Today we talk to Dr. Kevin Biese, from the UNC Chapel Hill School of Medicine and Megan Donovan, an Atlanta-based independent management consultant, about Geriatric Emergency Departments and the role they play in value-based care.
I’d like to start off by asking what is a Geriatric Emergency Department, also known as a GED, and how is it different from a standard ED?
Kevin: Thank you so much Thomas. And I’ll go ahead and just give a little bit of background history on that. So, anything that I say that suggests about how emergency departments can do better comes from an understanding or perspective that there’s a number of wonderful people that work in emergency departments, but that the system isn’t really quite designed right for the needs of older adults. And when I say older adults, I really mean vulnerable older adults. Not 66-year-olds who sprain their ankles playing tennis. I mean it can always be better, but I’m really thinking about people with cognitive deficits, perhaps with needing caregiver assistance, with complicated medical history, with multisystem issues like you know like heart failure or lung disease. A lot of complicated issues. The system of emergency medicine isn’t optimally designed for this specific, complex, multilayered needs of older adults by that definition.
And so, an geriatric ED, just a brief story if I can. I was a third-year resident on a four-year emergency medicine program at really good program in Boston. So, it doesn’t matter, at Mass General. And it’s Mass General, they’re supposed to be really good. Like they’re really, but we didn’t learn anything about the care of older adults, specifically. Like when I was at residency, we knew that a 2-year-old wasn’t a 40- year-old and we knew that 80-year-olds got sick more than 40-year-olds. I mean you could kind of tell by looking around. But there wasn’t like a month of like, well what’s different about older adults, or what is polypharmacy mean, or what about hyper, what is the difference between delirium, dementia, and depression, and why would that matter. That wasn’t part of what we learned. So, one day I’m leaving the end of a 12-hour shift at Mass General in the trauma section, and there is this older woman on a cot in the corner. And I didn’t think anything of it. We were really busy. We were full, heart attack, stroke, gunshot. There was always an older person like kind of waiting to go upstairs or something. And I just, I was tired, stinky, exhausted. Well, I came back 12 hours later, because we were you know in 12-hour shifts, same woman, same corner, same cot. And I got mad. I didn’t know that she had hypoactive delirium. I couldn’t even have told you exactly what that was. I didn’t know that we’d probably given her a urinary tract infection through prolonged foley use. I did know that that cot looked really uncomfortable, and she probably needed something to eat. And I knew that like my grandma helped raised me and this didn’t seem OK. You didn’t have to go to geriatrics training for this to seem like, “wait a second. You were here 12 hours ago and here you are now, same place. This can’t be good.”
And so, we started to do some stuff around emergency medicine in residency and then when I came here to the University of North Carolina, Jan Busby-Whitehead, who’s the chief of geriatrics, sort of adopted me. And a lot of the work that we have done in the decades since come from that initial awareness of how can we do better for older adults in the emergency department. In about 2013, a group of us in emergency medicine, and my colleagues actually wrote some geriatric ED guidelines about how to do best practices in geriatric emergency medicine. That was really important. We were fortunate to get that like signed off by the big nursing and physician organizations in geriatrics and emergency medicine. And we established best practices. And then about three years ago, we started to create an accreditation system for emergency departments to recognize when they’re doing better jobs for older adults. Hospitals speak accreditation systems. They understand that like, OK if I need this, this, this, and this, and this, and then I get recognized as being a stroke center of excellence. A cardiac center of excellence; a trauma center; a geriatric emergency department. It’s a currency in hospital language that they can use to drive towards certain quality improvement goals. And so, the American College of Emergency Physicians started that effort in 2018, and there’s now about 320 or so geriatric EDs mostly in the United States, but in about 4 countries overall. But like 315 of those are in the United States or 314 or something like that.
So, a lot of work has gone into this space, but as our demographics have continued, there’s more older folks, their medical needs are increasing, there is a tremendous imbalance between social support and medical support on a financial level across this country, which means that people come to healthcare systems for a myriad of reasons, not all of which are clearly medical in nature. For all these reasons together, along with the move to value, the fact that we are now in at some sort of stumble towards value-based healthcare on a national basis. All of those confluent factors have led for the opportunity for systematic evolution in how we take care of older adults in a geriatric ED, or in any emergency department.
