Are we Helping All Older Adults who need Enhanced ED Care?

Diversity Equity and Inclusion in the Geriatric Emergency Department 

Kevin Biese, MD

What’s different about a Geriatric Emergency Department?

In essence, a Geriatric Emergency Department (ED) does a “deep dive” on older adults to address underlying social and medical complexities that may be the reason behind the reason for an ED visit.  For example, traditional and a geriatric EDs both take good care of older adults who fall, and excellently manage injuries occurring from the fall. However, a Geriatric ED will take additional steps to decrease the risk of repeat falls. These steps may include medication reconciliation, physical therapy, home safety evaluations, or other interventions that address underlying geriatric syndromes and/or social needs.  Indeed, a geriatric ED may do its best work by offering the exhausted care giver a cup of coffee and a social work consult to identify other resources available to the vulnerable older adult.

Geriatric EDs are expanding their reach, but to whom?

I am incredibly proud of and grateful for the evolution in geriatric emergency care that the Geriatric Emergency Department Collaborative (GEDC), and Geriatric ED Accreditation (GEDA) are leading in partnership with West Health, the John A Hartford Foundation, and so many other healthcare and community-based partners across the globe. At the time of writing this article, over 50 Emergency Departments freely share best practices, research, and education with each other and that number is growing. Additionally, 9 of our nation’s leading health care systems meet quarterly to share system-wide Geriatric ED (GED) deployment strategies. There are over 280 accredited Geriatric EDs in 4 countries and the demand continues to grow. Both California in the Master Plan for Aging and New York in the 2018 annual State of the State address have identified Geriatric EDs as a critical tool to help their states better care for older adults.  Leading Geriatric Emergency Medicine researchers have demonstrated some of the positive impact of Geriatric ED interventions including reduced admissions, reduced ED revisits, improved patient satisfaction, and significant cost savings. Clearly, Geriatric EDs provide higher value care. Which is why it is estimated that in 2021, there will have been over 2 million patient visits to Geriatric EDs nation-wide.

Unfortunately, our care improvements might not be reaching all older adults in geriatric EDs equally. Language and cultural barriers can be difficult to overcome. Communication issues and cultural biases can complicate effective and equal delivery of service.  Furthermore, arranging follow up clinic appointments, home health services, and other outpatient referrals is greatly facilitated by patients having access to phones, computers, support networks, etc. Many patients either do not have or are unable to utilize these tools and some will not even have homes to return to. In the United States, patients without insurance, and perhaps even those with Medicare, have a harder time getting follow up appointments than well insured patients. All of this means that geriatric ED interventions are likely to be more utilized and impactful for socially connected, well-resourced, and English-speaking patients. We must create ways to include those who may be most in need of enhanced geriatric ED care.

We do not pretend that there are easy answers to these issues. But, if we fail to address dangers of inequitable distribution of enhanced care, we will certainly fail to increase equity and inclusion. We should be inspired by the improved and rapidly expanding systems of Geriatric ED care. However, we must do everything in our power to reach all patient populations, especially the disadvantaged and their caregivers, in order for us to realize the true potential of GEDs.

A step in the right direction

In 2022, the Geriatric Emergency Department Collaborative (GEDC) and Geriatric Emergency Department Accreditation (GEDA) will jointly create a Geriatric ED Equity and Inclusion Committee specifically charged with crafting opportunities to improve equity and inclusion in the Geriatric ED models of care.  The challenge to develop toolkits and resources that help EDs reach diverse populations of vulnerable older adults while evolving criteria to encourage diversity around the country and world will be met by GEDC and GEDA respectively.

Contributing Faculty

Kevin Biese

MD, MAT ( Co-PI )

Dr. Kevin Biese serves as an Associate Professor of Emergency Medicine (EM) and Internal Medicine, Vice-Chair of Academic Affairs, and Co-Director of the Division of Geriatrics Emergency Medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine as well as a consultant with West Health. With the support of the John A. Hartford and West Health Foundations, and alongside Dr. Ula Hwang, he serves as Co-PI of the national Geriatric Emergency Department Collaborative. He is grateful to chair the first Board of Governors for the ACEP Geriatric Emergency Department Accreditation Program. His passion is for improved education and systems of care for older adults, and he has published multiple materials in both these areas.

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