Intermediate Care Technicians (ICTs) are former military Navy Corpsman, Air Force and Coast Guard Medical Technicians, or Army Combat Medics integrated into interdisciplinary care teams within VA to provide high-level clinical support.^1-4 While in the military, corpsmen and medics provide primary care and emergency medical treatment such as intubation and central line placement during critical situations and evacuation from point of injury or illness for all Armed Forces and Coalition Forces personnel. Medics and corpsmen receive hundreds of hours of standardized medical training to support military field operations, but this training does not result in licensure.¹ VA started a program in 2012 to employ these former corpsmen and medics as ICTs in ED.¹ Similar to hospital based paramedics, ICTs work under the direction of a licensed provider.^1,4 ICTs specific scope of care allows them to perform skilled tasks such as ultrasound guided IV placement, laceration repair, or splinting.^{2, 3} Currently, there are 325 ICTs working in 72 VA medical centers in 17 different clinical areas, funded locally as healthcare facility staff.

In 2016, the Louis Stokes Cleveland VA Medical Center (LSCVAMC) and Geriatric Research Education and Clinical Centers started a pilot program to train ICTs to perform geriatric screens, ED care coordination, home visits and telephone follow-up as part of a plan to achieve Geriatric ED (GED) Accreditation through the American College of Emergency Physicians (ACEP).^4,5   Since ICTs in the military receive little geriatrics training, we developed a multimodal educational curriculum on eight domains of geriatric emergency medicine, case based discussions, standardized patient simulation experiences, observed patient screening encounters and shadowing.⁴  ICTs do not have a license so there is a specific competency process for each screen and discrete task they perform, allowing ICTs to perform screens for identifying high risk older adults, cognitive impairment, delirium, caregiver burden, elder mistreatment, polypharmacy, ADL/ IADL, fall risk, food insecurity, and depression.^4,5 To empower this novel workforce, we developed a handheld

playbook that includes flow charts for each screen.⁵ The playbook allows ICTs to approach VA ED providers

with a plan for care coordination and GED specific order sets.⁵

In addition to being competent screeners and care coordinators, ICTs connect with patients as one Veteran to another. As Veterans themselves they quickly establish trust even under emergent situations, help patients navigate a complex healthcare system, assist providers and Veterans to identify what matters, advocate for Veteran-centered care and help patients understand existing healthcare resources that VA provides.^2,4 ICTs connect with ED and hospital social workers, physical therapists, pharmacists, nurses and providers to develop care plan proposals while the patients are in the ED and after discharge. ED providers and GED medical directors approve and activate care plans based on the ICT presentation of the screening outcomes, patient interviews, and electronic health record reviews, the ICT documentation in the patients’ electronic medical record, and ED provider patient assessment.  After the LSCVAMC transitioned from pilot to permanent program in 2017, we supported additional VA EDs with onboard Geriatric ED programming on a voluntary basis.

A future direction sparked by healthcare modernization during the COVID-19 pandemic is Supporting Community, Outpatient, Urgent Care & Telehealth Services (SCOUTS) pilot, a home-based post ED care model where GED trained ICTs assist older Veterans with challenges like social isolation, functional decline, fall risk, caregiver strain, and digital divide. Through in-home geriatric screenings and telehealth connections to VA EDs and home support services, ICTs build trust while helping Veterans remain at home with optimal independence security, safety, and dignity.  The SCOUTs pilot if funded through VA Central Office through fiscal year 2022 at 10 VA sites with Geriatric EDs.The VA national program offices of Emergency Medicine and of Geriatrics & Extended Care are collaborating to transform urgent and emergency care of older Veterans. The standardized GED training for ICTs has been supported and promoted by these national Program Offices through the National VA GED Council to all 110 EDs and 31 Urgent Care Centers and is integrated within the ICT National Foundational Training curriculum, a course that will be required for all EM ICT personnel to complete. ACEP recognized the ICT role and approved ICT geriatric champions as an alternative to nurse champions, one of the criteria for GED accreditation in 2019. This allowed the LSCVAMC to be the 9^th hospital nationally and the first within the VA to achieve Level 1 Geriatric ED Accreditation. Shortly after, The Palo Alto VA Health Care System, in California received Level 3 GED accreditation with ICT geriatric champions. Currently, ICTs are working as geriatric champions, case managers, or screeners in 25/50 VA EDs that have received GED accreditation or are working toward accreditation. Ongoing assessment of the ICT impact on VA GED programming and GED accreditation is part of a planned analysis of the VAs GED program expansion from the initial pilot at the LSCVAMC to all 110 GEDs over the next 2 years.

Geriatric emergency care, domain management model, transitional care, ACE model