Kevin Biese, MD & Megan Donovan, MBA – The Value of Geriatric Emergency Departments Pt. 2

In this episode we continue our conversation with Doctor Kevin Biese and Megan Donovan about the role that Geriatric Emergency Department have in the move to value and how it touches all aspects of the quadruple aim.


What are the different staffing components that comprise the integrated care of a GED and what if any special training is preferred or required for physicians and APPs working in GEDs?

Kevin: Awesome. So, there are 3 levels of accreditation for geriatric EDs. Level one is the highest level, like a trauma center, it’s how we think; level 2 is silver; level 3 is bronze. All three of these levels have people at them that would be interested, and this is the theme I want to come back to, perhaps even eager to connect with ACO leaders in their neighborhood. They don’t, probably I’ll come back but, they probably don’t know who you are, or they might not even be able to tell you what an ACO stands for, but these are friends you just haven’t met yet. All three of them have that. All three of these levels have champion nurses and champion physicians, and those are the friends you haven’t met yet. People that are like, yes this is important to us, they’ve had some additional education in geriatrics, depending on what level is how many hours of geriatric emergency medicine. We’re talking about care transitions, polypharmacy, falls as a syndrome, etc. The two higher levels, silver and gold, two and one, also have all their staff has some training in geriatric emergency care, so that they are more, the different language, there’s a different culture. The things that are being talked about after an older person has a fall are a little different than a traditional ED, and everyone is acquainted with that language and that culture even if it’s not their specific expertise. Level 2 and level 1’s have requirements for either all or some of, depending on whether they’re a level one or level two, of physical therapy, occupational therapy, pharmacists, and care management, or social work, within that emergency department able to be turned towards the needs of older adults.

So, what you’ll find to varying degrees is a more interdisciplinary team with additional training in geriatric emergency medicine. And again, how much is contingent upon what level they got accredited at. But I can’t say this loudly enough, a Level 3 is meant to be in the zone of proximal development at all 5,000 EDs in the country. It’s not that hard to become a Level 3. However, you are doing a quality improvement project for older adults, and you have a champion nursing, a champion physician, which means that there are people there that would want to hear from people like you and you can work together to figure out. They’ve tilled the soil. They may not have grown the orchard yet, but the soil is tilled for collaborative efforts, such as you would be interested in pursuing if you’re listening to this podcast. Like huh, a whole bunch of beneficiaries go to Saint elsewhere emergency department. Oh, look there are Level 3 geriatric ED. Shouldn’t we connect these dots somehow. Answer yes. Champion nurse, champion physician is who you want to connect them with.

What is the role of a transitional care nurse in the GED and how does this role impact value-based care?

Kevin: Um so, Megan was just kind enough to cite some of the stats that come with geriatric emergency department, which is decreased admissions, decreased readmissions, improved patient satisfaction, and not surprisingly, decreased cost associated with these interventions.

The care transitions nurse is what makes that possible. They’re really the quarterback. Different geriatric EDs call that person by different names. Some of them call them the genie nurse, or the gem nurse, but essentially these geriatric EDs identify who are high risk patients, who are patients that maybe have suffered falls, have cognitive impairment, have social vulnerabilities, like they don’t have enough food, etc. caregiver burnout, and then send them the care transitions nurse. And that individual kind of quarterbacks some of the care. Like oh look at this bag of medication, someone get the pharmacist down here because like this is a mess. Or like you know, my goodness you look like you haven’t eaten a little while, I’m going to call the social worker and see what we can figure out. Right. Because it’s complicated, like what insurance do you have, where do you live, what county, and there’s all this stuff that like I, as a doc, I have no, I don’t know all that stuff. But the care transitions nurse is the quarterback of that additional care for high-risk patients. The majority of those stats about the admissions and readmissions rate, that research was done looking at if you had a care transitions nursing in a geriatric ED, how much less likely were you to be admitted? Answer, up to 16.5%. How much less likely were you to be re-admitted? Answer, up to 17.3%, etc. So, the care transitions nurse is the proven intervention that leads to these higher value care pathways.

