Now, shortly after being released, Rodgers got a knock at the door.

Nurse Tiffanie Abrajano and social worker Valerie Ellis were there to make sure his transition home had gone smoothly. They checked his medications one by one and made sure he knew how to take them. They walked through the house looking for loose rugs and other obstacles that could cause him to fall again. They also asked about safety bars in the bathrooms, and whether he needed a caregiver to help with bathing and dressing.

“We are trying to see if there is anything you might need here in your home to potentially keep you from going to the hospital,” Ellis said. “Do you feel like you have enough assistance?”

In recent years, federal health officials have begun for high rates of readmission and sponsoring  — like the one that sent a social worker and nurse to see Rodgers — to help ensure smoother discharges.

Hospitals and community groups are experimenting with different methods to improve the transition of elderly patients from the hospital.­

Some of them seek to strengthen communication with primary care doctors, or use technology to track patients across different health systems. Others emphasize closer partnerships between hospitals and community groups that provide meal delivery, transportation and other social services.

A developed at the University of Colorado, for example, follows patients for the first month after their discharge, helping them manage their medications, schedule follow-up appointments and recognize signs of trouble.

San Diego County received a federal grant to improve handoffs from the hospital using an adaptation of the University of Colorado’s program. The county’s Aging and Independence Services agency partnered with four hospital systems — Scripps Health; University of California, San Diego; Palomar Health, and Sharp HealthCare — to serve more than 50,000 Medicare beneficiaries at the highest risk of medical complications after discharge.

The efforts aim to improve care and save money. Poorly managed transitions can waste medical services and increase health care costs. The federal government has estimated that nearly 20 percent of Medicare patients return to the hospital within 30 days, costing more than $26 billion annually.

The penalties and programs around the country are starting to make a dent in the problems associated with poorly handled discharges, experts said. The saved Medicare an estimated $13.8 million over a two-year period between 2013 and 2015, primarily because of reduced hospital readmissions.

But experts are quick to note that more needs to be done. Naylor said providers can’t stop looking after patients just a month after they are discharged.  “It’s not just thinking about today or tomorrow or the next 30 days,” she said. “For chronically ill, older people, what is their long-term trajectory?”

Programs like the one in San Diego County aren’t a panacea. It serves only a portion of Medicare beneficiaries, and people aren’t eligible for the help while they are in a nursing facility.

John Statler, 88, for example, returned to the emergency room at Palomar Hospital three times within the first week of his discharge to a nursing home. Statler had spent several days at the hospital after a fall left him with a severe head wound. His daughter said the hospital saved his life but didn’t then ensure that he had what he needed to recover after being discharged. In the end, he had to be readmitted.

Transition difficulties often start for elderly patients when they’re preparing to be discharged from the hospital. That’s when medical staffers quickly read a list of instructions to patients and hand them new prescriptions. Older patients may not understand what they are being told because they have dementia or are weakened and confused from their time in the hospital. Some are simply anxious to leave and not paying close attention.

“You are trying to reach them and do that education at such a critical time, but they are nowhere near cognitively ready to receive that,” said Joe Parker, lead nurse of care transitions at Palomar Health. “And we don’t have the luxury of time to wait.”

Back at home, family members and caregivers are often asked to take on medical tasks that would make “most first-year RNs shake in their boots,” said Robyn Golden, director of health and aging at Rush University Medical Center in Chicago. That can lead to medication mix-ups, infections and other problems — especially since the average hospital stay has shrunk.

“People are going home sicker, quicker and they are not returning to their prior selves as quickly – if at all,” Golden said.

Adding to the potential complications is the fact that primary care doctors are often unaware their elderly patients are in the hospital, so they can’t step in to ensure treatment plans are followed.

The main issue the San Diego program is designed to address is the disconnect between hospitals and social services agencies, which have traditionally operated in separate silos, San Diego County and hospital officials said.

“There is a point where the hospital can’t do any more” for patients who have been discharged, said Cecile Davis, coordinator of the remote patient monitoring for Sharp HealthCare. “The key is to know when to turn them over to the community.”

To figure out what patients like Alton Rodgers need, nurses and social workers ask critical questions, said Carol Castillon, who manages the care transitions program for the county.

Do they have transportation to get to the doctor? Do they understand their medications? Do they need an in-home caregiver?

The over-arching question, Castillon said, is: “What are the long-term services we can bring in so that this person isn’t coming back to the hospital?”

Castillon said that before starting the project with the hospitals, the county regularly found older people in their homes who had been recently discharged and were unable to care for themselves. “They were sick, they were unable to get medications, they didn’t have food,” she said.

