healthcare in the outpatient setting: is your ed geriatric

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Healthcare in the Outpatient Setting: Healthcare in the Outpatient Setting: Is your ED Geriatric Focused? Is your ED Geriatric Focused?

Sponsored by

2 the practice of choice for providers | the provider of choice for hospitals

3 the practice of choice for providers | the provider of choice for hospitals3

Our distinguished panelists

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Mark Rosenberg, DO, MBA, FACEP, FACOEP-D Chairman, Department of Emergency Medicine Chief, Geriatric Emergency Medicine St. Joseph’s Healthcare System Paterson, NJ

Eric Heckerson, RN, MA, BSN, FACHE Vice President, Operational Performance TeamHealth Knoxville, TN


Agenda

• Making a case for a Geriatric Emergency Department (GED)• Program definition and goals• Potential roadblocks• What exactly is a GED?• Case studies

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ENA’s position statement

Care of Older Adults in the Emergency Setting

The subspecialty of geriatrics has clearly defined the special medical and nursing needs

of the geriatric patient. The emergency department offers a unique point of service

that may easily interact with outpatient, inpatient, case management, social service, pre-

hospital, home and extended care settings, thus allowing for the seamless transition of care.

If care of the older patient in the emergency department is to continue to improve, it will

require the efforts of an interdisciplinary team of skilled and knowledgeable

healthcare providers in combination with evidence-based practice and process

changes that culminate in improved care and outcomes. 1

1 Hwang, U., & Morrison, R. S. (2007). The geriatric emergency department. Journal of the American Geriatric Society, 55, 1873-1876.

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Studer Group findings

Studer’s ED National Learning Lab – filter results for patient satisfaction 65 years of age and older, they are less satisfied in the areas of:

“Kept informed of delays”“Understanding tests and treatments”“Staff cared about me as a person”

Stephanie Baker, RN, MBA, CEN, Studer Group

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Why?

• 79 million Baby Boomers become 65• Age 65 and over have increase healthcare needs• ED utilization of seniors• Contributing factors• Outcomes• Paradigm shift• More likely to fill out patient satisfaction surveys• More likely to be dissatisfied• VALUE-BASED PURCHASING

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8 the practice of choice for providers | the provider of choice for hospitals88

Population >65 years by size and % of total population


• CMS Data indicates that 15-20% of all ED patients are geriatric• TeamHealth’s database of 9MM+ ED visits:

– Consistent with national averages– Percentage growing over time

TeamHealth vs. national averages

Percentage

17.62%17.62%

17.90%17.90%

18.36%18.36%

Percentage of TeamHealth’s ED patients over 65

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• 7x more usage of ED services• 43% of all admissions• 48% of all Critical Care admissions• 20% longer length of stay• 50% more lab• 50% more radiology• 400% more social service interventions

CMS 2008 Data Set

Geriatric utilization rates

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Contributing factors

1.Shrinking primary care pool• Deficit of 25,000 Gerontologists by 2030

– FP Residents Decreased by 50%– IM Residents Into Primary Care Dropped from 54% to 22%

2.Lack of financial incentives• Medicare is primary insurance of the elderly• Medicare pays 25-31% less than private insurers

3.Complexity of care• Multiple chronic diseases compounded by social issues• Outpatient management issues

– Cognition– Mobility– Transportation– Subspecialist availability

4.ED most appropriate venue• One-stop shopping

– Labs, X-ray, specialists• Not more expensive

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Current model: poorer outcomes for seniors

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1. Delay in diagnosis & treatment• Acute MI• Sepsis• Appendicitis• Ischemic bowel

2. Unsuspected diagnosis• Delirium• Depression• Cognitive impairment• Drug & alcohol• Elder abuse• Polypharmacy

3. Under-treatment• Low rate of PCI in MI• TPA in stroke• Less surgical intervention• Inadequate pain management

4. Over-treatment• High rate of Foley cath• Adverse drug events• Overuse of sedation


Diagnose and treat

Single complaint

Two paradigms

Non-geriatric ED PatientMultiple problems

Medical FunctionalSocial

Acute on chronic, subacute

Control symptoms, maximize function, enhance quality of life

Continuity of care

Acute

Rapid disposition

Geriatric ED Patient


Define Your Goal

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More than 50 Geriatric EDs and growing…