So, to get to your question, sorry. How is it different? Why? What’s a geriatric ED? Like what the heck does that mean? A geriatric emergency department changes the way we do 4 elements of care to better meet the needs of complex older adults. One, we change the structure at least a little bit. There are some EDs that have been specifically built for older adults. But most hospitals don’t have $20 million or whatever it is to like build a new emergency department because it seems like a good idea. And even, most ACOs don’t have $20 million to give them. So, like, we you know, that’s not. So, I’d say out of the 320, like 315 are in not separate EDs. Like not like some new ED. But even in those EDs, the structure, you’re not shining bright lights on people’s faces all night. It’s quieter where older adults are. There is space for caregivers; don’t lock the caregivers out, it does not help you. There is an interdisciplinary, there’s space for interdisciplinary team like pharmacy, social work, etc. The beds are more functioning for older adults. Chairs even better when appropriate. So, there are some structural modifications. Light dimmers cost $12. You don’t need to rebuild your ED.
Two, education. As I just alluded to a minute ago, we didn’t learn about geriatric emergency medicine. We are now. There’s a lot more education in geriatrics for emergency medicine training than there was before, but still not enough. And what we’re really doing on an educational front in a geriatric ED is two things. One, you’ve got a champion nurse and a champion physician that have specific education and geriatric care. Which also means if you’re in an ACO, you’ve got friends. There’s somebody on the other side of the isle that’s interested in what you’re doing. However, the rest of the ED has its some additional training in geriatric ED so that you move geriatrics from the unknown unknown, like of course I know how to take care of older adults, I do it all the time, to the known unknown of oh there’s different things about this I need to look a little deeper before I make that disposition decision or that medication choice.
So, structure, education, staffing. I’ve already said, you know, it’s interdisciplinary. In many of these EDs, were bringing physical therapists down to the ED and making sure you’re safe to ambulate before you go. We’re connecting you with physical therapy on the way out. We’re doing medication reconciliation before we discharge you to make sure your medications aren’t contributing to problems, and we’ve got them straightened out etc. Social work connecting you with community resources. Connecting you with ACO resources that they may bring to the table.
And finally, as I just alluded to, community connections. Structure, education, community connections, and policies and protocols all work together to identify underlying challenges that older adults have and connect them with resources within the ED in the hospital, and within the community, like their ACO, that can help them get better care.
So, last thing I’ll say about this, promise. What’s a geriatric ED? A traditional ED, in contrast, tries to be a wonderful place. Sometimes it is, sometimes it isn’t. Wonderful people work in there. If you fall, if you’re 82-years-old and you fall, and they take you to that emergency department, a traditional emergency department will fix you up from the fall you had. They’ll make sure you didn’t have a big heart attack or something, and they’ll put a splint on your wrist, and they’ll fix you up, and they’ll send you home. And they’ve done their job, sort of. A geriatric emergency department says what an unfortunate opportunity to take a deeper look and see what’s going on. A geriatric emergency department recognizes that falls are a syndrome in older adults, not an event. That if you fell today, you might have fallen before, and you might be at risk for falling next week. And how can we decrease that risk. How can we make sure you’re not on 3 different beta blockers from three different doctors and no wonder you’re getting dizzy every time you stand up. That your house doesn’t have cord stretching back and forth and we can’t work with community paramedics to go home go with you and do a health about a house safety eval. That we don’t bring down physical therapy, make sure you’ve got the right mobility assist devices, or plug you into physical therapy as an outpatient. But traditionally, the ED fixes yet from what happened. A geriatric ED knows that in that immediate time after an ED visit, you are very high risk for further adverse outcome, and plugs you in with services to help decrease that risk and best of all, in close coordination with your primary care physician.
What role does a GED play in administering value-based care? How should GED’s interact with Primary Care?
