As a resident, Dr. Kevin Biese saw an older adult woman sitting in the hallway of an emergency department for 24 hours. Instances like this, as well as his close relationship with his grandmother, inspired Biese to search for ways to improve emergency department care for older adults.

“I’m incredibly proud of the nurses and doctors I work with in the emergency department, and yet I have been aware that the system of emergency care for older adults has not been designed properly for their needs for decades,” Biese said. “It’s been a passion of mine. My grandmother helped raise me. You don’t have to know much about geriatric care to know that boarding for older adults is a critical problem for older adults and we need to do things better.”

Biese, who serves as GEDC’s Co-PI and chair of the Board of Governors for the ACEP Geriatric Emergency Department Accreditation Program, spent much of the first half of his career creating and implementing educational tools for emergency departments with an interest in pursuing quality improvement initiatives to evolve care for older adults.

In recent years, Biese’s focus has shifted from education to the evolution of systems that shape the care older adult emergency department patients receive. Biese has investigated how factors such as public policy, CMS regulation and healthcare incentivization function within the healthcare ecosystem to impact older adult care. He has become an advocate for implementing models of value-based care in the U.S. healthcare system, as opposed to the country’s current fee-for-service healthcare model.

“The system inherently rewards volume and does not lean into continuity of care,” Biese said.
“At the end of the day, the things we do to make the emergency department better for older adults are, for the most part, not billable interventions. And so geriatric emergency medicine is tough because you do more and get paid the same.”

In a value-based care system, healthcare systems would be incentivized for demonstrating that efforts like spending time talking with older adult patients, making follow-up appointments and providing older adults with food during their emergency department visits can lead to fewer repeat emergency department visits and hospitalizations downstream.

“If we can support the systems, then we can spread the systems,” Biese said. “And the goal is to make geriatric emergency care the standard of emergency care for every adult who needs emergency care anywhere in this country. We’ve demonstrated that it’s possible in order to make it sustainable and scalable. We need to have it supported and the pathway to that support is through value-based care.”

Recently, Biese and his GEDC and GEDA colleagues have collaborated with the Alzheimer’s Association on work related to CMS’ new GUIDE payment model to provide dementia care navigators and 24/7 support for persons living with dementia and their care partners. The Alzheimer’s Association has assembled a Dementia Care Navigation Roundtable of healthcare leaders across the country to help healthcare systems make the most of the GUIDE Model, including representatives from GEDC and GEDA.

“I think that’s a great example of how the incredible work that the GEDC and GEDA teams are doing to advance emergency care for older adults is getting increasingly recognized by organizations like Alzheimer’s Association,” Biese said. “We are entering the conversation at a national level about what we need to have in place to help people age better, and in this case, to help persons living with dementia access better services.”

The GUIDE Model exemplifies value-based care, as healthcare systems are allotted a budget and can choose how to most efficiently and effectively use those resources to serve persons living with dementia.

Another such example of value-based care in action is the atrial fibrillation clinic Biese and his colleagues have implemented at the University of North Carolina. Atrial fibrillation, which often impacts older adults, has traditionally been treated by admitting emergency department patients to the hospital and monitoring their heart rate for 24 hours.

At the University of North Carolina, patients who present to the emergency department with atrial fibrillation are able to get a real-time appointment with a specialized cardiologist and pharmacist instead of being admitted to the hospital. This not only allows patients to recover in the comfort of their homes, but it also decreases healthcare costs.

“The clinic is an example of the way that acute unscheduled care for complicated patients like older adults has to evolve,” Biese said. We want to be able to diagnose the problem and then refer you for rapid follow-up whenever possible, as opposed to admitting you if you don’t want to be in the hospital. But in order to do that we have to create the systems of care that make this work.”

Throughout his 20 years as an advocate for better emergency care for older adults, Biese has found the progress he’s witnessed in healthcare systems rewarding.

“There’s still way more to be done, but we’re making progress,” Biese said. “I estimate that we’ll have seen 4 million older adult patient visits in geriatric EDs in the United States in 2023. Many of those have been improved by the care processes that these emergency departments have done. I think my grandmother would be proud of me, and that matters to me. When I think about that, I’m grateful to be doing this work.”