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Program keeps elderly out of ED, produces substantial cost savings
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A program utilized in Australia known as Hospital in the Nursing Home, where routine procedures were conducted at aged-care facilities instead of in an ED, resulted in fewer elderly patients presenting at an ED and provided significant cost savings, according to an analysis appearing in PLOS One.
“Many countries, including the United States, Europe, and Australia, have reported a faster growth in health expenditure than that in the broader economy over recent years,” Lijun Fan, department of biostatistics and epidemiology at the School of Public Health, Sun Yat-sen University, Guangzhou, China, and colleagues wrote.
“Yet it remains a demanding challenge to reduce people's reliance on seeking for the expensive hospital care whenever they feel physically unwell. This applies especially among the very elderly people such as those living in the residential aged care facilities, who represent one of the most vulnerable population disproportionately occupying the hospital resources. They are usually borne with multiple chronic diseases prone to deteriorations and thus require frequent presentations to the emergency departments and admissions to the acute hospitals,” they added.
Researchers performed a cost analysis where common care such as changing catheters and providing blood transfusions or wound care in the elderly was received at a hospital vs. having such procedures performed at an aged-care facility under the Hospital in the Nursing Home program.
According to a press release, after the program was implemented at the aged-care facilities there was a 17% drop in patients presenting to an ED, a 36% decrease in hospital admissions per emergency presentation and a 47% drop in overall hospital admissions.
In addition, there was a return of 17 Australian dollars in savings for every 1 Australian dollar spent after the aged-care facilities program started, and Hospital in the Nursing Home resulted in “a substantial cost savings to the health care provider,” that was due largely to reduced need for ambulances, ED utilization and hospital beds, Fan and colleagues wrote.
“This study suggests that the [Hospital in the Nursing Home] service may act as a viable and worthwhile complement to hospital care in managing the demands for emergency department presentations and acute hospital admissions from [residential aged care facilities]. A wider-spread adoption of the program to other similar contexts may be supported on the basis of costs, yet requires further research to explore its actual expanded feasibility,” they added.– by Janel Miller
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Kevin Biese, MD, MAT
As a 16-year emergency medicine physician dedicated to improving and advancing geriatric acute care across the country, I’ve experienced first-hand the many challenges experienced by seniors and their families in times of crisis as outlined by Fan et al.
Despite the best efforts of many excellent hard-working ED physicians, nurses and medical personnel, emergency geriatric care is expensive, especially when it results in an admittance to the hospital, and often is not in accordance with patients’ end-of-care directives. And the health professionals aren’t to blame — too often, they don’t have access to a patient’s directive, and that’s a shame.
As a result, for many of these patients, geriatric emergency care involves an ongoing cycle of going to and from the person’s home, assisted living, nursing home, the ED, and in-patient hospitalization. Tragically, even though 80% of older Americans say they want to die at home, 60% of Americans die in the hospital.
Something must be done. Our country spends an exorbitant amount of money on acute unscheduled care of older adults. When that care does not markedly benefit the patient and/or is not aligned with the patient’s wishes, it does a grave disservice to the patient and their loved ones.
From both a patient and financial perspective, we need to look at holistic models of care. We need to bring care to the person, rather than the other way around. Telehealth, enhanced training, or a combination of these methods and technology enhanced models of care can help us keep our seniors out of EDs, receiving treatment in places they prefer.
Fan et al are certainly on the right track with their findings and should be widely acclaimed for going against the status quo in much of geriatric care. And they are not alone. The American Geriatrics Society, the American College of Emergency Physicians and other medical societies, in partnership with West Health and the John A. Hartford Foundation, have accredited 13 EDs for emergency geriatric care, meaning they have a template for staffing, equipment, education, policies and procedures, follow-up care and performance improvement measures as it applies specifically to the geriatric population.
Since formally launching the nationwide accreditation process earlier this year, more than 100 EDs have expressed interest and/or begun applications pending for this status. More information on these guidelines is available at: https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf and about geriatric ED accreditation at https://www.acep.org/geda/GEDA-Home/index.html. The goal is for these guidelines and protocols to set health care systems on the path to affordable quality care that, we hope, will become the norm, rather than the exception, in the next 5 -10 years.
Additionally, an incredibly important component of delivering care that is tailored to seniors’ unique needs is for clinicians to stress the importance of creating clear, advanced care, end-of-life directives and making the specific components known. To be frank, just writing ‘do not resuscitate’ on a piece of paper does not suffice. The directives should address specific components of what patients want and need, including where they want to receive their care. These directives have to be available to family members, caregivers and their physicians so all are aligned in treating the patient in a manner consistent with his or her wishes. I am looking forward to many more EDs making the journey to make their ED one that is delivering excellent care tailored to the unique needs of frail older adults, an incredibly fast-growing demographic in our nation. It’s what we should all expect and deserve as we continue to age.
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