Embedding Care in the ED: Liz Goldberg and Lauren Southerland

Eric 00:13

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:17

This is Alex Smith.

Eric 00:19

And Alex, we got a great topic today. I can’t believe we haven’t. We talked about palliative care in the emergency room. We haven’t really talked about integrating geriatrics or integrating specific programs in the emergency department for vulnerable older adults, but today we do. Alex, who do we have with us to talk about this subject?

Alex 00:39

Well, I talked to Liz at the Beeson meeting in D.C. a few months ago.

Eric 00:45

Liz who?

Alex 00:45

She was like, I haven’t been on the GeriPal Podcast. And I was like, you’re right. That is shocking, and you absolutely should be on the GeriPal Podcast. So I’m so glad to welcome Liz Goldberg, who is emergency medicine doctor and researcher and associate vice chair for research at the University of Colorado and past president of the Academy for Geriatric Emergency Medicine. Liz, welcome to the Geripal podcast.

Liz 01:12

Thanks so much for having me. Excited to be here.

Alex 01:14

And we are delighted to welcome Lauren Southerland, who is also an emergency medicine doctor and researcher and director for clinical research at the Ohio State University. Lauren, welcome to the GeriPal Podcast.

Lauren 01:28

Glad to be here with all of you.

Eric 01:30

So we got a lot to talk about about integrating programs in the emergency room for older adults. But before we go to that topic, Lauren, do you have the song request for Alex?

Liz 01:40

Actually, I do.

Eric 01:41

Oh, Liz has the song request. I should have wrote that down. What’s the song?

Liz 01:45

It is Gravity by John Mayer, and it’s because I love everything falls, prevention. And gravity is just. Yeah, it’s wicked.

Alex 01:54

Yeah, that’s.

Eric 01:55

Alex, you just did Gravity and Wicked, right?

Alex 01:58

What’s that? Last week we did Defying Gravity.

Liz 02:03

Awesome.

Eric 02:04

On a gravity kick. Here we are.

Alex 02:07

All right, here’s a little bit.

Alex 02:21

(singing)

Alex 03:50

I could just keep singing on and on. I love that song. Great choice, Liz.

Eric 03:57

All right, Liz, I’m starting off with you. What got you interested in older Adults in the emergency room integrating geriatric principles. Like, where did this come from?

Liz 04:08

Yeah, happy to tell my origin story. I worked at a busy level one trauma center in residency, and we did these 24 hour shifts that were pretty grueling on the trauma service where we saw all the ED patients that came in for serious injuries. And one thing that irked me as a. As a resident on that service was we would see so many patients come in with falls, and it felt like there was so much variation in care. Sometimes we would admit them for maybe this was syncope.

Sometimes they were discharged. We almost never figured out what their etiology was for their fall. And then we would see them back. But next time I was on call, it was like a 72 hour call situation or 24 hours, and I’d be back on 72 hours later. And I was like, we need to do something about this. So I walked up to our case managers and said, you know, what do you think we need to do for these false patients? And they had just done this audit, and they had learned that they really needed PT services in the ed. And that would be so helpful because we would be able to identify functional impairment and lower extremity strength issues.

And so I dreamed up this study that involved having patients that come to the ED for a fall, seeing both a physical therapist to kind of address those things that I’ve listed, and then a pharmacist to look at polypharmacy and fall risk increasing medications. And like, lo and behold, the intervention worked. We were able to reduce recurrent EV visits for falls by 66%. And that was one of our first, and actually it was the largest US trial to date in falls prevention that was randomized. And we recognized it was really valuable to have PTs and pharmacists in the ED to help us with these older kind of complex patients. And since then, I think we’ve just seen a huge uptick in embedding services in the ED for these vulnerable older adults.

Eric 05:58

And it had a catchy title. If I. What was the catchy title?

Liz 06:02

It’s GAP Care.

Eric 06:04

GAP Care. What does GAP Care stand for?

Liz 06:06

It stands for the Geriatric Acute and Post acute Fall prevention program. And not post acute like SNF Care, but really thinking about if we can help with their transition of care out of the ED back into the community, give them a good false prevention plan, then they won’t have to come back.

Eric 06:24

Okay, I want to go back to GAP Care, but I want to hear a little bit more origin story. Because I want to hear Lauren’s origin story.

