Introduction
The convergence of several forces is creating an opportunity to dramatically improve care for older adults in the emergency department (ED), which in turn has the potential to create benefits in the US health care system for everyone. These forces include demographic changes, a shift toward value-based health care, and the emergence of individual and organizational champions for optimal geriatric emergency care. This issue of Clinics in Geriatric Medicine, focusing on Care for the Older Adult in the Emergency Department, comes at the perfect time to help advance the field and improve ED care for all seniors.
Every day in the United States more than 10,000 people turn age 65. While in the last 2 years it has fallen, life expectancy has steadily increased in America over the last several decades. By 2060, the older adult population in this country will reach 98.2 million people, up from 49.2 million in 2016. This longevity brings with it challenges and opportunities as this increasingly complex patient population often has multiple chronic conditions, serious illnesses like dementia, and is resulting in increased health care utilization, including expensive ED care. With this shifting demographic, we have an unprecedented opportunity to improve care delivery in a meaningful way for our aging population.
Fortunately, the government and private sector have taken steps to contain health care costs and improve quality. The Medicare Access and CHIP Reauthorization Act of 2015, for example, continues to promote the use of alternative payment models that link payment to quality, rather than the quantity, of services provided. Accountable Care Organizations (ACOs) were encouraged under the Affordable Care Act and continue to grow. These provider organizations are able to share in savings generated from delivering higher-quality care at lower cost to a defined patient population, and therefore, have incentives to reduce unnecessary ED utilization. As of the first quarter of 2017, there were 923 active public and private ACOs covering more than 32 million lives, which is an increase of 2.2 million covered lives from the previous year.1
In particular, the ED represents a critical intersection in the health care system. People in the ED are either admitted to the hospital or discharged to their home or another setting, often determining the trajectory for future care and associated costs. The geriatric population is more likely to use the ED than any other age group, and annually, nearly one in two older Americans will have an ED visit.2 These older adults, however, are at increased risk for serious complications in the ED compared with younger people and much more likely to be admitted to the hospital.3 While representing only about 15% of ED visits, people over the age of 65 accounted for 47.5% of hospital admissions from the ED in 2014.4 Illnesses and injuries leading to an ED visit for people over age 70, even without hospitalization, are associated with a clinically meaningful decline in functional status during the following 6 months.5 This suggests that this period after an ED visit, when older adult patients are especially vulnerable, is a potential time for intervention and deserves our collective attention.
The estimated additional cost of medical and long-term care for newly disabled seniors in the United States is $26 billion per year.6 Therefore, older adults receiving care in the ED present an opportunity whereby improved practice can have large and far-reaching effects in terms of better outcomes for patients and potential cost-savings to the US health care system.
Fortunately, there is a growing body of evidence to support the importance of providing geriatric emergency care to seniors, as represented by this issue of Clinics in Geriatric Medicine. Several articles explore areas of clinical care whereby common practice has not yet reflected best practice, such as the use of screening tools to predict the risk of poor outcomes, the prevention and management of delirium, or appropriate medication management. Authors discuss challenging areas for ED staff, such as falls and geriatric trauma, frailty, and pain management. Other articles highlight the need to continue developing new approaches in areas such as advanced illness and end-of-life care, behavioral health, and elder abuse and mistreatment. Throughout this issue, the authors emphasize the importance of team-based care and system-level changes to achieve better results for older adults in the ED.
In addition to an increasing evidence base and collection of best practices represented in this issue, a growing movement of individuals and organizations committed to ensuring that all older adults have access to optimal geriatric emergency care has emerged. For example, between 2007 and 2017, more than 100 Geriatric EDs (GEDs) were established. The implementation of these programs demonstrates an interest in the benefits of providing senior-specific emergency care from the health care marketplace.
In fact, several of this issue’s authors have been trained in geriatric emergency medicine and were champions for the development of guidelines for these GEDs, which have shown a high degree of variability in their components.7 The GED guidelines were endorsed in 2014 by four national geriatric and emergency medicine organizations, including the American College of Emergency Physicians (ACEP), the American Geriatrics Society (AGS), the Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM), with each organization having a history of fostering improvements in emergency care for older adults.
For example, the AGS has supported the development of the geriatric emergency medicine field through its Geriatrics for Specialists Initiative, which has partnered with ACEP and SAEM to support academic career development awards in geriatric emergency medicine. The ENA has developed a Geriatric Emergency Nursing Education Course.
In addition, in 2015, ACEP, AGS, SAEM, and ENA joined with nine leading health care systems to launch a GED Collaborative, established with funding from the Gary and Mary West Health Institute and The John A. Hartford Foundation. The learning collaborative is beginning to identify, implement, and study best practices in ED care for older adults that are linked to improved health outcomes. The GEDC will then help educate health systems on the importance of providing senior-specific emergency care to scale this model of care to more EDs across the nation.
In 2017, ACEP added to this momentum by announcing its plans to establish a Geriatric Emergency Department Accreditation program and develop standards and a verification process for three levels of GEDs beginning in 2018. The John A. Hartford Foundation, as part of its work to create age-friendly health systems, and West Health, through its wide range of geriatric emergency care initiatives, remain committed to supporting these initiatives and helping align these efforts with the broader movement in health care toward better care of older adults in EDs that can result in better outcomes at lower costs.
This issue of Clinics in Geriatric Medicine represents an important contribution to making high-quality ED care for older adults a reality for everyone, thanks to the collaborative efforts of the authors, the national geriatrics and emergency medicine organizations, public and private sector partners, and the readers of this journal. It’s time we take a bold approach and spread these learnings to health systems across the nation and improve emergency care for seniors who deserve to age successfully with dignity, quality of life, and independence.