Geriatric Transitional Care Nurses and How They Could Help Your ED

With Pamela Martin and Ula Hwang

Geriatric EDs are about care, not space, Geriatric Transitional Care Nurses can help address the holistic, functional, and psychosocial needs of older patients in order to find alternatives to admission. In this episode of GEMCast, Dr. Christina Shenvi is joined by Dr. Ula Hwang and Pamela Martin to learn about the role of Geriatric Transitional Care Nurses and how they can be incorporated into an ED to improve care for older patients. Ula Hwang is a Professor of Emergency Medicine at Yale, her research focuses on improving the quality of care older adults receive in the ED. Pamela Martin is a Nurse Practitioner who has worked in geriatric emergency medicine for 10 years, she also has experience developing geriatric ED programs.


Key Points

  • Geriatric EM or Transitional Care nurses are nurses with additional training in geriatrics.
  • Their ideal patients are gray zone patients who are not safe for discharge but do not meet admission criteria.
  • Benefit to patients:
    • Reduce admissions and 30-day readmissions
    • Up to 60 days after ED stay, $3000 savings per patient
    • Reduce the risk of hospital-based delirium, deconditioning, and nosocomial infections
  • Benefit to ED clinicians:
    • Serve as an additional resource to help patient care
    • Bring downstream care upstream, reduce or make the most of boarding time
    • Reduce boarding/crowding
  • Tips for setting up a transitional care nurse program:
    • Focus on a specific older population, and specific diagnosis e.g. cellulitis, or CHF
    • Look within existing resources, e.g. UM
    • Leverage existing Geri/PT/palliative care consults


Hwang, Ula et al. “Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries.” JAMA network open vol. 4,3 e2037334. 1 Mar. 2021, doi:10.1001/jamanetworkopen.2020.37334 – View Article

Dresden, Scott M et al. “Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults.” Academic emergency medicine : official journal of the Society for Academic Emergency Medicine vol. 27,1 (2020): 43-53. doi:10.1111/acem.13880 View Article

Sanon, Martine et al. “ACE Model for Older Adults in ED.” Geriatrics (Basel, Switzerland) vol. 4,1 24. 21 Feb. 2019, doi:10.3390/geriatrics4010024 – View Article

Heeren, Pieter et al. “Unplanned readmission prevention by a geriatric emergency network for transitional care (URGENT): a prospective before-after study.” BMC geriatrics vol. 19,1 215. 7 Aug. 2019, doi:10.1186/s12877-019-1233-9 – View Article

Hwang, Ula et al. “Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use.” Journal of the American Geriatrics Society vol. 66,3 (2018): 459-466. doi:10.1111/jgs.15235 – View Article

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