Lauren 06:32

My true origin story was I was in college, wasn’t going into medicine, and was sitting next to a friend who was super smart. And he said, I just took the MCAT this weekend. I’m exhausted. And I said, you’re like this amazing physicist. Why’d you take the mcat? And he said, because I looked at my professor and thought, I don’t ever want to be that guy. And so I looked up and thought, I don’t want to be a pure researcher either. I want to be around people.

So I got into medicine, and then I found that the people that the patients that no one else cares for are the older adults. I really take more of a systematic approach to it, looking at how we provide acute care to all our patients, which works very well. You know, if you’re 30 years old and you need your appendix out, the ER is fantastic at that. But if you are 70 and you’re feeling weak or you’re not sure if it’s a medication or what’s going on, these patients sit in the lobby for eight to 10 hours. They miss doses of their home medications. We have a lot of areas we need to improve on their care.

And the ER can actually cause more harm than good sometimes for them. So my work is focused on how do we create an ER environment that provides the care these patients need when they need it. Because they definitely need the ER a lot. They need that acute care.

Eric 07:54

Yeah. How much, like in your daily life, how much of. Is it, is it that acute care, like, you’re, you’re seeing people in the emergency room that have like, new pneumothorax, pneumonia, Michigan stroke, trauma, versus more like they kind of need a really good primary care provider, a home based primary care or a social worker or man, if they just saw a physical therapist and a pharmacist two weeks ago, everything would have been fixed.

Lauren 08:23

Yeah, I think. And Liz can chime in on this too. I think we see the whole range of patients. We see those who have excellent care, good social support. They have resources for their medications and things, and a great primary care doctor. And maybe they’re coming to ER because their cancer’s worse and now they’re vomiting or something else that could not have been prevented. But I also see a patient, a shift, who’s an older adult who has a lot of comorbidities and is very socioeconomically vulnerable.

Maybe they’re unhoused. Maybe they have no social support or family caring for them. Maybe, um, they have alcohol use disorder. And we’re like, oh, they’re just drunk. Send them back on the street. That was, I was working on a patient the other day. Like the sign out was, he’s drunk. When he sobers up, send him back home. I’m like, okay, but he’s unhoused. He’s like, yeah, social worker will get him a, you know, lift somewhere. And I said, well, look at this person is older than 60s, they’re an older adult, they’re using the ER very frequently. That’s almost always either a mental health problem, a substance abuse problem, or cognitive impairment problem.

And we searched his chart and he’d never had any cognitive testing. So when he sobered up, we do a cognitive out and this person had, you know, severe dementia or some sort of cognitive impairment, probably from long term substance abuse. There was no way they could get to housing on their own or remember what you said. And so they needed to be admitted for legal guardianship. And that would have been missed if we didn’t, if I didn’t have a bigger viewpoint on what are the needs of these vulnerable older patients.

Liz 09:58

Eric, to your point, there’s at least one, two, sometimes like half of the patients in your shift that need that look that Lauren is talking about of someone that hopefully has additional qualifications beyond what we’re trained in, emergency medicine, residency training, to expertly help handle these acute issues. But to dig a little further, talk to a care partner, engage some of these embedded services and then, then you can stop this cycle of folks coming back in over and over again. And we don’t always have that cognitive bandwidth or really the time or even the beds to do that.

But the ideal care would represent doing what Lauren did, thinking a little bit more about, well, what, you know, if this person is coming back, that should trigger, like what I teach the residents is if this is a bounce back, if this is someone that has recently been in the ED and has gotten the same care that you provide today, who in their right mind would think that they wouldn’t come right back and do exactly what happened last time? So it’s about stopping that cycle and getting the patient what truly they need that they may not even be able to express.

Eric 11:09

How do you think we, we do that? Like, I just look back to my days when I was like ward attending. I was a terrible palliative care doctor despite actually have being a palliative care doctor at the time. When I’m on palliative care service, I thought it was pretty good. But when I’m ward Attending. I got everything else that I’m trying to do that it’s so hard to find the time to do what I usually have on the palliative care service or even, like, on the geriatric consult service. Does that seem like similar in the. In the ED for you? And if so, like, what’s the solution there?

Liz 11:45

Yeah. So I think we’re. We’re at the point where we’re finding those solutions, and it is these multidisciplinary care teams. It is not making that ED doctor be the only one thinking about these issues.

