As more and more of us live longer and healthier lives, we are becoming part of one of the largest demographic shifts in US history, as some 10,000 Americans now turn 65 every day. Innovations in health and care have helped make that increased longevity possible, and now a new wave of innovations to our health care system and community-based services must emerge to reflect our country’s changing demographic. One of these innovations is already occurring within emergency departments (EDs), which are increasingly becoming our nation’s “front porch” of health care for older adults. One out of every two older adults makes an ED visit annually, a large proportion of which result in hospital admission. As more Americans approach that “front porch,” the opportunity to ensure that EDs are delivering care tailored to the needs of older adults has never been greater.
In response, EDs need access to the wealth of research and innovation on senior-appropriate acute care, and with more than 5,000 EDs operating across the United States that is no small feat. The diffusion of innovations theory, which has a long history in the social sciences, helps explain how, why, and at what rate new ideas and technology can spread. While not without its critics, the theory remains widely recognized and has been applied to a variety of real-world challenges, including health care. At its core, the theory relies on three basic principles central to successful adoption of innovations: First is the perception of the innovation, notably the perceived benefit of change. Second are the characteristics driving those who adopt innovation (or fail to do so). And third, contextual factors such as communication, incentives, and leadership also encourage or potentially discourage how innovations get disseminated.
A new collaborative announced today known as the Geriatric Emergency Department Collaborative (GEDC) is demonstrating promising progress across all three of these principles. Supported by the John A. Hartford Foundation and the Gary and Mary West Health Institute and managed by the American Geriatrics Society (AGS), the GEDC is bringing together professional societies with a vested interest in older adult care—the American College of Emergency Physicians (ACEP), the AGS, the Emergency Nurses Association, and the Society for Academic Emergency Medicine—as well as hospitals and health systems across the United States. Early GEDC member sites—Aurora Health Care System (Wisconsin), Emory University/Grady Memorial Hospital (Georgia), Magee Women’s Hospital (Pennsylvania), Mount Sinai School of Medicine (New York), Northwestern University (Illinois), St. Joseph’s Regional Medical Center New Jersey), University of California, San Diego Health, the University of Chicago (Illinois), and the University of North Carolina—all represent early adopters within geriatric emergency medicine.
Perception: Why Innovation Of Geriatrics And EDs?
To understand how change happens, we first need to appreciate why it is necessary. With so many more Americans than ever before looking forward to the potential for longer active lives, the opportunities for health care professionals who can make that possible has never been greater. Today, for example, we need about 20,000 geriatricians—to care for our senior population, yet there were fewer than 7,300 certified geriatricians practicing nationwide as of 2016.
Additionally, EDs are also a critical medical and social safety net for many of our nation’s seniors. They manage care transitions to help us avoid hospital admissions when appropriate, and they connect us to ambulatory care options within the community, when available. Taken together, this growing reality has given rise to the field of geriatric emergency medicine, which focuses on providing senior-appropriate care in the ED to address both the acute and social services needs of everyone as they age.
In fact, between 2007 and 2017, estimates indicate that the number of geriatric emergency departments (GEDs) in the United States went from zero to more than 100, a trend that illustrates the perceived benefit of senior-appropriate care in the ED. Unfortunately, the evidence base for GEDs has not kept pace with their rapid growth—we still know too little about how and why GEDs provide better care and outcomes for seniors, which is why understanding the characteristics of early GED adopters has become so critical.
Characteristics Of Early Adopters: What’s Being Done Today?
Through the lens of diffusion science, early GED adopters represent “networks of influence” that serve as examples to help spread adoption of practices already showing promise for improving geriatric emergency care. The mantle of early adopters in this case is best represented by the GEDC.
Without requiring separate facilities (a potential barrier to entry), GEDs envisioned by the GEDC embrace a variety of best practices—from coordinating expert care to ensuring safe outpatient transitions so seniors can transition from the hospital to an outpatient setting whenever and wherever safely possible. Among other things, these GEDs can:
- Promote more accurate diagnoses by using senior-specific screenings performed by providers who recognize key characteristics of senior health. This can expedite care, improve health outcomes, and ensure that resources are used efficiently and effectively.
- Help improve the continuum of care, from ED intake to discharge. This is because the GEDC’s vision for GEDs relies on a range of health professionals (nurses, social workers, pharmacists, physician assistants, physicians, and so forth) to better coordinate care.
- Benefit health systems across the country. In addition to the potential to reduce costs, GEDs can improve care standards and reinforce a facility’s reputation for recognizing the needs of senior patients and their caregivers.
Professional societies and public organizations play a critical role in the accelerated diffusion of geriatric emergency care. In 2014, four national geriatric and emergency medicine organizations collectively endorsed guidelines for optimal geriatric emergency care. More recently, ACEP announced the creation of the Geriatric Emergency Department Accreditation program that will recognize EDs that provide varying levels of senior-specific emergency care. Establishing an accreditation standard provides opportunities to accelerate the spread of best practices in geriatric emergency medicine. Together, the leadership of early-adopter health systems and professional societies has put the pieces in place for geriatric emergency medicine to catalyze across additional GEDs nationwide.
