Creating High-value Care for Seniors Through Geriatric Emergency Department Partnerships

Value-based Care Activities:

• The West Health Institute recognizes the role of value- based care in lowering costs and improving healthcare quality for seniors and has previously conducted research on how ACOs have used telehealth and home- based care to better serve aging patients.

Background

In their mission to improve healthcare for seniors, West Health Institute has recognized the importance of preventing avoidable hospitalizations. Being in the hospital is a disruptive and uncomfortable experience that can be detrimental to the long-term health trajectory of aging patients. Despite the hospital staff’s best efforts, it is not uncommon for older patients to leave the hospital less functional and more cognitively impaired than when they entered.

Because 60% of older adults that are admitted to the hospital come through an emergency department, they are an important focal point for any efforts to prevent hospital admissions. Geriatric emergency departments (GEDs) are specially designed to provide geriatric-specific emergency care and help aging patients transition to the most appropriate care setting. GEDs have specially trained staff and specific screening processes to help identify and address issues unique to older adults such as dementia, delirium, and social vulnerabilities like food insecurity or elder mistreatment. GEDs are not usually a separate facility but can include enhancements to the physical space to make seniors more comfortable such as quieter designated waiting areas, more comfortable seating, and light dimmers.

Older patients that go to a GED are less likely to be admitted to the hospital or return to the emergency department within 30 days. They also have substantially lower healthcare costs (more than $3,000 lower for Medicare beneficiaries) in the 60 days following an ED visit. Their ability to provide high-value care for seniors makes GEDs a natural partner for value-based care organizations (VBCOs). VBCOs can amplify the effectiveness of GEDs by providing additional disposition options. For example, an ED physician may not need to admit the patient to the hospital, if a VBCO is available to provide the needed care in an outpatient or home-based setting.

Approach

Recognizing the synergistic potential for VBCOs and GEDs to work together to provide high-value care for seniors, West Health Institute created a toolkit to facilitate partnerships between these two types of organizations. The toolkit provides context about GEDs, their capabilities and priorities, and how partnering with them can yield better results for VBCOs. It then gives practical guidance on how to identify and contact potential GED partners including how to use resources from the American College of Emergency Physicians to find local accredited GEDs. VBCOs participating in the Medicare Shared Savings Program can also find instructions on how to identify specific GEDs where attributed beneficiaries have received care.

The toolkit also provides guidance on how to lay the foundation for a successful partnership including how to consolidate buy-in, align goals and expectations, remove barriers, and enable continued improvement. The toolkit also includes resources like example outreach emails and draft meeting agendas to make the partnering process as easy as possible.

During the development phase, West Health Institute initiated a pilot project to test a preliminary version of the toolkit. Lessons learned from the pilot project were then incorporated into the toolkit’s final version. The pilot project sites were Aurora Health, UNC Health Alliance, St. Joseph’s Health, and Gary and Mary West PACE and their GED partners at Advocate Aurora Health GEDs, St. Joseph’s Department of Emergency Medicine and UNC Hillsborough GED.

Partnerships are inherently unique, and each site faced different challenges and took different approaches. For example, one site used Bamboo Health’s real- time patient locator to notify the VBCO of an ED visit, while another focused on getting read-only access to the GED’s EMR. Despite the differences in approach, some common themes emerged. Each site acknowledged the importance of building a shared understanding of each partners’ capabilities and facilitating effective communication.

Key Learnings

• Emergency departments are an important leverage point for preventing unnecessary hospital admissions. By assuring ED physicians that patients will receive the appropriate care in an outpatient or home- based setting, value-based care organizations can help prevent avoidable hospitalizations.

• Geriatric emergency departments are natural partners for value-based care organizations due to their shared goal of transitioning elderly patients to the most appropriate care setting and their unique ability to identify and address geriatric specific issues.

• Real-time communication regarding patient arrivals in the ED enables the prompt responses necessary to avoid unnecessary hospital admissions.

• Building a shared understanding of each partners’ capabilities and motivations and facilitating effective communication are key elements of a successful partnership.

Challenges with Implementation

Each of the pilot sites faced unique challenges in developing their GED partnerships. Establishing new partnerships can be time-consuming for an already busy GED team. One site struggled to arrange meetings for the initial discussions but with patience and persistence was eventually able to kick things off. Many of the sites mentioned the challenge of gaining buy-in across the organizations. Executive attention is a limited resource, and it can require substantial work to make the case that a GED partnership is a high priority. Another challenge that sites mentioned was a lack of understanding of capabilities and priorities on both sides of the partnership. Overcoming the knowledge barrier was crucial to gaining organizational buy-in and laying foundation for the partnership.

Results to Date

The pilot project sample size was naturally low, but a survey of the participants yielded positive results. Two sites that had not previously been receiving notification when patients arrived at the ED were able to establish those processes enabling the responsiveness that prevents unnecessary hospitalizations. The sites unanimously reported that communication with the GED had increased as a result of the pilot project. They were also universally enthusiastic about continuing the partnership with each respondent reporting the highest level of interest. And most importantly, each site stated that they met their goals or motives for participating in the pilot project.

About the Institute

The Institute for Advancing Health Value (the Institute) is a non-profit organization with a mission to accelerate the readiness of health care organizations to succeed in value-based payment models. Founded by former Secretary of Health and Human Services, Gov. Mike Leavitt, and former Administrator of the Centers for Medicare and Medicaid Services, Dr. Mark McClellan, the Institute serves as the foundation for health care stakeholders across the industry to collaborate on improving the care delivery system. To learn more about the Institute, visit advancinghealthvalue.org. The Institute is formerly known as the Accountable Care Learning Collaborative (ACLC).

Tools and Vendors

There are two partners that maintain resources utilized by the toolkit to enable VBCOs to find potential GED partners. The American College of Emergency Physicians maintains a list of accredited GEDs by location and the Institute for Accountable Care has a data set that shows where MSSP ACO beneficiaries have visited a GED. The pilot sites and their corresponding GED partners also played an essential role in the creation of the final version of the toolkit. Bamboo Health’s real-time patient locator was a tool used by one of the pilot sites, while others used the local HIE, or shared EMR access for patient notifications.

About West Health

West Health was founded by Gary and Mary West in 2009 and aims to preserve the dignity, independence, and quality of life of aging seniors by lowering healthcare costs and ensuring access to high-quality healthcare and support services. West Health assembles a team of researchers and healthcare professionals working to advance these goals through applied medical research, policy research and education, and high impact grantmaking. They also partner with healthcare organizations, community organizations, universities, and foundations from across the country to explore and promote more effective models of care for seniors.