1 Department of Emergency Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
2 Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
Traditional emergency medicine is designed around providing acute care to people without significant comorbid conditions, and who have excess social supports systems as an outpatient to be able to help while a person recovers. What we are not as good at, is providing care for people with multiple medical comorbid conditions, or who is vulnerable in the community – needing more social or economic supports, and those who come with less common or vague clinical concerns. Older persons, suffer suboptimal outcomes when we fail to see how their symptoms or health fits into their overall life systems. Furthermore, older patients more frequently have unusual presentations of important illness, and have less physiologic reserve to compensate for illness or injury. To uplift their care, we need a team and a culture that aligns to improve the experience of getting care in the emergency department as well as is intentional about identifying issues in social or financial supports for a given patient to be able to try and activate solutions or resources for them.
Most regions of the United States have government and privately funded resources for older adults. Also, many different specialty clinics exist for delirium, falls, incontinence and other common geriatric concerns. Discovery of these and connecting ED care with these existing services and clinics is a low cost, high impact way to uplift the care for older adults. In this model, these connections and practice optimization pathways are coordinated and directed by geriatric champions.
In this model of care, patients are watched in the ED Observation unit until certain hours of the day when relevant consult teams and equipment can be brought to bear. This can permit smaller centers provide geriatric-elevated care without having to be ready to provide those services 24 hours daily, 7 days each week.
This is a regional area that is developed with specialized environmental modifications to minimize delirium, falls, and help older adults recognize signage. These units can house specialized equipment in readily accessible locations. This can deliver amazing care – with the cost of decreased throughput flexibility for patients. These are usually staffed by specialized trained individuals
In this model, all staff receive a minimum standard of geriatric EM training, all rooms, equipment and protocols are available for geriatric patients. In general, these improvements will be in line with desires or needs for patients of all ages. There is also specialized personnel in geriatric care who evaluate older patients simultaneously with standard ED care.
Being able to create a financially viable practice is essential for this to be sustainable. Therapists often are able to bill independently when they see patients in the emergency department. This outpatient billing is usually revenue generating encounter compared with inpatient therapy services because once inpatient, these services are bundled into the DRG payment. Subspecialty physician consults can also bill independently for the care they are providing while in the emergency department. Furthermore, the foundational improvement can be simply by connecting the emergency department encounter with existing clinics and social supports. This would be very low cost intervention and would also help maximize government support structures.
Learn about what you already have and don’t know about. Every area in the United States is broken down into area agencies on aging and these are government sponsored supports for older people in your area. This can be quite variable and also sometimes under accessed. Often, tax payer money has already covered the support and it can be low or no cost to any individual patients. Be sure to connect with adult protective services and how you both can collaborate. Reach out to specialty services like neurology, physical medicine & rehabilitation, as well as family medicine and internal medicine to talk about how to approach common challenges. Lastly, be sure to talk with insurance agencies as many of them will have resources they prefer their patients to engage with. They may have case management services through the insurance and you won’t have to duplicate those resources.
To reinforce the training specific to the care of older adults and the new multifaceted approach required for their optimal outcomes, Geriatric Emergency medicine concepts needs to be incorporated consistently in most if not all didactic presentations, be comprehensive in scope, and modeled by faculty and attendings.
Specific to the objectives of such a specific curriculum, Dr. Hogan and their team published twenty-six competencies of geriatric emergency medicine resident education in their publication in Academic Emergency Medicine that covered seven distinct domains:
(1) atypical presentations of disease
(2) trauma including falls
(3) cognitive behavioral disorders
(4) emergency intervention modifications
(5) medication management
(6) transitions of care
(7) effect of comorbid conditions.
Certainly all of the competencies are valuable, yet, based on her experience, Dr. Southerland’s top topics if she were to design an “essentials of geriatric emergency care” course would be:
Finally, although very challenging to implement, the way we assess our trainees would need to evolve to include these competencies.
