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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

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