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Memorandum To: Board of Directors Council Officers From: David P. John, MD, FACEP, Chair Robert T. Fitzgerald, MD, FACEP, Report Author Geriatric Emergency Medicine Section Date: October 7, 2008 Subj: Report on Council Resolution 24(07) Baby Boomers Recommendation HEADQUARTERS Post Office Box 619911 That the Board accept the report as submitted by the Geriatric Emergency Medicine Dallas, Texas 75261-9911 Section. 1125 Executive Circle Irving, Texas 75038-2522 Background 972-550-0911 800-798-1822 972-580-2816 (FAX) As a result of the Council Resolution 24(07) Baby Boomers, the Board charged the www.acep.org Geriatric Emergency Section to report on the impact of the geriatric population on the BOARD OF DIRECTORS nations emergency departments. Linda L. Lawrence, MD, FACEP President Nicholas J. Jouriles, MD, FACEP Resolution 24 Baby Boomers President-Elect Brian F. Keaton, MD, FACEP RESOLVED, That ACEP study the impact of the baby boomer generation on our Chair of the Board Immediate Past President nation’s Emergency Departments; and be it further Angela F. Gardner, MD, FACEP RESOLVED, That a report of this study be made to the 2008 Council. Vice President Sandra M. Schneider, MD, FACEP Secretary-Treasurer Action: Assigned to the Geriatric Section to provide a recommendation to the Board. Andrew I. Bern, MD, FACEP Kathleen M. Cowling, DO, MS, FACEP Leaders of the section are in the process of developing a report for review by the Board Ramon W. Johnson, MD, FACEP Alexander M. Rosenau, DO, FACEP by October 2008. The report will be provided to the Council after it is approved by the Andrew E. Sama, MD, FACEP Board. David C. Seaberg, MD, CPE, FACEP David P. Sklar, MD, FACEP Robert C. Solomon, MD, FACEP Through review of numerous articles and reports on this topic Robert T. Fitzgerald, MD, FACEP assumed responsibility for the development of the report. COUNCIL OFFICERS Bruce A. MacLeod, MD, FACEP Speaker The report highlights the increasing demands that will be placed on emergency Arlo F. Weltge, MD, MPH, FACEP Vice Speaker departments and emergency medicine, the changing of the paradigm of care in the emergency department, financial imperatives, a new model of geriatric care in the EXECUTIVE DIRECTOR Dean Wilkerson, JD, MBA, CAE emergency department, and the role ACEP can play in this arena. Prior Board Action None Fiscal Impact None Report on: The Future of Geriatric Care in our Nation's Emergency Departments: Impact and Implications 2008 The Future of Geriatric Care in Our Nation’s Emergency Departments: Impact and Implications INTRODUCTION Emergency medicine, like all of healthcare, is facing a “perfect storm” of challenges in the next twenty years: Increasing patient demand and expectations; Increasing regulations and unfunded mandates; Decreasing reimbursements and rising practice expenses; and Nursing and ancillary personnel shortages. But the one challenge that will trump them all and is indeed the driver of many of them is the aging of the population. More than 70-million baby boomers will become eligible for Medicare starting in 2011 with a corresponding huge increase in healthcare demand. Emergency departments (EDs) will play a pivotal role because they are at the interface between outpatient resources and inpatient care and have a significant effect on resource utilization. Emergency medicine must be prepared to assume that critical role. For the sake of simplicity this paper will define geriatric as patients >65 years based on two considerations. Many of the issues discussed revolve around Medicare/CMS mandates and reimbursements. In addition, many of the reports, population data and clinical studies use this age cut off in describing the elderly. This paper will address the following areas of the future of geriatric care in the ED: Increasing numbers and impact of the elderly Medical and financial imperatives to change the present paradigm of care Creation of a new model of geriatric care The role of ACEP in effecting change. I. The Impact of Geriatrics on Emergency Practice Elderly patients will be coming to EDs in ever-increasing numbers based on the sheer weight of demographics, the limitation of the primary care system, and changing utilization patterns. A. Demographics In the year 2000 persons over age 65 represented 13.1% of the population or about 35 million persons. By 2030 that number is projected to be over 70 million or 20% of the population. In addition, the fastest growing subgroups are the “oldest old” – a 28% increase in those >75 years while those >85 years are increasing at 3-4x the rate of younger cohorts. Even at present utilization rates at least 25% of patients in the average E.D. will be geriatric based on population statistics alone. B. Limitations of Primary Care Can the primary care system absorb the increasing healthcare demands of the elderly? There are four mitigating factors that will drive geriatric patients to EDs for care: 1. Shrinking primary care physician pool as a function of population and demand: There is projected to be a deficit of 25,000 gerontologists by 2030, and the picture is just as bleak for family practice and internal medicine. Between 1997 and 2005 the number of graduating family practice residents going into primary care decreased by 50% as a combination of a loss of residency positions, failure