Megan: And what I want to see happen eventually in my lifetime, hopefully in the not too distant future, is that these transitional care nurses in the GEDs also start to view value-based care plans, ACOs, other arrangements, as an additional tool for them to call to help the patients and the GED. And that’s what Kevin and I have been working on these past few years and really working towards is how do we make that happen. How do we help to create these communications pathways between these transitional care nurses and the other staff of geriatric emergency departments and connect them to value-based care? Because the reality is is that a lot of these value-based care arrangements have additional tools at their disposal for their beneficiaries that that transitional care nurse could use. She could use them, or he, on the ground, in the in the GED, to help bring higher value care to the patient. And that also helps to get value-based care insight into the fact that their beneficiaries are actually in an ED, which we know is a huge pain point for them right now. So, I think this transitional care nurse role is really critical. It’s really important. And if I was in, if I was an executive of value-based care plan, I would want to start talking to every single transitional care nurse in a GED in my geographic market. Because the reality is that they’re probably seeing my beneficiaries, and they are probably the ones directing their care in the GED, and they are also probably the ones that have a lot of influence, and a lot of, influence is probably the best word, about what happens to that patient. Do they get admitted or are they able to be transitioned and supported with other resources to a higher value setting of care.

One of the things that Kevin and I did about a year ago is we wanted to understand if this was actually happening. If beneficiaries in MSSP ACOs were actually seeking care at GEDs. And thanks to the partnership of the West Health Institute, which is a research organization based in San Diego, as well as the Institute for Accountable Care, we were able to run an analysis that looked at the overlap. So, pulled claims data and looked at if MSSP ACO beneficiaries were receiving care in GEDs. And what we found is that it was, it’s happening you know. MSSP ACO beneficiaries are seeking care at over all three, you know, at all 320 and growing GEDs in the country. And not only that, but a lot of the times their beneficiaries are going to the GED multiple times. So, on average 1.6 times these beneficiaries are seeking care at GEDs. And what was even more surprising was the volume for certain MSSP ACOs. So, there were about 20 MSSP ACOs who had about 1,000 beneficiary visits to a GED in that given year, which is a lot. If you’re thinking about 1,000 of your beneficiaries potentially not being admitted to a hospital, that’s a tremendous cost savings. So, we know that this is happening. We know that beneficiaries in value-based care arrangements are seeking care and receiving care at geriatric emergency departments. And one of the things we wanted to know is we wanted to understand it more deeply, so we actually ended up conducting a focus group between some MSSP ACO executives and their GED counterparts, and actually got them to talk to one another. Talking about us, trying to facilitate and really create these connections. And the most fascinating thing and the most fascinating outcome from that conversation was that 2/3rds of the ACOs had no idea what a GED was and they had no idea that a GED even existed within their own health system or within their own geographic market. So, that to us was a huge area of opportunity. Right? We really need to start making sure that there is an awareness about what a GED is and the value that it provides because it’s key. What happens inside the GED can create such value. So, that was that was really interesting. The results of that analysis and that focus group were really interesting.

How can an EHR and other resources be leveraged to integrate GEDs and ACO beneficiaries who may need additional social support?

Megan: One of the big things we heard in the focus groups we conducted was that one of the largest pain points for both ACOs and GED clinicians is a lack of awareness. ACOs don’t know when their beneficiaries are in a GED and ED clinicians don’t know when a patient they’re treating is in a value-based care arrangements. So, creating this communication pathways to both alert an ACO to let them know that their beneficiaries in a GED, and to alert the clinician that the patient you’re treating might have additional resources available to them is going to be absolutely imperative to move emergent geriatric emergency medicine towards value-based care. One of the ways that you could do this is through your EHR by creating some sort of an alert mechanism, you know, within the EHR. One of the things that we’ve also heard of that’s happening is that some hospitals are using their states’ health information exchange data to facilitate that connection. And there’s other industry solutions out there. There’s software solutions out there that can help. So, there’s a lot of ways that this can be done, and that people are kind of experimenting with. I don’t know what Kevin thoughts would be on this, but I can’t say with any certainty that there is one way that’s working the best or that most people are using, but what we do know is that in order for this to ultimately be successful in the move to value that that ability to remove that communication barrier is going to be very key.

