Some of the tasks those clinicians added were: assessments for risk of potential adverse outcomes, for cognitive impairment and delirium, for interventions to decrease falls and improve mobility and function through physio and occupational therapy consultations; evaluation of polypharmacy and potentially inappropriate medication use;  coordination of direct admission from ED to skilled nursing facilities or subacute rehabilitation; coordination of transportation to and from ED to home;  coordination of care transitions with outpatient evaluation and referrals with home care agencies; goals of care, advanced care planning discussions with palliative care;  follow-up calls for discharged patients.

Dr. Biese reinforced that geriatric ED change is also likely to happen by addressing the strategic priorities of hospital leadership.  It is essential for ED changemakers to know those priorities.  Do they want to decrease hospital admissions? Or draw more older patients to the ED?  Or enhance the hospital’s reputation in the community? Or do they “risk-based contracts” that allow them to offset some of their other expenses by saving money here?  Or all of those.  His main message was to make sure that you are paying attention to “what keeps an executive up at night”:  what are the problems that you can help them solve?

Dr. Wilber is both a long-standing proponent of geriatric ED initiatives and an executive at a large hospital. He reinforced that it is possible, at the executive level, to bring all the players together to demonstrate that spending money in one area can lead to a significant cost-saving in another. He described some of the complexities of hospital funding that explains how an avoided hospital admission can be a large cost saving, including the “opportunity cost” of freeing up a bed for higher remunerating patient. Where does the financial benefit accrue for a hospital? It is essential that, before making proposals for improvements in the ED, clinical champions find out how those “improvements” are going to help your executives run the hospital! Know what the hospital’s strategic plan says. Understand what performance metrics are important to senior leaders at your health system. Be familiar with things such as the hospital’s balanced scorecard (re-admissions, hospital-acquired infections, patient experience, length of hospital stay); the publicly reported metrics (CMS 5 star, IBM Watson, Leapfrog) and how your plan will fit with them. Be sure to consider the difference between adding capital expenditures (building new things – relatively easy) and operational expenditure (paying staff – relatively hard because it is a permanent expense.)

Scott Wilber, MD, MPH
Chief Medical Officer
Mount Carmel Health System
Columbus, Ohio

Kevin Biese, MD, MAT (GEDC Co-PI)
Associate Professor of Medicine and Internal Medicine
Vice Chair of Academic Affairs
University of North Carolina, Chapel Hill

Ula Hwang, MD, MPH, FACEP (GEDC Co-PI)
Department of Emergency Medicine
Yale School of Medicine