Eric 11:58

Do better ED doctor.

Liz 12:01

Exactly. It’s. I mean, ideally it would be doing what Lauren described in her manuscript of, like, there’s people that are really good at figuring out social services for folks. It’s not the ED doc. It’s probably not the ED nurse that is carrying six patients at the same time and treating someone with sepsis and stroke. It. You really need to sometimes pull in this additional expertise if you want to stop that cycle.

Eric 12:27

Lauren, tell me about this manuscript.

Lauren 12:30

Why, yes, sir, I will tell you about my research. I think what Liz has identified is that the emergency department is run incredibly leanly. We do not have any extra capacity in our staff. We’re often understaffed. You often don’t have enough nurses or techs. Asking people to do more is difficult. It also isn’t an even flow. So, yes, you might know that a patient, hey, this patient probably needs a full hospice and palliative care discussion. You know, the last hospice discussion I had was at the front door of the ER as the patient and their family were walking out from the waiting room because they’d waited too long.

And so I had to chase after them and tell them that their triage X ray showed worsening cancer and discuss like, hey, I’m really worried about how you function at home. They said, well, we know she’s going to die. We’ll just bring her home to die. Like, okay, well, let’s get hospice involved. And so I’m doing this at. At the front door of the er. Not the right place, not the right person. We need more capacity. And the way to bring in that capacity is to ask your administration to hire more staff. No, I’m joking. We know that’s a lie. No one’s getting more staff. So what do we do? We have to leverage what we have and make it so that these patients are a priority because we know that if we start interventions from the emergency department, we reduce those downstream falls re ER visits, re hospitalizations.

And we know we reduce the hospital rate. So if anybody’s at a hospital that’s always operating at or over capacity and aborting patients in the emergency department, these are the kind of mentions they can look at to stop this cycle and help these patients. So we’ve done several things. Bringing physical therapists down to assess people in the emergency department rather than waiting for them to be admitted and seeing them a day or two later. Front loading. Those types of evaluations can be incredibly helpful. And sometimes they can avoid the admission altogether. Another project we did at OSU was partnering with our county Office on Aging. What we found was that our hospital case managers and most emergency departments have hospital case managers already, would see a patient say, oh, you know, you would qualify for these county services.

You might do better if we had some home delivered meals, people checking on you, a county case manager. And so the person would agree, I really need this stuff. And the case manager would send their name and contact information to the county. Done. Hospital evaluation complete, we solved the problem. Except then the county would get it, try to call them back a couple of days later. Do they answer their phone?

Alex 15:13

No. Maybe.

Lauren 15:15

Maybe. Probably not. Right? It’s an unknown.

Eric 15:17

Nobody answers their phone number from an unidentified number anymore.

Liz 15:21

Yeah.

Lauren 15:22

And so we would put in all these referrals and they would go nowhere. So what we did, instead of the hospital case management team doing one thing and the county doing the other thing, we connected them and we actually took county case managers from where they were sitting in their office downtown and have them sit in the er. So now they go to the patient’s room, see them immediately, sign them up for services, and it’s worked amazingly well.

Alex 15:46

So they sign them up for services on the spot in the emergency department.

Lauren 15:51

Yeah.

Eric 15:51

Like, can you give me some examples? Like what services?

Lauren 15:55

Sure. So our, we’re a big county with Columbus is the state capital. And so our county has a lot of older adult services. They will do medical or non medical transport, home delivered meals, they’ll help with utility payments. Like if they’re behind on their utility payments. The number of patients I have who, who I finally figure out that their water and electricity has been shut off and they’re trying to live through that is too high to tell you.

And they can also tell us if somebody already has a case manager or has an open adult protective services referral or how we can advance things. So one case we had was an older man who kept coming to the ER and he had cancer and he was always malnourished and cachectic and then he’d be in the hospital for a few days and they would tank all the fluids and he’d go back home. Well, he had dementia and he wasn’t living with anybody and he would forget that he had meals in the house or he would worry he was going to run out of food.

So instead of eating his Meals on Wheels, he would hoard them and not eat anything and then call 91 1. So the county case manager said, well, we have him on weekly delivery. Why don’t we change him to daily? So someone comes to his house daily, helps him prep a meal and eats with him. So he’s eating every day. Stop the ER visits.