to fill available slots, and graduates choosing other career paths. In the last ten years the percentage of internal medicine residents going into primary care fell from 54% to 22%. The distant future doesn’t look much brighter. A recent survey of medical students indicated only 2% were considering careers in primary care. 2. Lack of financial incentives for primary and preventive care: Outpatient care of the elderly is cognitive, labor-intensive and time-consuming. Under present CMS guidelines which pay physicians 25-31% less than private insurers, most practices have experienced a 4-6% operating loss/year over the last 5 years. As a matter of financial necessity, many primary care practices avoid elderly patients. No wonder a survey of physicians in Washington state in 2006 found 65% saying they are not accepting new Medicare patients. 3. The complexity of care: Geriatric patients often have multiple chronic diseases compounded by significant social issues. Managing their medical problems in the outpatient setting where limitations imposed by issues of cognition, mobility, transportation and the availability of subspecialists becomes challenging and often impossible. Hospital-based EDs which are seen as medical one-stop-shopping become an attractive alternative for their primary care. 4. The ED as the most appropriate medical venue: The medical complexity of this population, coupled with the high risk of significant acute disease, often means than an acute care setting like the ED is the most appropriate medical venue for their evaluation and treatment. C. Changing Utilization Rates ED utilization rates for geriatric patients have increased 26% between 1993-2003. Coupled with the population increases in those >75 years and the limitations of the primary care system, these rates are likely to increase even faster in the future resulting in an increasing burden of geriatric care for EDs. As a result of these three factors, the number of geriatric patients presenting to EDs is likely to increase dramatically in the next 15-20 years. Presently they represent about 15% of all ED patients and even the most conservative estimates see 28% by 2025. Many experts, however, feel the number will be at least one-third of all patients nationwide and closer to 40% in rural and many suburban areas. Of course there are presently many areas in Florida and Arizona and parts of the Northeast where these numbers exceed 60%. Not only will their numbers increase but, once in the ED, geriatric patients will have a disproportionate impact on resources. While they represent 15% of all patients they account for 43% of all admissions and 48% of those admitted to the ICU. Their length of stay is 20% longer on average and they use 50% more lab and radiology services and are 400% more likely to require social services interventions. The increasing numbers, acuity and complexity of these patients will have a huge impact on ED operations and will complicate issues of overcrowding and caregiver stress and may contribute to poor outcomes. II. Changing the ED Paradigm of Care The present model of care is designed to best serve acutely ill and injured patients that require rapid interventions and treatments and, in fact, does quite well as evidenced by improving outcomes and morbidity and mortality statistics for most disease entities. However, this paradigm is ill-suited for the typical geriatric ED patient with multiple co-morbidities and with enigmatic complaints that evolve over longer periods of time. There are both medical and financial imperatives that will drive a new model of care. A. Medical Imperatives Compared with younger, severity-matched cohorts, elderly patients have poorer clinical outcomes in the ED. This is manifested in a number of ways: Delayed or missed diagnoses such as acute MI, sepsis, appendicitis, ischemic bowel, pulmonary embolus, etc. Unsuspected diagnoses such as delirium, depression, cognitive impairment, drug/alcohol dependence, elder abuse, polypharmacy, etc. Undertreatment – as exemplified by the low rates of PCI in acute MI, TPA for stroke, less surgical interventions, and inadequate pain management. Overtreatment – as exemplified by the high rates of foley catheterization and adverse drug events with inappropriate medications, especially sedatives and hypnotics. The reasons for these less than acceptable outcomes are multiple and begin with an educational deficit. Numerous surveys confirm that geriatric-specific education and clinical exposure is missing in most residency training programs and many (if not most) practicing emergency physicians feel uncomfortable and burdened treating geriatric patients. Our nursing and EMS colleagues often share this anxiety. Diagnoses are often delayed, missed, or unsuspected because in this age group common disease often have atypical presentations and require a high index of clinical suspicion based on extensive experience with the elderly. Often we do not have evidence- based protocols and outcomes research to guide our care. Patients >75 years are not included in many research protocols which also limits therapeutic decision-making. But, most importantly, the present ED model of care does not allow caregivers the time or support to provide optimal care. The rapid triage and care process is often “unable to elicit full understanding of the patient” and