Listening and reading this could leave you feeling that the task of incorporating this level of older-adult care would be too difficult; the truth is that with some planning and thought everyone can elevate the care we deliver through three approaches:
Plan to elevate the care as a team. Bring together like-minded people from a variety of professions such as nursing, social work, pharmacy etc for training on key geriatrics topics. Then, clinically, delegate or partner with these myriad professionals to get all the assessments and screening done. You can also mobilize resources I the community that can help your specific patient.
Choose effective screening tools to implement. Dr. Southerland’s practice is able to have a delirium screen, fall-risk screen, and use the identifying senios at risk score in their practice. The identifying senios at risk score involves the following questions, which are easy to incorporate into even the busiest practices:
With a little planning, equipment that is commonly needed for hearing and sight aide, etc for your patients can be placed accessibly within your department. In addition, creating EHR macros and dot-phrases ahead of time for the common conditions, discussions, and assessments in your practice will help reduce time spent documenting them robustly.
This is an older concern in that Medicare wouldn’t pay for hospitalizations if there isn’t an acute medical issue. However, observation status has different guidelines. This can help get just enough time to make everything come together. Sometimes this leads to more justified admission. The observation status tag can create concern for patients because there is a deductible that applies to this. There is also a MOON notice: multiple overnight observation notice ***Patient’s copay can sometimes be lower than what they would owe if they were made inpatient. The three night inpatient stay before nursing home placement has temporarily been repealed because of COVID. Hopefully this will be a lasting change.
There are accredited 1 and 2 year geriatric fellowships which are available for emergency medicine physicians. The optional second year is usually engineered to provide additional advanced degree such as a masters in business administration, or education. The fellowship usually integrates clinical ED shifts with geriatric duties, such as experiences in geriatric psychiatry, urology, etc. The fellowship experience often involves experiences with skilled nursing facilities and community resources to better understand the experiences of older adults.
Palliative care fellowships have similarities with geriatric medicine fellowships including a multidisciplinary approach to providing care. Both programs also emphasize symptom control and transitions of care, and methods for engaging the patient’s entire community in elevating their experience. Despite the numerous differences, there are also very important distinctions. In particular, palliative care fellowships provide training for patients of all ages and have a deeper focus on symptom control and overall experience of receiving healthcare; whereas, geriatric medicine will train learners on aspects of geriatric care outside of end of life or symptom control states such as preventative services.
One way we can all help improve care for older adults is to facilitate better transitions with nursing homes. Imagine caring for a person, sending them to the emergency department out of concern for their wellbeing only to receive them back with generic, “come back if your symptoms recur,” instructions. This would be very disheartening and leave lingering concern. Furthermore, we should be as detailed and thorough in the transition as if the patient would not have access to another doctor for three days. To this end, being very detailed in your recommendations for the next several days, including as much information you discovered, and clear description of any new prescriptions and follow up recommendations you have are some of the key best practices.
We are all seeing plenty of older adult patients in emergency departments – this is a great opportunity to ensure we are providing the very best care and experience for them. Despite sharing this goal because it’s the right and best thing to do, the way we do it might look very different. There are several different models of geriatric emergency care delivery. Its best to select the one that matches your specific resources the best.
Elevating geriatric emergency care doesn’t have be expensive – in fact, accessing existing resources accompanied by small interventions like making hearing and visual aides accessible can be cost neutral or even cost savings in the long run.
Furthermore, connecting more fully with patients is likely to improve a clinician’s love with the specialty, potentially creating more resilience or lowering risk of burnout. Providing better care for older adults by mobilizing more resources and understanding your patient better will most likely resonate with your intrinsic values as well.
Continue this conversation with Dr. Lauren Southerland via twitter @LSGeriatricEM or Dr. Venk Bellamkonda via twitter @VenkBellamkonda
All illustrations within this document are licensed by Dr. Venkatesh Bellamkonda