Alex 17:12

Yeah. And your article in JAGS has all of these great, like five case examples in a row that really help clarify for readers. Like, this is how this can be useful in this real world clinical scenario. I also say it has great figures, as does the editorial by Liz Goldberg and colleagues. Lauren, I wanted to ask you though, how on earth did you get these area resource aging on Aging people to come to the emergency department to leave their desks in their office to get into the emergency department? Because that seems like monumental.

Lauren 17:50

Yeah, it was. I had been working with their team for a long time. Every county in Ohio has an interdisciplinary elder protection team. So we meet monthly with, I’m the medical representative and we also people from legal, from police, from different social services who’ll bring up cases. So it’s, it’s really neat and it’s gotten me a chance to see how care outside the hospital happens. I mean, we feel like we do everything, we do everything for the patient. We’re so good, but actually we do such a minuscule amount of their care. And what these other community services are doing is providing so much more day to day support and keeping these people healthier than any medication change I’ve done from the hospital or er.

Eric 18:33

I can also imagine though, and I think you wrote about this in the JAGS piece, which we will have links to both the editorial and the article on the show notes. But how did the hospital administration feel about this? Because like they’re not privileged to do stuff in the hospital. These, these individuals. Right?

Alex 18:52

Yeah.

Lauren 18:53

We had to be very careful to say that they are not providing clinical care. And initially I wanted to get them electronic health record access so they could look and give us lists of like, oh, these people already have services, these people don’t have services. But that was, that was not allowed. So we had to be very clear about what’s our hospital case management and social Work team’s job and what’s the county care manager’s job?

Eric 19:20

And Liz, when you read this article, cause right. You wrote, wrote the editorial, did this surprise you? Did you say, oh my God, this is great. Like, how did you think about this and is it applicable elsewhere? Like, can you imagine doing it in Colorado?

Liz 19:33

Yeah. I mean, first of all, it’s a major, major implementation feat. One thing you should know about Lauren is she’s this incredible dissemination implementation scientist. And I think her knowledge in that area and in frameworks and how to bring teams together and what types of parties she would need to engage and strategies are part of the reason that this, a large part of the reason that this was successful. I think that’s where a lot of these programs fail, is that you need a champion that is going to be doggedly pursuing this for their patients, regardless of the barriers and challenges you run into. And one of those things is, yeah, you’re bringing an insider into a hospital.

For us, that seems really simple. Here’s your chair in the ed. Please, you know, have a seat. But there’s so many like regulatory legal processes that go into play and we’ve met those too. Not only with kind of funding. Like for instance, we have a social work embedded program here at UC Health and part of their funding comes from outside county funds. So just to come from clinical revenue per se. And just working through those challenges can be pretty significant, especially in health systems where they’re academic affiliated, but the university sits on one side and the health system sits on the other side. So Lauren did a really nice job of describing sort of overcoming the hurdles that were, that were there.

But I do think every ED can do this. When I showed up here in Colorado, I moved about three years ago. I found out that community eds that were part of our health system in our north region were running a version of GabCare where they were having PTs and pharmacists see every falls patient on their own. They had read my manuscript and they had started the program. It was an emim doc that just had read this, thought it was great and started it had a dashboard and it was the most amazing moment when I moved here and I was like, oh, we can do this in the community. And this champion, who’s really a clinician doesn’t get any academic buy down was like had bought into it and had put together this multidisciplinary group and they had started it.

And this is sort of what I love about emergency medicine is that. And I think we see this in other Specialties as well. But people just realize to do the right thing for our patients, sometimes it takes more than just showing up for your shift. It takes like, listening to what their concerns are, where the social needs are, where the other needs are, and convincing hospital leadership, convincing outside community partners, convincing your own colleagues that this is the right idea, and then measuring it and hopefully sharing that with others.

So I think that’s the model that we’ve been seeing in emergency medicine for the last 10 years with these embedded programs. And I’m just incredibly proud that we’re able to launch these things. And Lauren’s perfect example of that.

Eric 22:26

And can I ask you. So I. Because I said I’d go back to gap care, I just want to clarify. So you have an older adult who comes in the emergency room with a fall. Does that like auto trigger, a physical therapist and a pharmacist to see that person, or is that.

