Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Senior ED Helps Reduce Repeat Visits, Readmissions

5/17/2016 5:12:20 PM | 5 comments

All my life, I've had a passion for working with our elders. As a teen, I loved volunteering in our church's senior fitness program. And I gained even greater empathy by caring for each of my parents through a serious illness.
 
Today, I'm an assistant ED medical director at the Saint Agnes Hospital in Baltimore. Like most large EDs, ours can be a loud, busy, bewildering place. This is especially true for the large population of elders who visit us each year.
 
When I learned that CEP America and Saint Agnes were collaborating on the development of a new Senior ED, I jumped at the chance to get involved. In today's post, I'll describe how we created a setting that helps elders feel safe and empowered while boosting our hospital's quality metrics.
 
A Growing Need
 
Over the past few years, geriatric emergency medicine has emerged as an important specialty. Patients over 65 are more likely to utilize the ED, and their average cost per visit is far above the national average. They're also about three times more likely to be admitted to the hospital.
 
Despite being well represented among ED patients, elders face some significant barriers to emergency care:
 
  • Physical. Elders with hearing impairment may have difficulty understanding discharge instructions in the noisy ED environment. The layout of the department may require patients who are at risk for falls to walk long distances.
  • Psychological. Older adults who are fearful of losing their independence may withhold information about their medical history or living situation.
  • Cultural. Prejudices and stereotypes about older adults can impact the care they receive. For example, providers might assume that an older adult "doesn't really know what happened" or "can't understand" rather than making an extra effort to communicate.
 
As a result, many elders end up feeling distressed, lost,and helpless in most EDs. This stress can reduce satisfaction and escalate symptoms, particularly in patients with delirium or dementia.
 
These issues are particularly salient to Saint Agnes, which serves a large geriatric population. About 10 percent of our ED patients are age 65 and over. While many come from the multiple nursing homes and rehab facilities in the area, others are living at home and value their independence.
 
About two years ago, Saint Agnes received a generous donation for the enhancement of geriatric care. The hospital had recently created a successful pediatric ED in partnership with CEP America, so a Senior ED seemed like a logical next step.
 
Transforming Emergency Care
 
The Senior Emergency Department at Saint Agnes Hospital is the 73rd geriatric ED in the United States, the second in Maryland, and the first in Baltimore. The hospital and CEP America collaborated in its creation with valuable guidance from the Schumacher Group and The Erickson School of Aging Studies at the University of Maryland, Baltimore County.
 
In order to better serve our older adult patients, we first needed to create a culture that was sensitive to their needs and preferences. This would require each of us in the department to evaluate our attitudes, beliefs, and prejudices.
 
Early in the planning process, we held an integrated planning meeting for all providers and staff who touch the ED patients. Our group created two word clouds:
 
How older patients feel in a typical ED:
 

 
How we want them to feel:
 

 
Throughout the planning process, we worked to replace the negative feelings from the first cloud with positive feelings from the second.
 
Next it was time to assemble our team. Research suggests that the complex health needs of seniors can best be met through a multidisciplinary approach. All ED physicians, PAs, NPs, and nurses received training in geriatrics. In addition, we invited nutritionists, social workers, and pharmacists to participate.
 
We also oversaw the renovation of a small section of the existing ED to create a safe and inviting environment for elders. The new layout consisted of seven walled treatment bays around a central nursing station with alcoves for pharmacy and nutrition consults. Safety features included no-slip flooring and handrails. Walls were soundproofed and painted soothing colors. Beds were fitted with softer mattresses, thicker blankets, and pillow speakers. Even the lights and TVs were adjusted to reduce glare.
 
Finally, we developed screening tools to address common health issues among older adults, including falls risk, delirium, in-home safety, and medication interactions. These assessments are usually administered at triage, which allows us to begin discharge planning immediately. They also help us to pinpoint the underlying causes of our patients' health issues.
 
No Age Limit on Quality
 
The Saint Agnes Hospital Senior ED opened in 2015. Just one year later, our patients and hospital are reaping many benefits:
 
Patient satisfaction. The service has developed a positive reputation in the community. Older patients will actually tell their referring physicians to send them to the "geriatric side" of the ED.
 
Fewer repeat visits. Our screening process enables us to treat the root causes of health problems, which really makes a difference in the lives of our patients.
 
For example, a man in his late 80s came in after a fall and screened at high risk for future falls. He was very independent, and we couldn't imagine him in a nursing home. Within a few hours, our social work team had set him up with home health services and arranged to have some simple safety equipment installed in his house. The patient was discharged that day to a safe home situation.
 
Reduced admissions and readmissions. Another patient came in after falling repeatedly. She was very undernourished, which was causing her to feel weak. One option was to admit her in order to place a feeding tube. However, we felt we could provide the resources to correct the problem.
 
And we did. Our social worker set up home meal delivery. The consulting pharmacist recommended supplements. And the physician followed up with the patient's primary care doctor to ensure continuity. As a result, the patient avoided a hospitalization and maintained her independence and dignity.
 
What's Next?
 
While our senior ED is now up and running, it's still a work in progress. We're currently collecting outcome data for this setting so we can further refine our approach to care. We also hope to incorporate telehealth into the program in order to assist outlying EDs in caring for elders.
 
Geriatric emergency medicine is quite intellectually challenging, and the field is advancing rapidly. One of our biggest challenges is providing team members with the educational opportunities they need to stay on top of the latest research and recommendations.
           
For myself, this journey has been incredibly rewarding. Now that the Senior ED is up and running, I'm beginning to share our story with the community through speaking engagements. I tell my audience about the wonderful patients I've met, and how they've challenged my own views on aging.
 
In both my personal and professional lives, I've seen how the needs of elders can fall by the wayside in healthcare settings. As providers, we can ensure that their voices are heard and that each person is treated with respect and dignity. 


Comments
Molly Hartle
I so enjoyed your article. It reminds me that we, too, will be old one day. Happily the systems we set up for the elderly today will be there for us tomorrow. Great topic, great work.
5/23/2016 10:28:53 AM

Trish Jones
Thank you everyone!

Dr. Birdsall,
Very good point. Pharmacy is definitely included. If a patient is on more than 5-7 medications it will automatically trigger a message to be sent to our clinical pharmacists. They will evaluate the patient's medications an make recommendations as they see fit.
5/19/2016 6:01:01 PM

Dave Birdsall
Awesome article Trish and great work. I heard that everyday 10,000 people turn 65. We are all going to have to do a better job treating the elderly. I wonder if you all are also focusing on med recon. The number of medications these folks are on is astounding. Just to keep the meds straight and taking the right ones at the right times requires a pharmD.
5/19/2016 5:14:29 PM

Barbara Victor
Great article Trish! Sometimes as practitioners we need to be flexible to meet the special needs of our patients. This is a wonderful project to improve the patient experience.
5/18/2016 4:01:37 PM

Richard Newell
Great article Trish - thanks for sharing!
5/18/2016 6:53:47 AM