The Geriatric ED: Making the Case for Its Financial Impact

Main Learning Points

Dr. Ula Hwang

Dr. Hwang described the study that her group published in JAMA Open Network paper. It looks at 25,000 ED older patients who visited an ED and were assessed by either a geriatric nurse or social worker and compared them to 25,000 patients who were not. In the following month after that initial visit, for patients assessed by the Geriatric nurse or social worker, overall costs to the system were less by up to $3,000 per patient compared to those not seen. She suggested some hypotheses as to why that might be and the source of those cost saving – most likely from avoided admissions and decreased ED re-visits.

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. Kevin Biese

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. Scott Wilber

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.)

Details

Goals

• To engage with policy makers and payors nationally and internationally about return on investment in geriatric ED care
• To review a landmark article in the Geriatric ED literature demonstrating the financial impact of geriatric ED interventions
• To consider different financial arguments in favour of geriatric ED interventions

Moderated By

Don Melady

MD

Bio

Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.

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