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August 3, 2017

How 4 hospital EDs are preparing for a surge of senior patients

Daily Briefing

A rising tide of elderly patients, who often have different medical needs than younger patients, is leading hospitals to make geriatric-specific investments in their EDs—such as nonslip floors, alarms that warn medical staff of fall risks, and care pathways that avoid the use of narcotics.

New: Learn the 4 primary care models for elderly patients

Writing for the San Diego Union-Tribune, Claudia Boyd-Barrett, of Center for Health Reporting at the University of Southern California's Leonard D. Schaeffer Center for Health Policy & Economics, and Paul Sisson, a Union-Tribune staff writer, highlight the trend.

Why elderly patients are different

Seniors "tend to be heavy users of the" ED, Boyd-Barrett and Sisson write. Such patients typically need complex care and are more likely to have several chronic conditions. Compared with younger patients in the ED, seniors have a higher risk of falling or becoming delirious. Further, research shows that one-third of patients over age 70, and more than half of patients over age 80, leave the hospital with more significant disabilities than when they arrived.

Shawn Evans, an emergency physician at Scripps Memorial Hospital La Jolla, explained, "(Seniors) are not like older, middle-aged people, just like kids aren't small adults. They're the most vulnerable, the most sensitive, require the most input."

To better accommodate those needs, some hospitals are adjusting their care delivery methods for the growing senior population. For instance, St. Joseph's Regional Medical Center in New Jersey launched one of the first and best-known geriatric EDs in 2009.

Through senior-specific emergency care, health care providers aim to reduce the number of seniors who are admitted to the hospital and help those seniors avoid returning, while also supporting seniors' desire to live independently, outside of a facility.

Tess Hogan, director of geriatric emergency medicine at the University of Chicago and co-author of a 2013 survey into the prevalence of geriatric-focused emergency facilities, estimated that as many as 150 such facilities could exist today, up from 36 in 2013—though she doesn't have an updated tally. She added that some hospitals purport to provide specialized geriatric emergency care but don't do so in reality.

Meanwhile, the American College of Emergency Physicians, working with other medical and geriatric organizations, in 2014 published guidelines for geriatric-focused EDs. Now, the process is underway for creating a corresponding accreditation system.

A spotlight on San Diego hospitals

According to Aimee Moulin, president-elect for the California chapter of the American College of Emergency Physicians, specialized geriatric emergency medicine is lagging on the West Coast compared to the East Coast and the Midwest. She said, "There's a growing recognition of the special needs of the geriatric population (in California) … but certainly it's not the majority."

San Diego, however, "is well ahead," Moulin said, characterizing the area as "the leader in terms of geriatric emergency medicine" in the state. In San Diego, individuals 65 or older make up more than 20 percent of ED visits—above the state and national average, Boyd-Barrett and Sisson report.

Individuals over age 65 comprised an estimated 13 percent of the San Diego County population in 2016—or about 445,000 people. The number is expected to hit 724,000 by 2030, according to the San Diego County Senior Heath Report.

Several San Diego-area hospitals have launched or are in the process of launching senior-focused emergency care, Boyd-Barrett and Sisson report. For instance:

Kaiser Permanente's San Diego Medical Center has nonslip floors, adjustable lighting, and a computerized guardrail system, which aim to reduce common complications among seniors, such as falls and delirium;

Palomar Health is testing a new hip fracture pathway in which specialists provide patients with local anesthesia rather than narcotics, with the goal of promoting faster recovery;

Scripps Memorial Hospital La Jolla opened an emergency center with glass doors in patient rooms, rather than open doorways, to reduce noise; beds with extra-thick mattresses; alarms that warn medical staff of fall risks; and a 16-bed "clinical decision area" where mostly senior patients get specialized help from geriatric-trained staff members; and

UC San Diego's medical campus in La Jolla, where the region's first ED intended specifically for geriatric patients is scheduled to open next year.

Does geriatric-focused emergency medicine really help?

According to Boyd-Barrett and Sisson, so far there's been only limited research into geriatric-focused emergency medicine—and the studies that have been conducted have shown mixed results.

On the one hand, a 2014 study in Michigan found that geriatric-specific emergency practices at one ED did not reduce visits back to the hospital within 30 days or reduce average time spent in the hospital.

On the other hand, researchers from Northwestern University's geriatric ED found that hospital seniors who received specialized emergency care saw their hospital admissions decrease by nearly half compared with the control group. Thirty-day ED readmissions also fell. According to Hogan, Mount Sinai Hospital and St. Joseph's geriatric EDs have produced positive results as well.

For now, Hogan said, individual hospitals should weigh the most appropriate investments based on their budget, demographics, and locations. But she noted that the aging baby boomer population means health care providers need to make these decisions soon. "The huge demographic demand is now, and if it takes 20 years to get this up and running, there will be 20 years of older people that don't get the care that they deserve," she said (Boyd-Barrett/Sisson, San Diego Union-Tribune, 7/30; Minemyer, FierceHealthcare, 8/1).

New: Learn the 4 primary care models for elderly patients

As the geriatric population expands, health systems must adapt to manage the needs of this patient population. These patients are not simply older adults. They require specialized clinical care due to their unique health status and vulnerability.

This market scan reviews four models for fixed or mobile primary care, including geriatrics clinics, providing primary care in assisted living facilities, forming house call programs, and an overview of strategies to geriatricize existing primary care practices.

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