Geriatric EDs save money, improve outcomes — so why aren’t there more of them?

Geriatric nurse takes care of an older woman as part of nursing follow-up in a geriatric center.

Photo: Banc d’Imatges Infermeres via Flickr

Millions of Medicare beneficiaries are admitted to the hospital each year because they cannot be safely discharged to go home. Such hospitalizations come with an increased risk of infection, falls, delirium, functional decline and death. They also come with increased costs to the patient, provider and payer. A recent study found a significant reduction in the total cost of care when these older adults were treated in a geriatric emergency care department instead of a more traditional ED.

According to the study published Marh 1 on JAMA Network Open, this specialized geriatric emergency care can lower Medicare expenditures by up to $3,200 per beneficiary. Yet, there are only about 200 specialized geriatric emergency departments in the U.S., according to the American College of Emergency Physicians (ACEP), which accredits geriatric EDs. So, if patients fare better and it costs less, why aren’t more hospitals establishing geriatric EDs?

It comes down to reimbursement, according to study co-author Scott Dresden, MD, medical director of Geriatric Emergency Department Innovations (GEDI) at Northwestern Medicine and associate professor of emergency medicine at Northwestern University Feinberg School of Medicine.

“It’s a new idea, and there hasn’t been a mechanism to bill for that,” he said in a phone interview. Northwestern has seen cost savings and better outcomes by reducing unnecessary ED visits and admissions up to three months after someone is discharged home with support from a geriatric ED. “That a couple hours in the emergency department has long-lasting effects, at least 90 days out, is pretty remarkable to us,” he said.

Geriatric emergency department (GED) programs incorporate specialized staff who focus on transitional care for older adults to reduce unnecessary hospitalizations and improve outcomes for this vulnerable patient population. Currently, these programs are not reimbursed by any health care payers, despite previous studies which have found positive associations of GEDs with clinical outcomes, including decreased hospitalizations, intensive care admissions, 30-day readmissions and cost.

A growing need for specialized care

More than 20 million people 65 years and older show up in U.S. emergency departments each year, the study authors noted. People in this age group are hospitalized three times as often as adults ages 45 to 64. Individuals age 85 and older account for 9.2% of all hospital discharges, although they are only about 2% of the total population. Additionally, patients 85 and older are less likely to be discharged to their homes and are more likely to die in the hospital. The Centers for Medicare & Medicaid Services (CMS) estimates the average cost of an inpatient hospital stay is more than $13,800 per Medicare beneficiary; 60% of hospitalized Medicare patients arrive through the emergency department.

For the study, data were collected from nearly 25,000 Medicare fee-for-service beneficiaries treated at Northwestern Memorial Hospital in Chicago and Mount Sinai Medical Center in New York beginning in January 2013. Researchers found a significant reduction in total costs of care when beneficiaries were seen by a transitional care nurse (TCN) or a social worker trained to deliver geriatric emergency care.

Per beneficiary, savings ranged up to $2,905 after 30 days and up to $3,202 after 60 days compared to those who did not receive care through a GED program. The authors believe this is the first such study to quantify the potential cost savings of GED programs.

“When you consider the potential savings per beneficiary when geriatric emergency departments programs are implemented, it’s a very significant cost reduction for patients and the payers while also resulting in better care for older adults,” Dresden said.

Cost savings most likely result from the change in health care utilization and trajectory of the patients. The specially trained TCNs and social workers can perform comprehensive geriatric, emergency care-specific assessments for older adults who come to the emergency department. Treatment is more likely to be based on overall needs, not just clinical presentation.

“By assessing their needs and living situations in the emergency department, the nurses and social workers can connect older patients with necessary resources, such as home care, physical therapy or medical equipment, making it safe to discharge them home and avoid unnecessary inpatient admissions,” said lead author Ula Hwang, MD, MPH, professor of emergency medicine at Yale Medicine and previously of Mount Sinai Medical Center.

Falls are a good example of a risk that can be reduced. “We’re actually providing the patients with the right level of care as opposed to the highest level of care, where a person who does have risks of falls and needs additional physical therapy and that sort of thing,” Dresden said. “Because we’re looking and finding additional problems, whereas previously we would fix the fracture discharge them home.”

The authors hope their findings serve as a framework for calculating the bundled value and potential reimbursement per patient for GED care programs by CMS and other payers.

According to the authors, these programs improve care and outcomes for older adults and have direct economic value for patients and payers. Dresden said hospitals and clinicians who incorporate these integrated geriatric care programs in their emergency departments should receive some of the benefit from that shared savings. “While more hospitals and health care systems have incorporated geriatric emergency programs, most have not, and without reimbursement they are not incentivized to do so.”

Northwestern Memorial, Mount Sinai and St. Joseph’s Regional Medical Center in Paterson, NJ, were the first hospitals in the country to launch geriatric emergency departments through the Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancements (GEDI WISE) program in 2013. In 2018, ACEP created the first GED accreditation program to recognize hospitals for providing higher levels of geriatric emergency care to standardize and improve emergency care for older adults. Currently, 226 hospitals worldwide have achieved Geriatric Emergency Department Accreditation (GEDA). Accreditation is given at three levels and is adaptable based on a hospital’s needs and resources.

Since launching its program in 2013, Northwestern Memorial has cut hospitalizations for older adults by 33%., according to Dresden.

That has been important during the pandemic. “We saw the devastation that COVID had among people in skilled nursing facilities despite everybody’s best efforts. Helping older adults to live independently at home with the right supports is the right thing to do,” he said.

Dresden is optimistic that as evidence of cost-savings mounts for geriatric emergency departments, Medicare finally will be willing to pay for them. So far, hospitals have absorbed the added costs. “We’re providing a valuable service to Medicare, and these data show that we have decreased the costs to Medicare. This seems to me like a great investment for payers like Medicare, to be investing in to provide the right care to patients but also to potentially save the payers money as well.”

Journalists may want to see whether their community has a dedicated geriatric emergency department:

  • What have they experienced during the COVID-19 crisis?
  • How many people have avoided hospitalization due to the program?
  • How has keeping older community members out of the hospital potentially impacted infection risk or caseload?

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