No one can deny the aging of our population in general, and of the emergency department patient load in particular. But there is some disagreement about how EDs should respond – specifically whether it is appropriate to design geriatric emergency departments.
Geriatric emergency departments can pay for themselves by meeting healthcare reform incentive goals
No one can deny the aging of our population in general, and of the emergency department patient load in particular. But there is some disagreement about how EDs should respond – specifically whether it is appropriate to design geriatric emergency departments. After all, in an era of belt-tightening and budget slashing is it really our priority to invest in softer mattresses, warmer lighting and aromatherapy?
I aim to dispel the myth that geriatric EDs are just about superficial aesthetic improvements and show that these departments, far from being a drain on the bottom line, can actually pay for themselves by meeting healthcare reform incentive goals. We’ll focus specifically on cost, revenue and savings. But first we need to have a better understanding of the essential ingredients of geriatric emergency medicine. For that we turn to the ACEP Geriatric EM Section’s draft, which pulled together the current literature and research; the collective experience and consensus of the Geriatric EM section as well as input from ENA, SAEM, and AGS. The draft document of the Task Force identifies key elements of a Geriatric ED. A partial list of recommendations follows from the document as well as a couple attributes from my geriatric ED:
1. Environment of care
- A patient area that provides a quieter, safer, “less typical ED” environment conducive to establishing a rapport between a very busy doctor and an older patient that have just met. A place that my Mom and other seniors feel comfortable enough to talk about their medical symptoms rather than hurrying out the door to leave.
2. Staff education
3. Quality Care Initiatives
- Medication Review
- Fall Assessment
- Dementia Screening
- Nutrition Screening
- Depression Screening
4. Transition of Care Initiatives
- 24 hour Call Back Program
- Extended Home Observation
- Primary Care Notification
- Case Management
- Social worker services
5. Coordination of Current Resources
- Hospital Based Resources such as Physical Therapy and Pharmacy
- Community Based Resources such as Visiting Nurses and Hospice
6. Staffing Enhancements
- Nurse Navigator
- Patient Liaison
So, how can we justify the expense of added services? Let’s look at the cost of putting together a geriatric program.
The much discussed “environment of care” is only one small part of a geriatric program. Improving the physical environment of the ED can be a big-ticket item, but it doesn’t have to be. A fresh coat of paint can do wonders. Typical 4 or 6 bulb fluorescent lights can be easily changed to warm light bulbs with dimmers. The cost to do this is a couple hundred dollars per fixture. When in need of new stretcher mattresses, get the thick comfortable ones. It is also inexpensive to add soundproofing above the traditional ceiling tiles. Floor coatings can change a shiny tile floor and to a non-shiny, non-glare floor. Major renovations are not needed.
Another way to look at it is to think in terms of “universal design” when updating your existing department. How can you implement improvements, which will allow the department to be more comfortable for all patients, regardless of age, gender, or ability? This will improve your geriatric services while benefiting the entire population. Simply walking through your hospital’s automatic doors is a great example of this kind of universal design improvement.
Looking at the other key elements listed by the ACEP Geriatric Task Force, there is not much additional cost that is needed except for the staffing enhancements. A geriatric ED most likely will need a nurse and physician champion. The other staff that can be added may include case managers, social workers, patient liaisons and a pharmacist. Many of these individuals already work in the hospital. It may be an easy fix to look at what resources already exist in the hospital and how can you make those resources more responsive to the ED needs. For example, a geriatric call back program may be possible during early morning hours when the ED volume may be less. Another example is having the hospital case manager also assist in difficult geriatric dispositions.
I can go on and on about how to manage the geriatric program in your ED, but for the sake of this article, allow me to say that in my experience, it simply is not a budget breaker. While you can obviously spend a lot on a geriatric ED, the program simply does not demand it.