I’ll throw out a story to begin that answer with, and then let Megan talk specifically to those interaction and the value-based care in the rubrics. But just a story. From couple years back, I had the opportunity to meet Eric Harden, who’s the Deputy Secretary of Health and Human Services from the last administration. I had a half hour meeting, and eight minutes into the meeting, Deputy Secretary looked at me and said “Kevin. Haven’t you gotten the memo. We don’t want anyone to go to the emergency department,” and I said, “Yes Sir. How’s that working for you?” Like so, he laughed, and we went on for 45 minutes until his staff dragged him out of the room. Because the reality is that in a really perfect healthcare system, the need for complex older adults to utilize the emergency department would be substantially decreased. All of us want to care to be quarterbacked by the primary care physicians as much as possible. What a geriatric ED does is identify the underlying geriatrics syndromes that are going on, the social vulnerabilities, and get that patient back to the care of the primary care physician as soon as possible. That’s what geriatric EDs do, and that’s why they’re so important to value. You cannot win at value, one of my roles is to help, I’m the vice chair of our ACO at the UNC Health Care System, vice chair of the board, and I help oversee our clinically integrated network. You cannot win long-term in the area of increasing benchmarks, everybody putting down the screws harder and harder. How do you win long- term if you don’t have your hand on the steering wheel when your members are at greatest risk of admission and deleterious effects afterwards? You can’t afford to give up on ED care and still win in the ACO world. We make it possible for you to lean in, connect, and coordinate the care of your patients.
Megan, I don’t know if you want to add some stuff to how we create high value care and some of the data around what’s been created.
Megan: Absolutely, I think you did a really great job Kevin of summarizing what a GED is, how it’s different. I think the important thing to really call out about GED’s role in administering value-based care, is that much like value-based care arrangements, GEDs want to transition patients to the lowest setting of care possible. They want to help avoid that hospital admission or that hospital re-admission. How do they do that? That’s what Kevin really just described. Right? They have this specially trained staff that understands and knows what these underlying kind of geriatrics syndromes and symptoms are. They have standardized care protocols that they deploy across the GED for this incredibly complex patient. And they’re more focused on the continuity of care. And they’re more focused on addressing social needs after a patient leaves the GED. One of the things that I find really fascinating about some GEDs is that one of the screening tools that they use is for food insecurity. And so, when that screening tool comes back positive that this particular complex older adult is food insecure, that GED is able to connect that individual with their local Meals on Wheels program. Right? So, I think this is where the intersections between GEDs and value-based care really come alive, is when we start to see and understand how GEDs have some of the same goals that value-based care does. They don’t want to admit the patients to the hospital. They want instead to address some of those underlying social determinants to make sure that you know they don’t get admitted, they don’t get re-admitted, and instead push them to the lowest you know and transition them to the lowest setting of care possible. And like Kevin said, you know, connect them back to their primary care provider. GEDs really want that primary care provider to be the quarterback for that patient’s care. So, I think some of the I think those are the really the highlights around how GEDs play a role in administering value-based care.
Kevin: You know, Megan, it’s so true. And yet, I think as a doctor that works in a GED, we’re really trying to push folks to the highest value setting of care possible. There are patients that it is consistent with their care wishes; with what matters to them. Care wishes aren’t just end of life care wishes. It’s their priorities. To have what we might call really aggressive medical care. And I know you mean this, but I just want our audience to know it too, then that is absolutely where that patient should be. But we are trying to push them to the highest value setting. Where is the highest quality going to happen for that patient? With an eye towards sustainability of the health care system. But the great, we’re not making a choice here between cost and quality. Many of our unneeded medical admissions today are also deleterious medical admissions. The patient comes out weaker than they were before. The patient comes out less able to do their daily activities of living. The patient gets delirious from their hospital stay. So, we are always trying to do the thing that gets the care to the highest value setting and lines up with the patient’s values. And yet, even when we do that or because we do that, we’re actually substantially driving down the cost of care.
Megan, I don’t know if you want to share just a little bit of some of the data that you’re so familiar with as far as like decreased admissions, readmissions, cost of care.