Participating hospitals identify patients for the program before they are discharged.

At Palomar Hospital one spring day, nurses Patrice Gadd and Rachel Ricchio stood at the bedside of 88-year-old Joseph Taylor, a former physical therapist who had come to the hospital with pneumonia and was diagnosed with congestive heart failure.

Gadd told him that he could get a home visit and a month of follow-up to help keep him out of the hospital. Taylor and his wife, who had recently moved from Colorado, both agreed that any help would be welcome.

Gadd urged Taylor to call the doctor if he started feeling sick again.  “The problem is that the older we get, the less reserves we have in our gas tank,” she said. Things “can go south really, really quickly.”

Nearly three months after his hospitalization, however, Taylor hadn’t returned to the hospital.

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from , and its coverage of late life and geriatric care is supported by .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

“This is actually a little bit alarming,” Bailey said.

He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal’s breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

And even if a drug doesn’t cause an adverse reaction, that doesn’t mean the patient necessarily needs it. A of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.

“There are a lot of souvenirs from being in the hospital: medicines they may not need,” said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky, said many doctors who prescribe drugs in hospitals don’t consider how long those medications might be needed. “There’s a tendency in medicine every time we start a medicine to never stop it,” Covinsky said.

When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don’t have a family member or a caregiver to help, the consequences can be disastrous.

One found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.

UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients.

Speaking from his hospital bed at UCLA’s Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.

Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

“I’m very confused about it, to tell you the truth,” he said after talking to Bailey. “It’s complicated. And if the pills are not right, you are in trouble.”

Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after Bailey started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.

“As you know, our elderly are already at risk for an accumulation of drugs in their body,” he told the group. “If you put a drug that has a really long half-life, it is going to last even longer in our elderly.”

The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey’s services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.

Bailey said he tries to answer several questions in order to determine what’s best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?

One of his go-to references is known as the — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.

When he’s not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients’ medication lists are accurate and up to date. He also monitors patients’ new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.

“Medications only work if you take them,” Bailey said dryly. “If they sit on the shelf, they don’t work.”

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.

Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.

Bailey said he’s constantly weighing the risks versus the benefits of medications for elderly patients like Cal.

“It is figuring out what they need,” he said, “versus what they can survive without.”

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from , and its coverage of late life and geriatric care is supported by .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

“It’s like a war zone,” said physician assistant Emmy Cassagnol. “When it gets packed, it’s overwhelming. Our sickest patients are often our geriatric patients, and they get lost in the shuffle.”

But just on the other side of the wall is another, smaller emergency room designed specifically for those elderly patients.

Patients like Hattie Hill, who is 105 years old and still living at home. A caregiver brought her in one rainy day in late spring because she had a leg infection that wasn’t responding to antibiotics. Hill, who also has arthritis and a history of strokes, said she prefers the emergency room for seniors because she gets more attention.

“I don’t have to wait so long,” she said. “And it’s not so loud.”

Packed emergency rooms are unpleasant for everyone. But they can be dangerous for elderly patients, many of whom come in with multiple chronic diseases on top of a potentially life-threatening illness or injury.

“You’ve got this surge of more and more older adults coming to the emergency departments,” said Kevin Biese, co-director of geriatric emergency medicine at the University of North Carolina School of Medicine. “Yet there hasn’t necessarily been this recognition that [they need] different screening, different treatment and they are going to have different outcomes.”

Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.

The staff in these specialized ERs collaborate closely not only to treat the seniors’ immediate health problems but also to reduce their risk of confusion, bed sores and over-medication. Senior ERs are designed to be more quiet and tranquil.

Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls, Hwang and others said. That tends to reduce hospitalizations among the elderly.

Mount Sinai, which opened its in 2012, is part of a nationwide effort to find a better way to treat elderly patients. The first geriatric ER opened in New Jersey in 2008, and now there are more than 100 such units nationwide.  Several others are being planned, including in California, North Carolina, Connecticut and Texas.

Geriatric ERs vary widely. Some are separate units with trained staff; others are merely sections within traditional emergency rooms with extra hearing aids and other senior supplies. But professional medical organizations have developed to standardize design, staffing and patient screening.

The boomlet in geriatric emergency rooms stems in part from an with complex conditions who are seeking care in regular ERs. That has caused some providers and hospitals to seek more effective and efficient ways to treat them.

About 20.4 million patients over the age of 65 were treated in emergency rooms in 2011, up from 15.9 million a decade earlier, according to a national hospital survey conducted by the Centers for Disease Control and Prevention. As the population ages, older patients are expected to make up an increasing share of ER patients.

