As the population of Massachusetts ages, the unique safety and care needs of geriatric patients are receiving increased attention in hospitals, due in part to new state requirements for identifying patients with dementia and optimizing their care.

Sturdy Memorial Hospital, a community hospital in Attleboro, started more than five years ago to develop better systems for emergency care of geriatric patients, work they have more recently expanded into inpatient units.

Other Massachusetts hospitals, including Boston Medical Center, are also finding they are already in good alignment with new requirements that went into effect this month directing acute care hospitals to have an operational plan for patients with dementia.

The law, signed by Governor Charlie Baker in 2018, was originally scheduled to go into effect in October 2021, but key provisions were postponed a year in deference to the pressures put on hospitals by the coronavirus pandemic.

Sturdy Memorial and BMC talk about their approaches

Dr. Brian Patel, who is an emergency physician, Sr. Vice President of Medical Affairs, Chief Medical Officer and Chief Quality Officer at Sturdy Memorial, is one of a number of champions of improved care for geriatric patients in the hospital setting.

Dr. Patel served on a workgroup convened by the Massachusetts Health & Hospital Association in 2018 to develop guidance for complying with the new law, which prompted Sturdy to implement recommendations from the MHA workgroup’s 2018 report ahead of the law’s effective date. “We knew this work needed to be done. We used the plan as a framework to start advancing our geriatric care,” he says.

Dr. Patel reports that Sturdy participates in NICHE — Nurses Improving Care for Healthsystem Elders — a program designed to enhance nurses’ knowledge and evidence-based practices in caring for older adults and has been working closely with the American College of Emergency Physicians, which accredited Sturdy as a Bronze Level 3 geriatric ED in 2018 and, more recently as a Silver Level 3 in 2022.

“The work we've been doing with ACEP and on and the inpatient side with NICHE overlaps with the Massachusetts requirements around management of dementia and delirium,” says Dr. Patel. Sturdy also uses components of the Age-Friendly Health Systems initiative offered by the John A. Hartford Foundation and the Institute for Healthcare Improvement.

Boston Medical Center also has leveraged a variety of resources to build an operational plan for geriatric and dementia care. Lisa Caruso, M.D., geriatrician and Director of Quality and Patient Safety in the Department of Medicine at BMC, says the hospital joined the Age-Friendly Health System program in 2017. Dr. Caruso recalls that creating a geriatric order set, implementing a mobility program and using the Confusion Assessment Method were among their first improvement projects. All address the issue of delirium, which Dr. Caruso says, “is one of the worst things that can happen for somebody who has dementia in the hospital.”

Optimal dementia care extends across six functional domains

The Alzheimer’s Association estimates that the number of people ages 65 and older with Alzheimer’s dementia in Massachusetts will have increased more than 15% between 2020 and 2025 and that people with Alzheimer's disease have almost twice as many emergency department visits and hospitalizations as seniors without dementia. 

The MA Department of Public Health first issued recommendations for managing patients with dementia in acute care settings in 2017. Following up on its workgroup report from 2018, MHA published an operations “roadmap” in conjunction with the Alzheimer’s Association this summer.

The roadmap calls for attention to:

• Advance care planning — including disease progression, health care proxy, advance directives and palliative care
• Staff training — including all patient-facing staff, using resources from initiatives such as the Nurses Improving Care for Health System Elders
• History, screening and assessment — engaging with the patient and care partner, assessing known and suspected diagnosis of cognitive vulnerability
• Dementia-capable environment — prioritizing safety and minimizing use of chemical and physical restraints
• Treatment and management — preventing delirium, managing dementia and delirium when it occurs
• Transfer and discharge — optimizing intra-hospital transfers, to/from outside facilities and home

Liz McCarthy, Health Systems Director at the Alzheimer’s Association, New England region, explained during a webinar co-produced with MHA, that hospitals need to work on all six domains simultaneously. “You're not starting with one of these,” said McCarthy. “They're all going to be happening at roughly the same time.” She also emphasized the importance of engaging with the patient’s care partner throughout the hospital stay and the role of senior leadership to sponsor and direct this wide-ranging effort. McCarthy served with Dr. Patel on the MHA workgroup in 2018.

Describing BMC’s operational plan, Deborah Whalen, R.N.P., Associate Director Quality and Patient Safety in the Department of Medicine at BMC, emphasizes collaboration among the hospital’s departments. This is particularly evident in planning for transitioning patients with dementia to discharge. "Because we're a safety net hospital,” says Whalen, “we have always focused on transitions in the various settings. We often work with our community partners as we help our patients move them through the settings and back into the community.”

Whalen also reflects on how the state law helped her and her colleagues at BMC see the work they already were doing in a new light and showcase it in the operational plan. “The law requires that we have a plan available for the Department of Public Health to review, right? We went farther than that,” says Whalen. “We created a plan that is alive. Now when DPH comes, they can walk through our organization and see it in action.”