Megan: No absolutely, there’s really a growing body of evidence to suggest that GEDs really help to address that quadruple aim of value-based care. So, with the intervention of a transitional care nurse, which Kevin can talk about a little bit more, there’s been a huge reduction in risk for hospital admissions. So, a 16.5% reduced risk of hospital admission and a 17.3% reduced risk of readmission. And that holds true over a period of time in addition to it, we’ve seen a $3,000 savings for Medicare beneficiaries after 30 days. So, one of the really impressive things that we know is happening is that this works, and not only that, not only are GEDs and some of the that the interventions that occur within them able to lower costs, they’re also able to improve quality. So, one of the things Kevin talked about was how there’s an interdisciplinary team that oftentimes treats patients in GEDs and one member of that team is oftentimes a physical therapist. And there was a study done that showed when a physical therapist came and addressed a patient’s fall or other underlying issue that there was a decreased odd of a 30 and a 60 day repeat ED visit with that PT consult. So, it’s just great because we know that this is helping to improve quality as well and to improve the patient and the caregiver experience. There was a big retroactive study done that showed an 87.3% satisfaction with the clarity of discharge information received in a GED. And we know that creating communication pathways and helping to clarify discharge recommendations and connecting that patient back to their primary caregiver is such an important part in adding value. And that’s something that GEDs do as well. And I know too, and I’ll ask Kevin to talk about this, that GEDs really help to improve the care team experience as well. Just knowing that these physicians and advanced practice providers and nurse champions and interdisciplinary clinicians. When they work in a GED, they know that they’re doing better by their older adult patients. And I know that Kevin sees that every day.
Kevin: Absolutely, I’ll lean in there and then Thomas, we will give you a chance to ask questions, I promise. But the, you know, there’s a risk of moral injury. I heard this summarized nicely by one of the healthcare systems leaders I work with. There’s a risk, a real risk, of moral injury when you work in healthcare today. And what I mean by that is, sometimes it can feel like you’re trying to like keep a tidal wave away, a tsunami, from landing on the beach by sticking your hands up in the air and you know it’s going to stay. And there are days when we look out in the waiting room and there’s 40 patients in the waiting room, and you know, the older adult is in the same corner, same cot, and you’re fighting all of these systems that you know, I mean most of us who practice healthcare went in here to try and help people, and we know some days the system is just not succeeding. You know, when a daughter of an older adult comes up and says how come my mom is still in the ED 20 hours later. I can say whatever I want to say in response to that, but I know she’s the daughter is right. The mom shouldn’t be there. And I want to fix that. And I can feel defeated when I can’t. We have a healthcare system worker crisis in this country right now. Go interview any healthcare system leader and ask do you have all the nurses you need, you have all the physicians you need, you got your whole team all set? I’m going to guess that the vast majority are going to say “No, we’re in deep doo doo.” We can’t afford to run a system that continues to inflict repeated moral injury on the workers we’re depending upon.
So, the fourth part of the quadruple aim is a GED helps you feel better. You get those systems in place. You know you help people. The best GED systems in the country actually send monthly newsletters to all their parties, like all the hospitals, and workers, like, “hey here’s a couple stories about patients we helped.” Of course, anonymously. But here’s what happened when we screened for delirium. We’re able to get this help. When we connected him with that Meals on Wheels, we’re able to get this help, etc. Keep doing the good stuff you’re doing. Mark Rosenberg is the former president of the American College of Emergency Physicians and the leader of Saint Joseph’s Emergency Department, which is like the fifth busiest emergency department in the country. It’s outside of New York City. It’s in a, you know, not high socioeconomic part of outside of the city in New Jersey. He talks about when he opened up his geriatric ED like 15 years ago, none of the nurses wanted to work there. A couple years later, they all wanted to work there for all the reasons we’re talking about right now. I think that not only do you meet the needs of the patients better, not perfectly, but better, and the needs of a sustainable healthcare system slash move to value, you also create a more sustainable environment for your care delivery team. Which hopefully results in higher retention as well.
Kevin Biese, MD serves as an Associate Professor of Emergency Medicine (EM) and Internal Medicine, Vice-Chair of Academic Affairs, and Director of the Division of Geriatrics Emergency Medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine as well as a Vice-Chair of the Board of the UNC Health Care Senior Alliance. He also serves as a consultant with West Health, a San Diego based philanthropic organization dedicated to improving care for older adults. With the support of the John A. Hartford and West Health Foundations, he is the co-leader alongside Dr. Ula Hwang of the national Geriatric Emergency Department Collaborative, serving as PI of the implementation arm. He is grateful to chair the first Board of Governors for the ACEP Geriatric Emergency Department Accreditation Program which has now improved the quality of care in over 300 emergency departments in 40 states and 4 countries.
Megan Donovan is an Atlanta-based independent management consultant. She helps executives turn their ideas into reality and works closely with entrepreneurs, academic medicine and healthcare policy leaders to shape business strategy and operational implementation. Megan has a BA in psychology from Wake Forest University and an MBA from the University of North Carolina at Chapel Hill where she graduated in the top 10% of her class.