The Affordable Care Act also has fueled the expansion of senior emergency rooms. The law assesses penalties when too many patients return to a hospital too soon after discharge. Facilities have tried to reduce readmissions in part by providing better emergency care and triage.

Now, that growth could continue as hospitals face additional pressure to provide more efficient and less costly care to their Medicare patients. The Centers for Medicare and Medicaid Services announced in January that within two years, half of all traditional Medicare payments will go to providers based on quality of care rather than quantity of services.

Emergency departments are the perfect places to make changes that could help control spending, because they are gateways between home and costly hospitalizations, Hwang said. About 60 percent of elderly patients who get hospitalized come through the emergency room, according to a 2013 study. A quarter of those hospitalizations are preventable, according to one 2012 .

“Hospitals that before didn’t think there was any need for this are saying, ‘Can you help us create a geriatric ED?’” Hwang said.

Hospitals also may view specialized emergency departments as a marketing tool to reach the growing elderly population.

The geriatric emergency room at Mount Sinai is set up differently than traditional emergency rooms. It has thicker mattresses to help reduce the chance of bed sores, raised toilet seats, hand rails in the hallways and reduced-noise curtains.

The department is allotted 20 beds, but the main hospital sometimes steals them for other patients. That leaves some older ER patients waiting in the hallway.

Over a two-day period in May, dozens of older patients were treated for falls, dizziness, severe pain and shortness of breath.

John Fornieri, 80, came in after falling on his floor at home. Fornieri, an artist with arthritis and a heart condition, said he nearly lost consciousness. An x-ray showed he had broken a hip.

Fornieri said he was grateful that the geriatric emergency room staff was trained to care for the elderly. “Seniors need a different kind of attention,” he said. “We can’t see and we can’t hear like we used to. We can’t even talk the same.”

Denise Nassisi, a physician who runs the geriatric ER, said her patients are at greater risk of falling, medication errors and infections than younger patients. Seemingly routine injuries can have devastating effects. Broken arms, for example, can make it difficult for elderly people to care for themselves.

Many also have dementia or other cognitive impairments that make it harder to get an accurate account of their medical history and the reason for their ER visit, she said. About half of the patients arrive unaccompanied by relatives or caregivers.

In the past, Nassisi said, doctors frequently just admitted the patients, leaving it to the hospital staff to do a more complete workup. But now, Nassisi and her team of social workers, therapists, nurses and others try to screen, diagnose and treat patients more thoroughly in the ER, she said.

Part of their job is to determine whether older patients can be safely discharged. That means they aren’t automatically admitted to the hospital, which would raise their risk of confusion and loss of independence. “We are trying to change the culture of just admitting,” Nassisi said.

A patient doesn’t need a clean bill of health to be discharged. One 81-year-old patient came in for a toothache but also had a long list of illnesses: coronary artery disease, chronic pulmonary disease, arthritis, high blood pressure, prediabetes and high cholesterol. She was released with pain medication, antibiotics and an appointment with a surgeon.

Another patient, who was 83 and had high blood pressure, anxiety and cancer, had fallen in her kitchen. She, too, was discharged after staff ensured she could walk on her own and had help at home.

As providers determine where the patients should be treated, they also try to prevent them from becoming delirious, developing additional problems or taking potentially harmful medications.

Physician assistant Jaclyn Schefkind evaluated Hill, the 105-year-old patient.

“How are you doing?”

“Bad,” Hill said, wincing in pain.

Schefkind looked at Hill’s leg, red and swollen. She said they were going to get her some stronger antibiotics and something to relieve the pain.

“Let’s start with Tylenol,” Schefkind said. “I don’t want to give you something too strong because it’s not safe when you’re older.”

Shortly afterward, the team decided the best place to admit Hill so doctors could get her infection under control. A nurse pulled Hill’s blanket up to her chin, packed up her belongings and rolled her through the door toward the main hospital.

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from , and its coverage of late life and geriatric care is supported by .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Terri Middlebrooks, a nurse at the hospital, tried to figure out how active the 92-year-old Atkins was before the incident. “Are you up and moving at home?” she asked.

“I can manage, but I have to have help sometimes,” Atkins replied.

Atkins said she uses a walker to visit friends and to get to the communal dining room. But she’s also fallen a few times in recent years.

“Don’t quit walking here,” Middlebrooks told her. “It’s the most important thing you can do. … This bed is not your friend.”

The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at for blood clots, pressure ulcers and confusion.

Immobility can also reduce patients’ ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of to the hospital, according to .

Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.

Instead of returning home to their normal lives, patients who can’t walk when they leave the hospital are more likely to go into nursing homes, said Seth Landefeld, chairman of the Department of Medicine at the UAB School of Medicine.

“They don’t bounce back,” Landefeld said. “The pneumonia is better, but Aunt Mary is not walking and talking the same as before.”

Landefeld said hospitals frequently take the “smart bomb” approach to illness. “We blow away the disease, but we leave a lot of collateral damage,” he said.

Making sure hospitalized patients spend sufficient time out of their beds can save money, keep them and improve their overall health. Researchers in Texas found that increasing the number of steps elderly patients took on their first and last days in the hospital reduced their risk of dying over the following two years. A study of pneumonia patients of all ages showed that walking early in their hospital stay shortened its duration, saving an average of $1,000 per patient.

The hospital hosts a twice-weekly session called “Move and Groove,” designed to get older patients dancing. At a recent session, a music therapist played the piano as the patients held tambourines or bells and moved their feet to the beat. All of the patients used walkers. A few had oxygen tanks and most wore bracelets indicating they were at risk of falling.

Occupational therapist Linda Pilkerton said she doesn’t give patients a choice of whether to participate.

“We don’t ask them if they want to do an x-ray or if they want a CT scan,” she said. “This is ordered by the doctor. If they don’t get up and move, they start the death spiral.”

After Atkins was admitted to the unit following the scooter mishap, Middlebrooks told her it would only take two days of lying in bed to lose muscle mass. “And if you lose muscle mass, you get weaker and you’re more apt to fall,” the nurse explained, adding that Atkins had done enough of that.

Atkins, who has a pacemaker and has had hip and hernia surgeries, said she has lived alone a long time and doesn’t want to end up in a nursing home. As she pushed her walker down the hospital corridor, she acknowledged that she’s gotten weaker as she’s gotten older and that her arthritis makes it more difficult to shower and dress by herself.

But she said she’s determined to keep walking — at home and in the hospital.

“I don’t want to lose more independence,” she said. “I’ve already lost a lot of it.”

But even if patients spend a lot of time out of bed while they are in the hospital, it does not guarantee they will recover.

Willie Mae Rich, 86, came to the Alabama hospital this spring because her doctor was concerned about her heart. Rich knew her bones wouldn’t withstand a fall, so she worried about walking around too much.

“I’ll break up like peppermint candy,” she said.

But the hospital staff didn’t give her a choice. They urged her to eat meals while sitting in a chair, get herself dressed and get up as often as possible.

“The more time you spend out of this bed, the healthier you’ll be,” Viles told her.

Despite staying active in the hospital, Rich, a great-grandmother, became more sedentary over the next several weeks. Her daughter, Debra Rich-Horn, said her mother continued to walk when she first came home, but soon she could barely get out of bed.

In May, she passed away.

“Her heart was already at a bad stage,” Rich-Horn said. “By the time [the hospital] got her, it was too late.”

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from , and its coverage of late life and geriatric care is supported by .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Doctors cared for her wounds and treated her pneumonia. But Prochazka, 75, didn’t sleep or eat well at Zuckerberg San Francisco General Hospital and Trauma Center. She became confused and agitated and ultimately contracted a serious stomach infection. After more than three weeks in the hospital and three more in a rehabilitation facility, she emerged far weaker than before, shaky and unable to think clearly.

She had to stop working and wasn’t able to drive for months. And now, she’s considering a move to Maine to be closer to relatives for support.

“It’s a big, big change,” said her stepdaughter, Kitty Gilbert, soon after Prochazka returned home. “I am hopeful that she will regain a lot of what she lost, but I am not sure.”

As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

“The older you are, the worse the hospital is for you,” said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. “A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more.”

Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.

Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.

San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, the staff tests patients’ memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.

“Bed rest is really, really bad,” said the medical director of the ACE unit, Edgar Pierluissi. “It sets off an explosive chain of events that are very detrimental to people’s health.”

Such units are still rare — there are only about 200 around the country. And even where they exist, not every senior is admitted, in part because space is limited.

Prochazka went to the emergency room first, then intensive care. She was transferred to ACE about a week later. The staff weaned her off some of her medications and got her up and walking. They also limited the disorienting nighttime checks. Prochazka said she got “the first good night of sleep I have had.”

But for her, the move might have been too late.

“She will not leave here where she started,” Pierluissi said several days before Prochazka was discharged. “She is going to be weaker and unable to do the things you really need to do to live independently.”