Switch gears to the other half of the budget equation: revenue. What we know about healthcare reform is that there will be more money from insurance payments held back as an incentive in coming years. Some sources suggest it will be as much as 13% of the potentially reimbursed healthcare dollar. Core measures, value-based purchasing, readmissions, hospital acquired conditions, and meaningful use measures will be phased in as reimbursement incentives over the next several years. The geriatric ED addresses all of these incentives in the following ways:
- Improvement with core measures
- Improved patient experience of care (Value Based Purchasing)
- Decreased hospital readmissions
- Improved transition of care
- Decreased hospital acquired conditions
Improvements in these five areas can help retain the incentive money that is built into the healthcare reform initiative The government uses incentive-based methodology to meet “The Triple Aim” of healthcare reform: Better Health Care; Better Health Care for the Population; and Decrease Cost to Beneficiaries.
Geriatric EDs provide “better health care” by providing safe, effective, patient-centered, timely emergency care. The Geriatric ED screenings also better identify patients at risk for functional decline, missed delirium, depression and falls risk.
Geriatric EDs provide “better health care for the entire population” by improving patient care transitions with follow-up phone calls to the patient and the primary care physician. There is also coordination of patients’ needs with resources in the community and hospital, and advanced care planning are all accomplished in the geriatric ED.
Finally, these EDs “lower cost for beneficiaries” by improving patient care, patient care screening and by improving transitions of care. Research is currently being done to show that readmissions and ICU days are decreased by Geriatric EDs. The rate of hospital admission likely decreases as the Geriatric ED is able to manage more patients at home rather than hospitalizations.
Having a Geriatric ED creates other opportunities for cost savings as well. This is most easily explained in an example of a program called “Admit to Home” or “Extended Home Observations”. This program is appropriate for many seniors with a diagnosis that right now can be managed as an outpatient but has a significant risk of requiring admission and intensive therapy. A perfect example is diverticulitis. A 79-year-old patient with an abdominal pain workup shows diverticulitis with possible small abscess. The patient is very stable and the decision is made to admit the patient to home. The plan would be to give antibiotics, liquid diet, monitor temperature every 12 hours, possibly get surgical and GI consults in the ED, reassess daily by a telephone call from the Geriatric ED team and repeat CT scan and labs in 48 hours. Instead of being admitted to the hospital, the patient is essentially admitted to home. A member of the geriatric team calls the patient the next morning and more-or-less makes rounds, evaluating the temperature, making sure the patient isn’t feeling significant pain and is tolerating their diet, and reminding them that they have an appointment to return to the Geriatric ED the next day for reassessment. This patient is reassessed in the ED without waiting for a bed. Most of these patients will have a straight forward transition of care plan. On revisit, the disposition can be determined based on the patient’s response to therapy. “Admit to home” programs combined with an observation program can save significant health care dollars.
To have a successful Geriatric ED we as physicians need to appreciate the fact that a Geriatric ED is about a lot more than thick mattresses and soft lighting. It requires a reworking of our EDs to provide appropriate geriatric screening and seamless transitions of care. The Geriatric ED is also the rapid assessment center for geriatric illness and, if we want, it can be the Hub of Geriatric care in your medical community.
Mark Rosenberg, DO, is the chairman of emergency medicine and chief of geriatric emergency medicine and palliative medicine at St Joseph’s Healthcare System in Paterson, New Jersey.
In this day and age a “great idea” isn’t good enough. It needs to meet strict criteria for budget, corporate mission, vision and values and must be consistent with the culture of the organization. And the most important of these, at least when trying to convince a CEO, is budget. Is this a profit maker or a profit drain? Dr. Rosenberg has made a compelling case that a Geriatric ED can be a means of improving your system’s bottom line. Given the competitive Medicare Supplement market, having a geriatric ED is a strong marketing tool as well.
I concur and would encourage the patient’s primary, guardian, family, caregiver and the patient themself to arrange “direct admission with preadmission orders” and “timely (4 hours?) evaluation by the preactitioner who knows them”. ERs and hospitals are deadly to the elderly, making them frail, if not actively fixing the medical problem they came in for, already arranging cheerful in-hospital rehabilitation and providing discharge planning/needed in-home services to assuage the patient’s fears. It is neigh impossible for ER physicians and even regular providers to develop rapport appropriate to the elderly patient who is deconditioned by illness, fear, stroke, aphasia, depression, etc. and too often these are mistaken for Alzheimers. I would like to be a contributer to GEMS. Please RSVP. Is there going to be a meeting at Seattle ACEP?