Kevin: I think that your patients, your members, your ACL partners, your value partners need the primary care team and the ACO team leaning in as soon as possible when that patient hits the emergency department. And actually, the ER docs often want that too. An 80-year-old comes in saying they have chest pain. What am I going to do? I’m going to admit that patient unless you call me and say, “Miss Smith has had chest pain for 20 years Kevin. Like and I can see her in clinic tomorrow. That EKG looks like the last EKG. We can figure this out.” And what you just did for me, to be very frank, is now Miss Smith doesn’t have to wait for a bed. Every hospital is overcrowded. Many hospitals are overcrowded. And you’ve actually helped me with like throughput and different ways of making sure that I’m not sustaining moral injury putting Miss Smith in the hallway to wait 20 hours for a bed for something that’s not really going to help her. I think that there is a real opportunity here for ACO and value partners to lean in to when their beneficiaries are hitting the doors of an ED and have a conversation both about a little bit more medical perspective and also just the resources. I don’t know that you have a system in your ACO that’s going to help this patient have care in two days. I don’t know that. I don’t know what home health options you have. But all of those things are going to be meaningful to me about what option, what I can then do to help this patient and get her to the highest value care setting. So, Megan and I are both very eager to deploy this more aggressively, in a more embedded way, and demonstrate the improved value of care that can be created through this. It’s kind of happening in different places, including in my own spot at the University of North Carolina, but only kind of. There’s a lot more work that can be done on this front.

Are CMS or the MA payers taking notice and creating any additional financial incentives for standing up GEDs?

Kevin: The conversations are there, but I think we’re just now getting enough of evidence to really have a meaningful conversation about setting up alternative payment models based around some of what we’re saying. And I guess I’d make one other comment on that, I don’t know. I can’t look into the future. But especially if you look at Liz Fowler and others are doing at CMMI right now, having separate APMs for emergency departments alternative payment models is probably not the way to go. And instead, what we really need to do is crosswalk some of the value that can be created in a GED with an ACO and just think about how we work together to drive this forward. So, early conversations, interest, and awareness, but more to be done to really develop that data and think together about how we can really drive higher value care. And prove it, continue to prove it, and then facilitate it.

What can a health system do right now to begin the process of having their older population of patients start receiving the right care in the right place at the right time?

Kevin: I think, so, a health care system can do, can basically go down the pathway of helping create the infrastructure of a geriatric ED within their system. If you Google geriatric emergency department accreditation; if you Google equally good, the geriatric emergency department collaborative, you’ll find lots of toolkits, resources. Your EDs that you work with do not have to figure this out on their own. There’s podcasts, they’re journals around this, there’s every-other-month webinars with over 100 doctors from around the world. There’s lots of resources. We’ve been fortunate with Johnny Hartford and West Health to create infrastructure. Lean into that infrastructure. Do that in collaboration with your healthcare system leadership so that you can really play to what their strategic priorities are so you can get the resources you need to do this well. Equally important, if you’re listening because you’re part of an ACO or you’re a provider wondering, “well this isn’t what happens when my patients go to the ER. What are they talking about? Like they just get admitted and like 6 MRIs or I don’t know whatever.” So, like if that’s what you’re thinking right now, then I would suggest that what you need to do is look at the directory and see if there are geriatric EDs in your neighborhood. Reach out to the American College of Emergency Physicians; it’s on the website. If you can’t find it, we can help you. Reach out to Nicole and others there and find out who the nurse and physician champion is. And reach out to them. Share a lotte. Separate lattes. Sit down and just begin to figure out where you’re overlapping interests lie. What are they struggling with with their patients, and what resources do you have that might help? And what are you struggling with and how can they lean into that. One really important point here is you’re probably only going to be able to offer additional services to your ACO beneficiaries and they’re going to have other patients in their ED that aren’t yours, but you know what, that’s normal. Some patients come with their daughter or son at bedside, some don’t. Some have a robust social network they can lean into, and some don’t. When I’m making a disposition decision on a patient, I want to know what resources are available for that patient. You’re not going to tell the ED what to do. You’re not going to tell them whether to admit them. You’re just going to say, “Hey listen team. Before you admit Miss Smith, know that this is what we could do for her.” So, if you’re an ACO leader, go find your geriatric ED. There may be one in your neighborhood. These are friends you have yet to meet, and they’re going to help you take that next step and your benchmarks and driving your care forward because how can you improve the value to your whole population if you lose visibility, if you lose any control or influence, once they hit the ER. I know we’re all trying them to not have them hit the ER, but they’re going to. You need to have that connection if you’re going to continue to rise in the value stream.

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.