By Kevin Biese and Robert Mechanic
February 17, 2022
Older adults—particularly those with complex medical and social needs—are frequent users of medical care, but they are often not well served by America’s fragmented healthcare system.
Most healthcare systems, particularly hospitals and other healthcare facilities, are not organized or operated with the needs of elderly patients in mind.
In an important editorial now nearly a decade old, Harlan Krumholtz, MD, coined the term “post-hospital syndrome,” which describes a period of heightened risk that many Medicare patients face following discharge from the hospital. The elevated risk comes from stresses endemic to being in the hospital including poor sleep, poor nutrition, and physical deconditioning due to long periods of inactivity. Post-hospital syndrome can lead to poor post-discharge outcomes including readmissions unrelated to the original reason for hospitalization.
A growing awareness of the challenges facing older adults in the US healthcare system has led to calls for “age-friendly health systems” that proactively address the unique needs of geriatric patients such as mobility, cognitive function, appropriate medication management, and decision making based on patients’ goals and priorities. By 2035, nearly 22 percent of the US population will be older than age 65, and 11 percent will be older than age 75. This creates an imperative for increased investment in geriatrics capacity and in age-friendly healthcare more broadly. But improvement will depend on health systems’ ability to make major changes in culture, process, and priorities.
An important place to promote age-friendly healthcare is the emergency department (ED), which is the gateway to the hospital for 60 percent of Medicare admissions. A growing interest in making EDs more responsive to the needs of older adults has led to the development of geriatric emergency departments.
In this Forefront article, we describe geriatric emergency departments and the role they can play in reducing potentially avoidable hospitalizations. Traditionally, health systems that were paid primarily based on fee-for-service may not have seen a business case for a model that could reduce inpatient volume, but in today’s healthcare landscape of frequently full hospitals and staff shortages, diverting patients who are not critically ill to alternative settings is necessary to make room for patients who require hospital-level care. In addition, geriatric emergency departments should be highly attractive to accountable care organizations (ACOs), which have financial incentives to manage Medicare spending. We argue that there is a great opportunity for ACOs and geriatric emergency departments to work together.
Geriatric emergency departments are designed to improve patient experience and minimize potential iatrogenesis that can occur among vulnerable older adults in the fast-paced ED environment. Geriatric emergency departments have processes in place to identify underlying medical conditions and social supports needed to prepare older patients for a successful transition home after an ED visit. For example, geriatric emergency departments train their staff in geriatrics and make changes to the ED’s physical environment to improve the comfort and safety of older patients with diminished cognitive function, hearing loss, and poor mobility. Geriatric emergency departments screen for underlying geriatric syndromes such as cognitive impairment, repetitive falls, and elder mistreatment, and they establish connections with community-based resources. In parallel to providing rapid care for emergent medical conditions, geriatric emergency department staff work to address underlying medical and social needs by identifying older adults likely to benefit from social work, physical therapy, occupational therapy, and pharmacy management.
In 2018, based on geriatric emergency department guidelines, the American College of Emergency Physicians (ACEP) began a geriatric emergency department accreditation program. There now are nearly 300 accredited geriatric emergency departments across the US. The ACEP has established criteria for three levels of geriatric emergency department accreditation (exhibit 1). About 20 percent of geriatric emergency departments are accredited as Level 1 or Level 2, which require the geriatric emergency departments have identified physician and nurse champions, a transitional care nurse present at least 56 hours per week, an interdisciplinary geriatric assessment team, and an identified executive sponsor.
Early research into the economic and clinical benefits of services provided at several geriatric emergency departments are promising. For example, one study identified a 5 percent to 16 percent reduction in hospital admissions from the ED for patients seen by a geriatrics-trained transitional care nurse. Another study found 10 percent to 17 percent fewer readmissions in older adults visiting a geriatric emergency department within 30 days of a hospital discharge. A third study found savings of $1,200–$3,200 per Medicare beneficiary within 60 days of the index ED visit for patients receiving services from a geriatrics-trained nurse or social worker in two academic medical centers. Finally, a recent study conducted in a Veterans Affairs hospital found that at-risk veterans cared for in a geriatric emergency department had high rates of referral to pharmacy, social work, and home-based primary care. They also had lower rates of hospital admissions without increasing ED lengths-of-stay.
ACOs are natural partners for geriatric emergency departments. ACOs are groups of providers that participate in payment models such as the Medicare Shared Savings Program (MSSP), where they are subject to an overall spending target for medical care provided to a defined beneficiary population. ACOs earn shared savings when their annual spending is below their spending target so long as they meet the program’s quality standards. To reduce spending and improve quality, ACOs invest in information systems that help them identify and address patient needs more proactively, and hire staff to coordinate care for patients with complex medical and social needs. Since they were introduced in 2012, Medicare ACOs have achieved 1 percent to 2 percent savings annually compared with traditional Medicare.