…But there is no standard

Accreditation Standard and Minimal Requirements Development…• ACEP

• AGS

• ENA

• SAEM

Nationally

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• Marketing• Quality• Meeting community need• What age• Nursing home• Decrease or increase admissions• Decrease readmissions

Goal and program definition

“Improving Health Care and Emergency Care to Functionally Independent Seniors”

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Potential RoadblocksPotential Roadblocks

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• Geriatrics isn't sexy• Reimbursement• “But we already see large number of seniors”• Bed pan unit• Little research on outcomes• When is the patient old?

• 65 to 74 = Young Old • 75 to 84 = Old• 85+ = Old Old

Potential roadblocks

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• Feel great• Exercise daily• Eat right• Drink socially• Very social

• High BP• High cholesterol• Cancer• Osteoarthritis• Elevated calcium score• On 6 medications• Countless vitamins• Contact lenses• Hearing aids

Am I old? Keep me functional and independent!

Controlled Health IssuesHealthy

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What is a Geriatric ED?

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1. Physical plant2. Quality initiatives3. Staff and provider education4. Operational enhancements5. Coordination of hospital resources6. Coordination of community resources7. Staffing enhancements8. Patient satisfaction extras9. Observation and extended home observation10. Palliative care

10 facets of a Geriatric ED

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• Separate unit? Versus Process? Universal Design?• Thick mattresses or hospital beds• Quieter, less crazy environment• Non-slip floors• Non-glare floors• Limiting tethers• Handrails• Corridors safe for walking• Lighting• Sound proofing• Family friendly

1. Physical plant

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• Separate unit?• Process? • Universal Design?

Facility options: Is it…

• Staff• Mattresses• Lighting• Floors• Hand Rails• Blankets• Follow up Processes

Make the entire ED Geriatric friendly:

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“If you don’t have space for a Geriatric ED…. make your entire ED a Geriatric ED.

If the ED is designed for the most frail and vulnerable ….. it will work for the strongest.”

Take home message of Universal Design…

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Poll Question.

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“Beers criteria is a list of inappropriate meds to use in elderly patients.

Are you currently using this list in the ED?”


2. Quality initiatives

• Drug interactions• 5 Meds = 70% chance of drug interactions• 7 Meds = 100% chance of drug interaction

• Falls risk assessment• Get-up-and-go testing

• Beers criteria• AGS 2012• Potentially inappropriate medication use in older adults

• Advancing ESI criteria for elderly*• Liberal EKG policy*• Abdominal pain awareness*• Relooking at ESI Triage criteria for elderly*

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Poll Question.

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“How do you currently assess fall risk in patient treated and/or medicated in the ED?”


Triage

• Be aware of vague complaints• A Fx wrist is a fall – not just a Fx • Normal vitals

• Normal BP in a hypertensive• “I Just Don’t Feel Well”• Presentation of ischemic heart disease

• CP isn’t the most common complaint• Abdominal Pain

• Be Afraid• Patient is a pending disaster until proven otherwise

• Strategies• ESI triage levels increase• Prepare for the worst…

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• All staff• Needs assessment through a quality program• Geriatric curriculum (ACEP, SAEM, ENA)

1. Physiology of aging2. Abdominal pain3. Falls and trauma4. Infectious disease5. The dizzy patient6. Pharmacology7. Chest pain and dyspnea8. End of life9. Delirium10. General assessment

3. Staff and provider education

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4. Operations

• Geriatric triage screening• Geriatric palliative care program• Medication reconciliation and interaction screening• Two-step call back program

• Step One – ED Visit• Step Two – Follow-up Program

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The two step process

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• Prevent functional decline within 30 days of ED discharge• Called by Geriatric Team within 24 hours of ED Discharge• Risk screening tools used• Need assessment• Medication Review• Hospital and community resources coordinated• Primary care doctor notified

