Two studies in the April 2015 JAMA Internal Medicine examine the effects of critical illness on the functional status of older adults. In the first study, the authors examined the records of nearly 300 older adults who had at least one intensive care unit stay between March 1998 and December 2011. Their prehospitalization functionality was categorized as either minimal disability (29.6%), mild to moderate disability (44.0%), or severe disability (26.5%). More than half of the patients experienced either functional decline or early death. Nearly one-third (31%) of the patients died either in the hospital or within 30 days after admission; of the surviving patients, functional status skewed more heavily toward functional decline, with patients categorized as minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). An accompanying editorial emphasizes the importance of all members of the care team thinking "beyond the critical illness." The second study examined hospital readmissions among 7,854 older adults who had 22,289 hospitalizations from 2000 through 2010, finding that prehospitalization functional impairment was significantly associated with higher rates of readmissions. Among adults who were dependent on caregivers for three or more activities of daily living, the readmission rate was 25.7%, while those who needed no assistance had readmission rates of 16.9%. An invited commentary highlights the need of targeting individuals with functional decline who may be at particular risk for readmission.

HRC Recommends: Early identification of patients at high risk for readmission and in need of comprehensive discharge planning services can help hospitals apply their discharge planning resources where they are most needed. The Centers for Medicare and Medicaid Services requires that a screening process be used for all inpatients in order to identify patients who are at high risk of encountering healthcare difficulties following discharge from the hospital without an adequate discharge plan in place. Patients treated for acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, or elective hip or knee replacements might be included in the screening criteria, in light of high rates of 30-day readmissions for these conditions. Hospitals should remain aware that the clinical conditions of patients not identified in the screening process may change during their admission, so the written policy and procedure should address how the individual responsible for discharge planning will be made aware of any changes in a patient's condition.