One of this blog post’s authors, Teresita Hogan, MD, speaks on care transitions during the Geriatric EM Boot Camp in Milwaukee.
Editor’s Note: In our Feb. 19 Health AGEnda post, the team we’re informally calling the Hartford Geri EM Champions shared information about the first two Geriatric Emergency Medicine Boot Camps and a meeting hosted by the John A. Hartford Foundation in late January to discuss new opportunities to improve acute care of older adults. Today, in the second of two parts, our EM experts discuss why our current system is failing older Americans, and share their vision for better emergency department care that can both serve the needs of older adults and contribute to a more efficient and value-based health care system.
The acute care provided to older adults in emergency departments (ED) across the country, and world, is often inadequate and sometimes dangerous.
In our current system, older adults are subject to treatment-related harm, including urinary tract infections from medically unnecessary urinary catheters as well as from overly aggressive chemical and sometimes physical sedation and restraints.
Acute delirium is not identified up to 83 percent of the time, despite delirium’s association with increased morbidity and mortality. Older adults’ pain is often undertreated; horrifyingly, up to one-third of older adults with pain-related complaints (such as broken bones) receive no pain medication. Many older adults receive inappropriate medications in the ED and suffer adverse consequences as a result.
The care transition arrangements for older adults leaving the ED are also often inadequate. Many older adults endure delayed follow-up appointments, poor two-way communication between their primary care providers and ED providers, and difficulty understanding their discharge instructions. It is no wonder that older adults discharged from the ED are at high risk of returning, being admitted to the hospital, or dying soon after.
These challenges are not because older adults are rarely seen in the ED. There are about 20 million older adult ED patient visits annually in this country. It is also not because many of the health care providers in the ED don’t care about all their patients, including the older ones. They do. And, it is not because there are no better ideas about how to care for older adults. There are.
Designed to disseminate the evidence-based Geriatric Emergency Department (ED) Guidelines, the boot camp is an interdisciplinary, on-site catalyst for system change. This slide was from the Pittsburgh event.
A number of interventions to improve the ED care of older adults have been instituted with evidence compiling that demonstrates each intervention’s success. These include the Mobile Acute Care for the Elderly team, ED-based geriatric observation units, paramedicine teams in which emergency medical services provide next-day follow-up of discharged patients, phone call follow-up of discharged older adults, geriatric-specific nurse-led case management, interdisciplinary geriatric assessment teams, and hospital at home models.
However, the system still works against providing good care to older adults in the ED.
Why does the system fail?
First, few ED providers are specifically educated in the care of older adults. The pharmacology and physiology of older adults are not part of the traditional ED residency curriculum.
Equally important is the glaring lack of ED resources for understanding the social needs that require older adults to seek care in the ED, or collaborating with case management or social workers to help meet these needs. These harsh realities are slowly changing with the incorporation of Geriatric Competencies in EM Residency Curricula, with increased interdisciplinary training and with on-line accredited learning modules such as Geri-EM.
In addition, the creation of Geriatric EM Fellowships, such as the one offered by New York-Presbyterian Hospital/Weill Cornell Medical Center, is providing the specialty with guidance, leaders, and a solid reference base, but much more educational development is needed.
Second, the systems of ED care are not well suited to caring for complicated older adults. The earliest model of ED care emphasized rapidly diagnosing a single underlying acute medical condition, treating it, and then sending the patient home or admitting them to the hospital. These traditional EDs were not designed to identify and treat social needs, or to optimally manage complicated sub-acute or chronic illnesses.
Also, it is tremendously challenging to coordinate outpatient care from an ED open 24 hours a day. The systems required for effective transitions of care are not open around the clock and often lack the capability to communicate between the ED and outpatient electronic medical records.
Given these challenges, it is not surprising that older adults are often admitted to the hospital for further evaluation and are forced to suffer the treatment-related harm and tremendous expenses inpatient hospitalization carries. Or, equally dangerous, they may be discharged home with an inadequate follow-up plan and a lack of demonstrated patient or caregiver understanding of their condition and how to best treat it.
Finally, even the physical structure of the ED works against providing optimal care for older adults. Noisy spaces, hallway beds, thin mattresses, bright lights throughout the night, and limited space for family or caregivers all present older adults with significant risks.
There is perhaps no better breeding ground for delirium in the world than the hallway of a busy ED. Yet, sadly, that is where older adults often end up since the modern ED acts as the medical safety net for off-hours expedited evaluations and as the front door to the hospital.
This suboptimal care yields suboptimal outcomes. And it’s expensive. The average ED charge for a patient over the age of 65 is more than $1,000; the average hospital charge for the same patient to have an inpatient hospital stay tops $12,000. It’s not just that ED care is expensive. If our ED providers can’t facilitate safe transitions home for these patients, the resulting inpatient costs are unsustainable.
One way to think about this is that the ED should be enabled to serve as a front porch to the hospital rather than as just a front door.
The good news is that, in late January, the Centers for Medicare and Medicaid Services (CMS) announced its drive to transform Medicare payment structures with 50 percent of payments tied to quality or value by the end of 2018.
This transformation will only be possible by empowering the ED to increase its care transitions work. The ED is the care transitions hub of the health care system and the primary decision maker determining the need for hospitalization.
One way to think about this is that the ED should be enabled to serve as a front porch to the hospital rather than as just a front door. In this way ED providers can partner with their hospital leadership to improve care while decreasing costs for older adults.
It is time to transform acute care of older adults in this country and around the world. Our health care system needs this transformation. More importantly, so do our older patients and loved ones.
Improving Geriatric Emergency Medicine has been a recurring topic on Health AGEnda. Previous posts include:
New Guidelines Show What a Geriatric Emergency Department Should Look Like
Can EMTs Improve Outcomes for Older Adults Leaving ER?
Collaboration Across Departments and Foundations Leads to Improved Emergency Care