Step two

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Role of patient call backs• Five concerns:

– Status– Meds– PMD– ADL– Support

Step two call back screen

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• Social workers• Case managers• Physical therapy• Pharmacist• Toxicologist• Telemed

5. Coordination of hospital resources

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6. Coordination of community resources

SNF

Home Care

Nursing Home

LTAC

Acute Rehab

Hospice

County Resources EMS

Adult Day Care

Respite Care

Visiting Angels


• Program coordinator• RN Champion*

• Nurse Coordinator• Geriatric Nurse Practitioner

• Physician Champion*• Medical Director• EM/IM• Fellowship Trained

• Social worker• Case manager• Pharmacist• Toxicologist • Physical therapist

7. Staffing enhancements

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• Addressing by preferred name • Patient liaison• Blankets• Nutrition• Space for Family• Internal waiting room • Reading glasses• Hearing assist devices

8. Patient satisfaction

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• Observation care in the Geriatric ED– Decreases need for admission– Admitted patient are better packaged

• Extended home observation– Visiting nurse – Paramedics– Return ED visit

9. Observation and extended home observation

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10. Geriatric palliative care

Proposed Trajectories of Dying

Figure 1. Trajectories of dying. Reproduced with permission of Blackwell Publishing (Lunney JR, Lynne J. Hogan C. Profiles of older Medicare descendants. JAGS. 2002:50;1108-1112).

Heart attack Stroke

Heart Failure Kidney Failure

Lung Cancer Brain Cancer

Dementia Parkinson’s disease

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Where people die and why they come to the ED

>70% die in a healthcare facility

~17% die at home

~13% die elsewhere

~100% want to die at homeAdmission through the ED

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World Health Organization, Cancer Pain & Palliative Care, 1990

Palliative care and EOL/Hospice

Palliative CarePalliative CareSymptom Management ofSymptom Management of

LifeLife--limiting Illnesslimiting Illness

End of Life Care/End of Life Care/ HospiceHospice

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Curative TherapyCurative Therapy

Palliative TherapyPalliative Therapy

End of life care/ Hospice Non-curative

symptom management

The Palliative Care continuum — think organ failure

Presentation Death

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Case Studies

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What are some TeamHealth clients doing?

• Larger rooms• Wide doors and hallways• Handrails• Thick mattresses• Non-skid floors• Large print signs and reading material • Warm blankets and warmer rooms

• Enhanced lighting• Tailored medication reconciliation

program• Softer paint colors• Hearing aids• Curbside service/valet parking• Staff training

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Studer Group and TeamHealth partnership

• Rounding for Outcomes:– Leader Rounding on Patients – to ensure older patients have a safe environment, understand plan of care

and have needs addressed

– Hourly Rounding – to address pain, plan of care and duration, and ensure safe environment

Studer Group & TeamHealth address special geriatric needs in the ED by hardwiring the following Must Haves®:

• Employee Selection/First 90 Days:– Incorporating standards for older patients in employee interviews and validating their knowledge base for

this population

• AIDET®/Key Words – consistent use of this tactic with specific emphasis on safety, pain management and explaining things in a way that older patients can understand

• Post Visit Phone Calls – setting a standard to call 100% of older patients and contacting at least 60% to ensure safety, knowledge of plan of care and next steps

Stephanie Baker, RN, MBA, CEN, Studer Group

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• 641-bed tertiary care teaching hospital• Paterson, NJ• Emergency Department - 2012

– 140,000 total visits/year:• 41,000 Pediatric Emergency Department • 38,000 Geriatric Emergency Department• 200 Emergency Department Palliative Medicine

Comprehensive stroke centerTrauma centerResuscitation centerHeart Failure centerToxicology reference center

SHOWCASE: St. Joseph’s Regional Medical Center

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Thank you for your participation.

Questions?

For any future questions, please contact TeamHealth at:

800.818.1498

[email protected]

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healthcare in the outpatient setting: is your ed geriatric

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