the “full breadth of medical conditions, a long list of medications, communication challenges and slowly evolving problems . . . all impair effective understanding of the patient’s needs.” Clearly a new model of care needs to be developed to deal with geriatric patients in the ED. B. Financial Imperatives Nobody has a crystal ball to tell exactly what Medicare reimbursements will be in the future; but, if recent history is any indication, it is clear that emergency services will not be compensated commensurate with the expenses and resources involved. This has implications for the ED and beyond. In areas with a high proportion of Medicare patients, such as many rural parts of the country, ED physician staffing at individual hospitals and the geographic distribution of doctors in general will become more problematic. Even in areas with moderate percentages of geriatric patients in the ED, falling revenues will strain physician-patient ratios. The financial impact of geriatrics will extend far beyond the walls of the ED and will dramatically affect the dynamic of patient management. EDs are the hospital’s biggest admitters of Medicare patients representing 57% of all admissions nationally. Of that number almost 70% are patients with a medical (as opposed to surgical) diagnosis at discharge which has a negative impact on the hospital’s bottom line with today’s CMS reimbursement guidelines. In a 2004 study Premera Blue Cross of Washington State demonstrated that hospitals lost 16.4% on all Medicare admissions, a number that is reflective of the national experience. And the future looks even less promising. The Budget Reconciliation Act of 2005 mandated spending limits that are built in to reimbursements regardless of demand. The President’s 2009 Budget in following these guidelines has proposed a $15 billion dollar reduction in hospital payments over the next five years. The Health Advisory Board in a 2002 study accurately predicted the future when it projected a 12% revenue decline per patient-day by 2010 and cited as two principle reasons the aging of the population and rising ED admissions. Add to this the recent implementation of non-reimbursements for “never happen” events and CMS’ cutting payments for previously lucrative procedures such as pacer-defibrillation and joint replacements and the financial picture gets even worse for hospitals. What is the implication of these financial realities on EM practice? There will of necessity be increasing pressures on EDs to act as more stringent gatekeepers for Medicare admissions, especially for those with vague medical complaints (the “soft” admissions). The era of a low threshold for admissions for the elderly will become a thing of the past. EDs will be expected to do more extensive evaluations, observe patients longer, seek more consultations, and explore outpatient alternatives. In this new gatekeeper role, EDs will become to a much greater extent observation units for geriatric patients to prevent questionable hospital admission. III. A New Model of ED Geriatric Care Because of the impact of geriatrics on EM practices and the medical and financial imperatives to improve outcomes, a new paradigm of care is needed. Because of the magnitude of this impact and the serious consequences of failing to respond appropriately, there has to be a man-on-the-moon-this-decade urgency to accomplishing this change. Organized emergency medicine has responded to such challenges in the past as exemplified by the improvements in pediatric and trauma care. This new model of care encompasses Infrastructure Integration Implementation A. Infrastructure (Fig. 1) FIG. 1 Clinical Protocols EDUCATION (Acute Care) + Clinical Pathways CLINICAL (Extended Care) RESEARCH Quality Measures The foundation of improvement rests on the dual pillars of education and clinical research. Until recently there has been a notable absence of geriatric-specific training in EM residency programs as evidenced by multiple surveys indicating trepidation in treating the elderly. A core curriculum needs to be developed and enhanced coupled with adequate clinical exposure to bridge this knowledge and comfort gap. Educational modules reflecting a core of geriatric knowledge must be developed and disseminated to front line caregivers and include physicians, nurses, ancillary personnel and EMS. Present efforts need to be elaborated and updated so that this core of knowledge gets to the bedside in much of the same way that acute pediatric and trauma concepts have permeated daily practice. The second pillar is clinical research with a special emphasis on risk stratification, prevention, disposition and outcomes that also includes the community hospital setting. This is a complex patient group and presently evidence is often lacking to guide the clinician’s clinical practice and decision-making. Older patients need to be included in acute care research protocols so that risks and benefits can be judged accurately. Besides raising the general level of knowledge about geriatrics, education and research should lead to at least three useful tools: Clinical protocols (acute treatment) Clinical pathways (extended treatment) Quality measures Evidence-based data will allow EM practitioners to effectively guide the acute evaluation and treatment phase in the ED and to integrate that care in the appropriate medical