Improving Quality of Care for Older Adults

When Snigdha Jain, MD, MHS, became an ICU physician, she found that two-thirds of the individuals she cared for in the ICU were older adults. She also found that illness did not end with survival and discharge from the hospital for these patients. The realization prompted her to better understand how the lives of older adults change after a critical illness.

Now committed to a career in aging research, Jain, an assistant professor of medicine in the Section of Pulmonary, Critical Care, and Sleep Medicine at Yale, recently won the American Geriatrics Society Health and Aging Foundation New Investigator Award. The honor recognizes individuals conducting new and relevant studies in geriatrics.

In an interview, Jain discusses the inspiration behind her research focus on older adults, the role of social factors in quality of care, and why people of all ages should strive to be active during hospital stays.

I was interested in improving outcomes after critical illness, which matters to many older adults because they value independence and quality of life, not just survival. Older adults may be at higher risk of decline after hospitalization because of pre-existing issues such as cognitive impairment, frailty, or chronic conditions.

I didn't realize how the questions I was interested in were the mainstay of geriatric research until I was introduced to the geriatric epidemiology training program at Yale. Working with Drs. Thomas Gill and Lauren Ferrante showed me how function and cognition are measured and helped me gain the tools to ask research questions that addressed the clinical problems I was seeing.

It’s important to listen to older adults, validate their concerns, and understand that they may have lingering symptoms and problems because of a critical illness. We need to provide them with all kinds of support, such as referral to a specialist or rehab. We also need to make sure that everyone, including low-income older adults, receives this support. For example, I might want a patient to go to an outpatient physical therapy center to strengthen their muscles, but the patient might not have the caregiver support or the transportation to do those things. Understanding how effective care processes, such as rehabilitation, are delivered across the continuum of care can help us design interventions to ensure equitable access and quality of care during and beyond hospitalization.

If patients are hospitalized in a skilled nursing facility or admitted to a nursing facility after staying in the ICU, as happens with a third of older adults, we need to ensure the quality of care they receive in skilled nursing can assist their recovery. It’s important to provide patients with support beyond the ICU and medical diagnostics to assist them in their journey to recovery.

One of my recent studies with Dr. Gill found that when many older adults leave the hospital after a critical illness, they still have symptoms like shortness of breath or fatigue within the first three months after hospitalization that restrict them to bed for more than half a day or that make them cut down their activities. We discovered that such symptoms are associated with downstream disability. How much dependence these adults develop over the next six months is linked to the symptoms that restrict their activity. If you're not moving around much, there is a possibility you’ll become more disabled down the road.

I encourage older adults and everybody who’s in the hospital to advocate for themselves about the need to be active. Being in the hospital should not mean inactivity. Studies support the value of mobilization in preserving downstream function and cognition in critically ill patients.

My research also shows that older adults with low income or limited English proficiency or those who live in rural areas are less likely to be mobilized or offered physical therapy. I hope to build on this work to advocate for systemic and policy changes to make sure everyone can get equitable access to therapy services. We need to take into account social vulnerability to improve outcomes for everyone, not just a select few.

The Section of Pulmonary, Critical Care and Sleep Medicine is one of the eleven sections within Yale School of Medicine’s Department of Internal Medicine. To learn more about Yale-PCCSM, visit PCCSM's website, or follow them on Facebook and Twitter.