Context: How Did We Get Here, And Where Are We Going?
The recent surge in geriatric emergency care activity stems from years of prior work to fuse geriatric care and emergency medicine. (See historical timeline in Exhibit 1.)Examples include the identification of high-yield research priorities in conjunction with the National Institute of Aging, development of geriatric core competencies for emergency medicine residents, and the creation of quality indicators for geriatric and emergency care.
Source: Based on authors’ review of literature.
For the GEDC, that past is now the prologue for future growth, advancement, and acceleration. Through the formation of the GEDC, partnerships among multiple professional societies, and contributions from nonprofit organizations—all with a shared vision of improved geriatric emergency care—a platform is now being established to identify best practices and build greater awareness about how we can improve care quality and outcomes for seniors in the ED.
Challenges And Future Outlook
While the field of geriatric emergency medicine has made significant progress in recent years, challenges remain. Currently, GEDs around the country are in the midst of dissemination and implementation efforts to ensure best practices are not only shared but implemented and sustained. The National Institutes of Health (NIH) offers a helpful framework for assessing dissemination and implementation (see Exhibit 2). Within the NIH model, the GED community has made its most significant strides in the areas of planning, delivery, and evaluation. For example, GEDC member sites have partnered to plan dissemination activities, including meetings to discuss building a clinical data registry focused on GEDs and the development of funding proposals to continue building evidence demonstrating the impact of GEDs.
In terms of improving care delivery, a core group of individuals from GEDC member sites have developed and facilitated “boot camps” to provide tools and training for interdisciplinary staff at hospitals committed to improving geriatric care in their EDs. These training sessions facilitate the adoption and dissemination of GED best practices based on local needs, with topics ranging from care transitions to delirium detection just to name a few. To date, the GEDC has conducted or scheduled boot camps in nine health care systems, which has in many respects spurred innovation among early GEDC sites.
Finally, the GEDC is actively pursuing evaluation and reporting efforts through analyses of existing data as well as designing and piloting a data infrastructure to enable future research. As the field grows, the geriatric emergency community is focusing on growing the evidence base for GEDs, which should facilitate the late majority’s entry into geriatric emergency medicine.
Exhibit 2: Abbreviated Framework For Enhancing The Value Of Research For Dissemination And Implementation
While, there are signs of progress in the dissemination and implementation of GEDs, there is still work to be done to understand long-term outcomes associated with GEDs. Establishing early adopters and planning efforts are indeed promising first steps—but they also must be amenable to change. Given the current trajectory of geriatric emergency medicine, we anticipate additional unknowns and challenges will emerge as evaluation continues and long-term outcomes become clearer. However, in spite of these unknowns, the overarching goal of geriatric emergency medicine remains unchanged: a better understanding of how EDs can serve our nation’s older adults.
Another challenge is around the sustainability of geriatric emergency medicine. In particular, there is a need for clear articulation of financial incentives, as there is currently no reimbursement mechanism for geriatric emergency care. The need for key financial drivers will likely only grow as health care shifts from rewarding quantity to quality of care, a trend epitomized by Medicare Access and CHIP Reauthorization Act (MACRA) reforms.
MACRA establishes two pathways to reward health care professionals for value over volume: the Merit-based Incentive Payments System and the advanced alternative payment models (APMs). APMs allow practitioners to earn more for taking on some risk related to health outcomes for those under their care. Since seniors often present to the ED with complex medical issues that are rarely fully resolved during an ED visit, follow-up care in other ambulatory settings is typically required. Thus, one approach to embedding geriatric emergency care within MACRA may be through the development of an APM focused on care delivered in the ED that extends to other ambulatory settings. Enabling the ED to manage a larger proportion of care for seniors through APMs may be one way to help develop incentives for improved geriatric care in the ED.
Additionally, there is a need to invest in the growth of future leaders in geriatric emergency medicine through educational opportunities and training initiatives. Some efforts are already underway. For example, the Geriatric Emergency Nursing Education program and clinical care models such as Nurses Improving Care for Healthsystem Elders and the Coleman Transitions Intervention all focus on senior care in the hospital setting, including the ED. Increasing awareness and participation in interdisciplinary advanced certificate or training programs such as these could help address geriatrics and emergency medicine workforce needs.
There are myriad opportunities to improve the care everyone deserves as they age. To increase awareness of these opportunities, online forums can help bridge the gap between research infrastructure and real-world needs to facilitate viable solutions to the challenges and opportunities faced by our nation’s seniors. Continuing to grow the field of geriatric emergency medicine will require increased collaboration between policy makers, health care administrators, clinicians, caregivers, and patients to ensure EDs deliver appropriate care to seniors. As such, we intend to report in greater detail on the continued progress of these collaborative activities in the future.
Are We Moving Fast Enough?
Collaborative partnerships such as the GEDC represent a flourishing body of research and innovation in the growing field of geriatric emergency medicine. However, the journey from theory to practice can be long, slow, and often tedious. While early adopters such as the GEDC are poised to move quickly to spread innovation within our nation’s EDs, whether diffusion is happening fast enough is yet to be determined.