setting through use of the pathways. As our knowledge base expands and outcomes can be more systematically evaluated, quality measures that are evidence-based, rational, relevant and doable can be developed to guide improvement efforts. B. Integration (Fig. 2) FIG. 2 Observation Hospital Links Inpatient CLINICAL PATHWAYS VNA SNF/NH Outpatient Rehab Links Hospice Primary Care The ED plays a pivotal role in geriatric care as the critical interface between hospital services and outpatient resources. The pathways should be a tool to guide the patient under the direction of the EM physician seamlessly through the system to the most appropriate clinical setting(s) and may include a period of observation before disposition. On the inpatient side of the equation, the ED evaluation and treatment should compliment and expedite the hospital care to minimize length of stay and maximize outcomes. On the outpatient side, the ED should be closely linked with all available resources pertinent to discharge including the ability to communicate data effectively and to ensure appropriate follow-up care. C. Implementation (Fig. 3) FIG. 3 MD RN GERIATRIC ED TEAM Social Services Geriatric MLP Pharmacist OT/PT OPERATIONAL CONCEPTS GERIATRIC ED DESIGN Rooms/space MACRO Obs Unit Adjacencies MICRO Comfort Safety Security To operationalize this focused geriatric care, changes need to be made in both the staffing model and department design. The complexities of these patients demand more time and attention than can be given in the typical acute care setting by the doctor-nurse-tech staffing model. A geriatric care team concept needs to be utilized that would include a social worker/care manager, and a geriatric mid-level provider, supplemented by a pharmacist, OT/PT, pastoral care, etc., as needed. The ED physician and nurse need to address acute medical problems but the rest of the team will often be necessary to gather all relevant clinical information, address important but not acute medical issues, to evaluate all disposition options, and to screen for other conditions that may affect outcomes. In order to support this new paradigm of care changes need to be made in ED design and consist of both macro and micro elements. The macro changes recognize that bed number estimates may have to be revised to reflect longer lengths of stay. Adjacencies for diagnostic studies and treatments need to be incorporated into overall hospital design as well as accommodations for increased numbers of caregivers and consultants within the ED. Observation areas either in the hospital or the ED may have to be designed to allow appropriate evaluations. Micro changes are geared to make the ED more geriatric-friendly and include modifications to address the bright, loud, chaotic and uncomfortable environment seen in most EDs today. These changes would include quiet, private rooms with thick mattresses and softer lighting schemes in close proximity to caregivers with adequate space for in-room family and visitors among other things. IV. The Role of ACEP – Next Steps There are many generic things ACEP is presently doing and should continue to do to improve the overall environment for ED geriatric care. On the political front, ACEP should continue to advocate with CMS and our congressional representatives for adequate reimbursements for the care provided to Medicare patients in the ED to ensure that resources will be available to care for their increasing numbers. ACEP should continue to be the leader in coordinating the expertise and resources of our colleagues in organizations dealing with geriatrics to focus efforts to improve care. In addition to these general approaches there are specific measures where ACEP can expedite this new model of care: 1. Education Prioritize and provide support for the development of an enhanced geriatric core curriculum for resident training. Prioritize and support the development and dissemination of a body of core knowledge for practicing emergency clinicians similar to that for pediatrics and trauma. 2. Research Prioritize and support clinical research projects especially emphasizing risk stratification, prevention, outcomes and disposition involving the community hospital setting. 3. Clinical Management Tools Prioritize and support the development of clinical protocols, clinical pathways and quality measures that are evidence-based and are geared to providing a road map for safe, cost- effective care. 4. Demonstration Projects Support and fund demonstration projects that implement and evaluate aspects of this new model of care, especially the utilization of a geriatric ED team, alternative outpatient care models, links with inpatient/observation systems, and new ED design elements. Conclusion Baby boomers are going to hit the healthcare system like a tsunami in the next 20 years resulting in a marked increase in geriatric ED patients beginning in the next 5 years. Our present paradigm of care and ED design are ill-equipped to address the health needs of these patients, and there are pressing medical and financial imperatives to change. ACEP needs to be the leading force in developing a new model of care to provide appropriate, safe, cost-effective care to the elderly. Robert T. Fitzgerald, MD, FACEP October 2008 References He W, Sengupta M, Velkoff VA, et al. 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