Emergency department program for older adults reduces admissions

Liz Seegert

About Liz Seegert

Liz Seegert (@lseegert), is AHCJ’s topic editor on aging. Her work has appeared in NextAvenue.com, Journal of Active Aging, Cancer Today, Kaiser Health News, the Connecticut Health I-Team and other outlets. She is a senior fellow at the Center for Health Policy and Media Engagement at George Washington University and co-produces the HealthCetera podcast.

A unique emergency department program focused on geriatric transitional care is helping older patients avoid unnecessary hospital admissions by as much as 33 percent, according to results of a study from Northwestern University Hospital in Chicago, Mount Sinai Medical Center in New York, and St. Joseph’s Regional Medical Center in New Jersey. They’re collaborating on The Geriatric Emergency Department Innovations (GEDI WISE) program, an interdisciplinary approach to improving acute geriatric emergency care.

The program keeps older adults out of the hospital while keeping them safe, and has shown to prevent both 72-hour and 30-day readmissions. The goal is to keep older adults functioning in the community rather than being admitted for non-critical reasons and then exposed to risks associated with hospitalization. Hospitalized older adults are at greater risk of negative events like delirium, infections and falls, say the authors.

Post-discharge, many experience a loss of independence and a decline in functional ability and quality of life. An ED visit is often a “sentinel event, signifying a breakdown in care coordination for older adults,” according to study.

GEDI WISE addresses their immediate and longer-term health issues, and follow up to ensure they’re addressed safely at home, according to study co-author Scott Dresden, M.D., an emergency physician at Northwestern and director of NWU’s geriatric emergency department innovations.

Physicians and nurses still focus on the acute cause of an ED visit, but GEDI team members, led by a transitional care nurse (TCN) or nurse practitioner identifies patients with geriatric-specific health needs, pinpoints areas for intervention and coordinates their transition home from the ED. An older adult may have physical or mental decline, trouble caring for themselves at home, or a complex medication regimen, a common issue for many older patients.

The support team at Northwestern includes a social worker and pharmacist, who can dig a little deeper. This results in a more holistic treatment approach, Dresden said in a phone interview. The team follows up by phone to track patients’ health and coordinates with the person’s primary care physician, with the goal of avoiding the need for a return ED visit, Dresden explained.

Compared to patients not participating in the GEDI program, the study showed a 17 percent absolute decrease on the day of the emergency room visit (day 0) at all three hospitals and a 14 percent absolute decrease in hospital admissions at 30 days at Mount Sinai and Northwestern. Nationally, an average of one-third of older adults are admitted the same day of an emergency room visit. This Health Affairs article reviews the GEDI program at Mt. Sinai. Carla Johnson covered the Northwestern program for The Associated Press.

“The most expensive thing that can happen in the ED is for someone to get admitted,” Dresden said. In addition to helping hospitals avoid 30-day readmission penalties, “we think there will be cost savings to Medicare because of the program.” Investigators are tracking cost-savings as part of the study follow-up.

In addition to benefitting patients seen by a transitional care nurse, the GEDI program has created a culture change so everyone is thinking differently about older adults, Dresden said. “Now we’re also thinking about the underlying issues and addressing those as we can.”

The study was published in the Jan. 10 issue of the Journal of the American Geriatrics Society.

Journalists:

  • What is your local hospital doing to reduce ED admissions of older adults?
  • Do any hospitals in your community have a geriatric-specific emergency department or other program which aids older adults?
  • This article by Judith Graham looks at why hospitalizations are often a “tipping point” for older adults.

One thought on “Emergency department program for older adults reduces admissions

  1. Paul Burke

    The study does not count how many patients died or deteriorated. And the control group was not random. Transitional help is great, but the goal of this demonstration was not “best care.” The goal was “avoiding inpatient admission when possible” (p.2), which is a biased goal. All 3 hospitals have paid huge penalties for multiple Medicare admissions within 30 days (FY17: St. Joseph $2.7 billion, Mt Sinai $1 billion, Northwestern $418 million), so have bitterly strong incentives to avoid as many Medicare hospitalizations as possible. As Dr. Jha writes in the Feb 6 JAMA, “hospitals’ incentives for reducing readmissions were between 6 and 10 times greater than the incentives for reducing mortality” (https://doi.org/10.1001/jama.2017.21623). Indeed, US heart failure mortality rose after readmission penalties were adopted, while heart failure admissions dropped (http://www.globe1234.info/medicare/effects). Reporters can see deciles of death rates for each condition at USNWR (not at Medicare, which omits hospice deaths). For example all 3 hospitals in the study have only average survival after hip and knee replacements.

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