Liz 22:43

Yeah, so initially we did as a pilot. So our research staff would call the pts, would call the pharmacists. But the way that it’s running now within UC Health, thanks to our champion, Bucky Ferozin, who’s a ED doc up north, is that they just have an automatic trigger when that chief complaint comes up for PT and pharmacy to see that patient, and the ED doc gets an OPA or a notice in their epic, and they can say, you know, this is not the appropriate patient to get pt, pharmacy, maybe, because that patient’s going to get admitted and then they can get those services upstairs.

We’re really looking at helping people that are going to be discharged and going back to the community. And same thing with, if they’re coming from a nursing home. They’re not great candidates for this. But, yeah, it’s an automatic trigger. And then it’s a standardized workup that the pharmacists and the PTs do.

Alex 23:34

And can you say the outcomes one more time?

Liz 23:37

Yes. So in our pilot trial, which was done at two EDs, one community, one academic, we saw that there was a 66% decrease in ED visits for falls within six months. And we also saw significant reductions in related hospitalizations in our second trial, which. Which we’re concluding now. So it looks like we’re preventing serious falls, but also, you know, any falls that are bringing folks to the ed. And it’s because we’re identifying reasons for that fall that the patient didn’t even know.

Like the amount of times that we’ve talked to the patient about their medications and found out they have two different prescribers, both which are prescribing pain medications or benzodiazepines and pain medications that’s causing falls, or the amount of patients that PT has walked and like, noticed that they have Parkinson’s features. And we’ve been able to get them, you know, the diagnosis they need. Once you start to see the results, you become such a believer in the fact that we can do this feasibly in the ED and it’s the right thing to do for patients.

Alex 24:38

That’s great. And we don’t have a link to the newer non pilot data study yet because that’s not yet published, though we can add that later. If Liz, you send it to us once it is published, we can put it. Add it to the show notes. But Liz, falls have been so hard to move the needle on. Like, I’m sure you’re familiar with stride study.

Liz 24:57

Yes.

Alex 24:58

We had a podcast with Tom Gill about that. And it’s just so hard to move the needle. Maybe the emergency department is the best place to begin this or one key location to begin this intervention. You think that might be the major insight from your trial?

Liz 25:16

I think that’s the question.

Lauren 25:17

Right.

Liz 25:17

With all of these, with all these services we offer in the ad, we’re like, acutely aware that there might be actually a better setting to get those in. But the question is, does the patient actually make it to that better setting? And in falls, what we know is that only one in four older adults actually report that they’ve had a fall to their primary care doctor in their annual wellness visit. So there’s this great study by Hoffman et al that showed that they’re just not reporting it, maybe due to stigma, maybe they’ve forgotten.

And so all these valuable prevention opportunities are being missed. So the idea is, while we have them in the ed, while they’re actually engaged about, like, why did this happen? And I never want this to happen again. What can I do to prevent it? That’s when we can do these brief interventions with some, you know, really actionable recommendations like use your walker correctly or it turns out that you have a real mobility issue that we need to start working on. Let’s get you some outpatient PT or home PT if you’re homebound.

Alex 26:16

Yeah, that’s a big contrast.

Liz 26:17

ED is only place to do it. But I think it’s not happening elsewhere because people have challenges getting to other appointments. They already have 10 specialists that, that are carrying for them and they don’t, you know, they can’t make it to, to another visit. So that’s what we’ve seen a lot of these falls trials is that it just required a lot of momentum from that individual patient to, to get places and do things and coordinate and that’s where folks fall through the cracks.

Alex 26:45

Yeah, yeah. And you’re seeing the people who are most likely to benefit who not only have fallen, this is an injurious fall. This has precipitated an emergency department visit. Like this is serious and like you said, they’re motivated to change. Very different from the outpatient setting where you might ask, like, have you fallen? Oh, yeah, I think maybe a while back I fell and then. Okay, you’re not as motivated. You know, maybe it wasn’t an injurious fall.

And stride was able to reduce, as I recall, non injurious falls, like overall any fall, but not injurious falls. So it’s interesting that your study, you’re reducing not only falls, but falls that result in ED visits and hospitalizations. That’s terrific.

Liz 27:24

Yeah.

Alex 27:25

And I know Eric, you got a question?

Liz 27:26

I work in falls too, so I wanted to give her a chance to.

Alex 27:29

Oh yeah, Lauren.