A major focus of ACOs is reducing avoidable hospital admissions. Acute inpatient care is still the largest component of Medicare spending, and nearly one in five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, despite efforts by payers and providers to reduce these events. ACOs have tried to reduce ED visits by assigning case managers to track patients considered at high risk for hospitalization so they can respond quickly to rapid changes in symptoms. Some ACOs have also developed alternatives to the ED including after-hours clinics and home-based care.
ED visits are a major pain point for Medicare ACOs because they can lead to unnecessary hospitalizations that are difficult for the ACOs to prevent. ED providers may admit vulnerable older adults to the hospital to facilitate further evaluation, which is costly in comparison to arranging for timely outpatient follow up and needed social supports. EDs are designed to identify the acute, emergent conditions that require immediate intervention. Accordingly, elderly ED patients are not typically screened for cognitive impairment, delirium, polypharmacy, or fall risk—conditions with important implications for care needs, clinical management, and patient outcomes.
ACOs and geriatric emergency departments share a common goal: ensuring their patients are cared for in the most appropriate setting. Geriatric emergency department nurse case managers look for opportunities to send patients to alternative treatment settings, including transitioning patients’ home with needed medical care and supportive services when hospitalization isn’t necessary. ACOs employ a range of personnel tasked with ambulatory care management who can potentially take warm hand-offs from geriatric emergency department staff to ensure that patients receive the services recommended by geriatric emergency department staff in a timely fashion.
We analyzed Medicare claims data to understand the overlap between ACOs and geriatric emergency departments. Overall, about 8.5 percent of ACO beneficiary ED visits were made to accredited geriatric emergency departments. Moreover, out of 479 MSSP ACOs in 2021, more than 100 ACOs had at least 1,000 patient visits to a geriatric emergency department. Forty-eight ACOs had at least 3,000 geriatric emergency department visits, and six ACOs had more than 10,000 geriatric emergency department visits. For the ACOs with a large portion of beneficiaries already going to geriatric emergency departments, developing collaborative initiatives should be a no-brainer.
To better assess the opportunities and challenges of working together, we identified eight ACOs whose patients already use geriatric emergency departments and invited their leaders to participate in focus groups to discuss potential collaboration with these geriatric emergency departments. While several of the ACOs had previously met with geriatric emergency department representatives in their own health systems, most of the ACO focus group participants were not familiar with geriatric emergency departments.
We held two virtual focus groups with ACO leaders along with local geriatric emergency department representatives. ACO and geriatric emergency department participants both identified mutually beneficial areas for collaboration. Some ACOs shared that they don’t know when their patients have gone to an ED until after the fact and would value receiving real-time notifications as part of a partnership. One geriatric emergency department told us that they make many referrals to outpatient services, but those services have a high rate of missed appointments, which could be reduced with warm hand-offs to an ACO care manager.
Readmissions are a common problem for ACOs and hospitals. One geriatric emergency department described using its health system’s transitional care clinic to follow up with high-risk geriatric patients discharged to their homes. For patients presenting with heart failure and COPD exacerbations, this geriatric emergency department stabilizes those who don’t require hospitalization before sending them home with a community paramedic who checks in with them periodically to support a safe recovery. But the program can only serve a limited number of patients. ACOs should consider supplementing these kinds of activities with additional resources.
Geriatric emergency department focus group participants raised several challenges. Most geriatric emergency departments are small units nested within larger EDs—making it difficult for them to effect change. Hospital managers may not prioritize resources for geriatric emergency departments because of misaligned incentives. For example, EDs are judged on patient throughput, but geriatric assessments may require that patients spend more time in the ED. Hospitals with empty beds may be inclined to admit more patients who meet inpatient criteria, potentially conflicting with geriatric emergency department efforts to triage patients who could be effectively cared for in an alternative setting.
The concept of geriatric EDs is relatively new and has flown below the radar of most hospitals and health systems. Despite the obvious potential for synergy between geriatric emergency departments and ACOs, the case for hospitals and ACOs to invest in geriatric emergency departments has not been well articulated.
But hospital incentives have shifted as the COVID-19 pandemic continues to put unprecedented stress on the US healthcare system. Hospitals in many parts of the country are overflowing, and organizations are facing serious staff shortages. Developing a capability to safely triage patients out of the hospital has become mission critical for many institutions.
A good next step is to raise awareness about the benefits of geriatric emergency departments and promote collaborations with ACOs and other value-based care models. The Geriatric Emergency Department Collaborative has many educational resources to get started. The list of accredited geriatric emergency departments is continually being updated, and a list of ACOs with at least 1,000 geriatric emergency department visits in 2019 is available here. Both health systems with geriatric emergency departments and ACOs with beneficiaries that use those geriatric emergency departments, should convene conversations among their senior leadership. There is natural synergy between geriatric emergency departments that need more care management support for their older patients and ACOs that may have strong incentives to provide it. Older Americans are the fastest-growing segment of the US population. The time to invest in age-friendly healthcare has arrived.