More than 20 million people 65 years and older present to emergency departments each year in the United States. Roughly one third of those patients are admitted to the hospital often because they cannot be safely discharged to their home. For an older patient, hospitalization comes with the increased risk of infection, falls, delirium, functional decline and death. Hospitalizations also come with increased cost to the patient, provider and payer. According to the Centers for Medicare & Medicaid Services (CMS), the average cost of an inpatient hospital stay is more than $13,800 per Medicare beneficiary.
As the U.S. population ages, more hospitals are implementing geriatric emergency department (GED) programs with specialized staff focused on transitional care for older adults aimed at reducing unnecessary hospitalizations and improving outcomes for this vulnerable patient population. A new study finds that providing specialized geriatric emergency care results in lower Medicare expenditures up to $3,200 per beneficiary.
In the study, which will be published March 1 in JAMA Network Open, data were collected from nearly 25,000 Medicare fee-for-service beneficiaries treated at Northwestern Memorial Hospital in Chicago and Mount Sinai Medical Center in New York beginning in January 2013. The study found a significant reduction in total costs of care when beneficiaries were seen by either a transitional care nurse and/or social worker trained to deliver geriatric emergency care.
Per beneficiary, savings ranged up to $2,905 after 30 days and up to $3,202 after 60 days compared to those who did not receive care through a GED program. The study is the first to quantify the potential cost savings of GED programs.
"It is estimated that 60 percent of hospitalized Medicare patients arrive through the emergency department. When you consider the potential savings per beneficiary when geriatric emergency departments programs are implemented, it's a very significant cost reduction for patients and the payers, while also resulting in better care for older adults," said study author Scott Dresden, MD, medical director of Geriatric Emergency Department Innovations (GEDI) at Northwestern Medicine and associate professor of emergency medicine at Northwestern University Feinberg School of Medicine.
The authors believe the cost savings result from the change in health care utilization and trajectory of the patients. The GED programs in the study are staffed by specially trained nurses and/or social workers who perform comprehensive geriatric, emergency care-specific assessments to older adults who present in the emergency department. Treatment is initiated based on the needs revealed during the assessment.
"These programs focus on transitional care and have been shown to improve clinical outcomes and reduce hospitalizations, length of stay and readmissions, all of which impact cost of care," said author Ula Hwang, MD, MPH, professor of emergency medicine at Yale Medicine and previously of Mount Sinai Medical Center. "By assessing their needs and living situations in the emergency department, the nurses and social workers can connect older patients with necessary resources, such as home care, physical therapy or medical equipment, making it safe to discharge them home and avoid unnecessary inpatient admissions."
Currently, geriatric emergency care programs are not reimbursed by any health care payers, although previous studies have found positive associations of GED programs with clinical outcomes, including decreased hospitalizations, intensive care admissions, 30-day readmissions and cost. The authors hope their findings serve as a framework that may be used when calculating the bundled value and potential reimbursement per patient for GED care programs by CMS and other payers.
"While more hospitals and health care systems have incorporated geriatric emergency programs, most have not and without reimbursement they are not incentivized to do so," said Dr. Dresden. "These programs not only improve care and outcomes for older adults, but also have direct economic value for patients and payers. Hospitals and clinicians who incorporate these integrated geriatric care programs in their emergency departments should receive the benefit of shared savings."
Northwestern Memorial, Mount Sinai and St. Joseph's Regional Medical Center in Paterson, NJ, were the first hospitals in the country to launch geriatric emergency departments through the "Geriatric Emergency Department Innovations in care through Workforce, Informatics, and Structural Enhancements" (GEDI WISE) program in 2013. In 2018, the first GED accreditation program was created by the American College of Emergency Physicians (ACEP) to recognize hospitals for higher levels of geriatric emergency care and to improve and standardize emergency care for the nation's older adults. Today, more than 200 hospitals worldwide have achieved Geriatric Emergency Department Accreditation (GEDA). Accreditation is given at three levels and is adaptable based on a hospital's needs and resources.
Northwestern Memorial was the first hospital in Illinois and among the first in the nation to achieve Level One GEDA, the highest tier of the ACEP's interdisciplinary standards. Since launching its geriatric emergency program in 2013, Northwestern Memorial has seen a decrease of unnecessary hospitalizations of older patients by 33 percent.
"We're really proud of what our geriatric emergency department has achieved. When we discharge an older adult, we can be confident that we are sending them home safely and providing them with the appropriate transitional care that they need," said Dr. Dresden. "This study reinforces our experience at Northwestern that providing specialized geriatric care from dedicated staff and focusing on transitional care, our older patients have better outcomes, fewer hospitalizations and there's substantial cost savings to the patients, and payers. Programs like this have a very positive impact for hospitals and their older patients."
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