Not A Priority

How hospitals handle the old — and very old — is a pressing problem. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. Patients over 65 already make up more than one-third of all discharges, according to the federal government, and nearly 13 million seniors are hospitalized each year. And they stay longer than younger patients.

Many seniors are already suspended precariously between independent living and reliance on others. They are weakened by multiple chronic diseases and medications.

One bad hospitalization can tip them over the edge, and they may never recover, said Melissa Mattison, chief of the hospital medicine unit at Massachusetts General Hospital.

“It is like putting Humpty Dumpty back together again,” said Mattison, who wrote a 2013 detailing the risks elderly patients face in the hospital.

Yet the unique needs of older patients are not a priority for most hospitals, Covinsky said. Doctors and other hospital staff focus so intensely on treating injuries or acute illnesses — like pneumonia or an exacerbation of heart disease — that they can overlook nearly all other aspects of caring for the patients, he noted.

In addition, hospitals face few consequences if elderly patients become more impaired or less functional during their stays. The federal government penalizes hospitals when patients fall, get preventable infections or return to the hospital within 30 days of their discharge. But hospitals aren’t held accountable if patients lose their memories or their ability to walk.  As a result, most don’t measure those things.

“If you don’t measure it, you can’t fix it,” Covinsky said.

Improving care for older patients requires an investment that hospital administrators are not always willing to make, experts said. Some argue, however, that the investment pays off — not just for older people but for hospitals themselves as well as for a country intent on controlling health care spending.

Though research on the financial impact of problematic hospital care for the elderly has been limited, a 2010 by the Department of Health and Human Services’ Office of Inspector General found that more than a quarter of hospitalized Medicare beneficiaries had suffered an “adverse event,” or harm as a result of medical care.

Those events, such as bed sores or oxygen deficiency, cost Medicare about $4.4 billion annually, according to the report. Physicians who reviewed the incidents determined that 44 percent could have been prevented.

In addition to outright mistakes, poor or inadequate treatment in hospitals leads to needless medical spending on extended hospital visits, readmissions, in-home caregivers and nursing home care. Nursing home stays cost about $85,000 a year. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality.

“If you don’t feed a patient, if you don’t mobilize a patient, you have just made it far more likely they will go to a skilled nursing [facility], and that’s expensive,” said Robert Palmer, director of the geriatrics and gerontology center at Eastern Virginia Medical School and one of the brains behind the idea of ACE units.

ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 Health Affairs , Palmer and other researchers found that hospital units for the elderly saved about $1,000 per patient visit.

A Different Life 

After coming home, Prochazka said she felt weak. It took weeks of walking her labradoodle, Gino, to regain strength.

Her stepdaughter, Gilbert, said Prochazka has started to improve. “We knew she was getting better when she was getting ornery,” she said.

But Prochazka, who is highly educated, still has some short-term memory loss, Gilbert said.

Prochazka knows that her life after hospitalization is different than before — she will have to depend more on others. It’s not an easy adjustment, she said.

“I have been somebody who has always been both mentally and physically active,” she said. “Before I fell … I was respected for what I have and what I did and all of a sudden, I’m not.”

She said her time at San Francisco General was frustrating. Getting the infection just as she was starting to recover was especially hard, she said. “I felt like I had been dealt a blow I really didn’t need.”

For other patients, being admitted proactively to the special geriatric unit can stave off such precipitous declines.

Rosenda Esquivel, 80, spent 18 days at San Francisco General, much of it in the unit, this spring. She suffered no noticeable setbacks, physical or mental, during her time in the hospital, according to Annelie Nilsson, a clinical nurse specialist in the unit.

Esquivel, an animated woman who used to work as a home caregiver, was admitted with intense arthritic pain and, while hospitalized, underwent a procedure to address an abnormal heartbeat.

Soon after her arrival, Pierluissi, the ACE unit medical director, speaking to Esquivel in her native Spanish, sought to determine how independent she was at home. He learned that a friend helped take care of her but that she took pride in cooking and cleaning for herself.

The doctor noticed that Esquivel needed help to get up from a chair but that she could get around with a walker. Her memory, though, wasn’t too strong. A few minutes after hearing three words — “honesty,” “baseball” and “flower” — she could only recall one of them.

Pierluissi came up with a plan for her time in the hospital: Get Esquivel’s pain under control. Make sure she walks three or four times a day. Arrange for her to have a caregiver at home to remind her to take her diabetes and blood pressure medications.

Then, release her as fast as possible.

“The less time she spends here, the better,” Pierluissi said.

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from , and its coverage of late life and geriatric care is supported by .

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