be possible to manage up to 40 patients daily.
There is no additional cost for patients to be managed by the Senior Patient Management Team. However, they must pay related costs if they need routine interdisciplinary treatment or physical therapy.
It's also necessary to work out a discharge plan after treatment. It aims to prevent patients from returning to the hospital's emergency room because the hospital treats them well but doesn't follow up afterward.
"Patients are worried about tomorrow's surgery but don't think about what they will do at home," Jang said. "However, even if the surgery goes well, many patients still can't leave the hospital because they don't have family to take care of them at home. It's not that they don't want to go home. It's just that they can't."
He went on to say, “There is an in-hospital task force to systematize post-discharge care. We're not at a point where we can announce it yet, but we're working on a pilot model that we hope will yield results within the year."
Managing 'high-risk elderly patients' is same as infection control
Jang explained that it is easier to understand elderly patients by considering them as students subject to the College Scholastic Ability Test (CSAT) grading system.
It takes a lot of effort to improve the grades of the top students, such as those in the first through fourth grades, but it is relatively easy to improve the grades of those in the fifth through ninth grades. In the same way, early identification of high-risk elderly patients and what problems other than the disease can cause their condition to deteriorate can prevent their condition from deteriorating and improve their prognosis after treatment.
The elderly patients we have to manage are in the fifth grade or below, Jang said. Students in grades 1-4 can often do well independently, but if you're in grade 5 or below, you have at least one problem in any subject (no matter how hard you try). The same is true for patients.
"For example, if a patient has a low total score, it means that even if they are at low risk for falls, which is one of the biggest problems in hospitals, they are likely to have problems elsewhere," he said. “So, taking a people-centered approach to identifying problems is important."
In conclusion, he compared geriatric care to infection control.
“It seems like we are doing it for the sake of the hospital because if we don't do it well, the hospital loses money and suffers. However, if we don't do it well, the people suffer," he said. "That's why the government motivated hospitals to do and pay for it. I think geriatric care is the same concept."
He reiterated that senior care is as serious as infection control.
“Hospitals are in trouble. Staff members are overwhelmed. Previously, they used to do four surgeries daily, but they can only do three because of the rising share of elderly patients," Professor Jang said. "Geriatric care is a clear and present crisis and reality. We must start by recognizing and understanding the crisis and reality."