Dr. Ula Hwang is the Medical Director for Geriatric Emergency Medicine at New York University and a core investigator at the GRECC (Geriatrics Research, Education and Clinical Center) at the James J. Peters Bronx VAMC.
Her research focuses on improving the quality of care older adults receive in the ED setting that ranges from observational studies of analgesic safety and effectiveness in older patients to multi-center implementation science studies of geriatric emergency care interventions. Hwang currently co-PIs the Geriatric Emergency Department Collaborative and is the PI on the Geriatric Emergency care Applied Research (GEAR) network.
Two CMS Measures Addressing Boarding
Boarding is endemic to hospitals and health systems across the country, which are under constant strain due to capacity limitations. While boarding impacts all patients admitted from the emergency department (ED), older adults are disproportionately affected. They board more frequently than younger demographics, and are significantly more vulnerable to functional decline, delirium, and other related harms, including higher mortality.
To address boarding, the Centers for Medicare & Medicaid Services (CMS) introduced two distinct quality measures: the Age-Friendly Hospital Measure (AFHM), and the Emergency Care Access and Timeliness (ECAT) Electronic Clinical Quality Measure (eCQM). While both measures target boarding, there are clear gaps between them — in terms of how boarding is defined, measured, and managed.
In a recent journal article, GEDC faculty member Dr. Ula Hwang and her coauthors examine opportunities to better align these measures and amplify their collective impact. Before diving into their commentary, let’s take a closer look at each CMS measure: what they aim to accomplish, and where they diverge.
Understanding the Gaps
Introduced in 2025, the AFHM asks hospitals to confirm whether they are providing age-friendly care to adults 65 and over. Boarding is one facet of this geriatric-focused measure, which sets the threshold for boarding-related harm at three hours.
In contrast, ECAT focuses on timely access to care for all patients. In 2028, it will require hospitals to publicly report metrics around patients who experience access failures such as boarding, with reporting tied to reimbursement. Unlike the AFHM, ECAT defines the threshold for harm as four hours, and while it stratifies reporting for pediatric and mental health patients, it does not distinguish older adults from the broader adult population.
What the Authors Recommend
As older adults are uniquely vulnerable to the harms of boarding, ECAT would benefit hospitals and patients alike through closer alignment with the AFHM. Similarly, the AFHM would be strengthened by ECAT’s approach to reporting. To that effect, Dr. Hwang and her colleagues offer several recommendations for cross-coordinating the measures.
- Position both measures for inclusion in performance-based payment programs
- Adopt a uniform definition of a boarded patient and boarding’s threshold for harm
- Stratify older adults in boarding reporting to highlight this vulnerable population
Each Measure Can Strengthen the Other
While the AFHM and ECAT each have their own focus, both measures converge on boarding. Boarding, then, presents a clear opportunity to better align these measures, so they can enhance one another’s impact on age-friendly care and timely hospital access.
As Dr. Hwang and her coauthors point out, older adults bear the heaviest burden when it comes to boarding. Given their vulnerability, age deserves greater consideration in both bed prioritization and hospital reporting.
Through consistent definitions and reporting requirements, CMS can standardize how hospitals are held accountable. And by tying both measures to performance-based reimbursement, they can incentivize ongoing improvements that reduce boarding times and protect our most vulnerable patients.
Read the Article
Explore the full article in Health Affairs Scholar, published by Oxford University Press.