Lauren 27:31

Well, I think what Liz has done is very impactful and I think it highlights that. The ED visit is what you were just saying, Alex. It’s a teachable moment. It’s a moment when they’re scared that something’s bad has happened and so we can leverage that fear between them and the family and have a true falls discussion. I have an extensive family with many older adults and none of them will admit to having actually fallen or be at falls, except for my mother in law who broke her arm falling so she couldn’t avoid that one.

But I think we also know that if they see the physical therapist in the ED and get things started, they’re more likely to follow up with them. And that’s anecdotal, but we do have very low follow up rates with physical therapy. If we just put in a referral.

Alex 28:16

Yeah.

Lauren 28:16

And I think there might be some bias against physical therapy in the older adult population because a lot of the people see it as painful or uncomfortable or you know, oh, you gotta go so many times and you even get better. So having that moment where they realize, oh, this is not just for pain, this is. They help with symptom control, definitely with injuries, but also with teaching and they can teach me ways to prevent this from happening. A lot of people are very receptive to that.

Eric 28:42

Yeah, I see a lot of therapeutic nihilists. Ah, physical therapy doesn’t. Won’t do anything until they actually start Working with physical therapy and then, hey, it’s doing something.

Alex 28:53

So should everything be in the emergency department? Because it sounds like everything’s better in the emergency.

Eric 28:59

If you can give all of our care to the emergency department.

Liz 29:02

This is a tough time to ask that, Alex. We’re dealing with this crazy influenza strain and just boarding. So the amount of inpatients that are currently boarding in our ED hallways, boarding in our beds, emergency medicine is really at a critical point. And so I think Lauren and I, as like these geriatric champions, we have these discussions all the time with our colleagues about what more can we possibly do for ready, treating strokes, heart attacks, seeing people that have no health insurance and trying to, you know, do our best by them, see people with all these social needs. So I think, you know, there’s, there’s limits on what we can do and yet some of these programs are effective.

So how can you not do them? And I keep coming back to that, I keep coming back to the patients that I know that we’ve helped and, and you know, we’ve done exit interviews with folks in our intervention and hearing, hearing from some of the folks that have been like, in our control arm and haven’t gotten that support and come home and they have, you know, they have a new humerus fracture. They are already walking with a walker. They are scared to go outside now because they have fear of falling and thinking, oh, you know, all we’re doing is X rays and CTs, and in this short, like four hour encounter, it’s real. It can be hard to do, do more than that. But if we, if we can bring in these professionals, we could really make a difference.

Lauren 30:27

I agree with that.

Alex 30:27

I think, yeah, the limits here, like, how far can we go? Can we get everything in there? What pushback have you had about this, like from the administration or from others?

Lauren 30:37

So I think that we can show that bringing these interdisciplinary teams to the emergency department and starting the evaluations there helps the health system. It does avoid admissions, it does avoid readmissions, it can increase ER length of stay. So if that’s a concern, then that can be addressed. When we originally started our program of multidisciplinary geriatric assessment in the emergency department, we ran it out of our OBS unit and that way people didn’t have concerns because they said, okay, we’ll put them in, they can stay overnight and see pt, ot, geriatrics, case management, the pharmacist. And it’s not, it’s not our E.D. length of stay. Yeah, that’s going to be affected.

Alex 31:20

But you in your case, the first case you mentioned where the patient had dementia who had been readmitted. Readmitted and they got admitted to the hospital for guardianship, like assigning conservator, which is in California where we are, that’s like a months long process. And now that patient is in the hospital for months at a time, which is the right thing to do and also incredibly expensive for the hospital if now you are uncovering cases such as this that fill up the hospital.

Lauren 31:51

So when I proposed the county case manager program, that was one of my hospital administrators questioned, you’re going to fill up my hospital with patients that need placement and need support?

Liz 32:02

Yeah.

Lauren 32:02

And so we said okay, well let’s try it and we’ll track it. And I think it’s off balance. We do identify some of these patients, but we also have systems in place to help them, including geriatric consultants, Python Medicine consultants and Ohio State partners with the county. They have a guardian services board. So a lot of those patients who would in the past wait honestly six months to get a legal guardian placed are now getting a legal guardian within three to six weeks, which is amazing.

Alex 32:38

So wow, that’s great.

Lauren 32:40

And that, yeah, that’s something that other large counties can do too.

Liz 32:45

One other argument that we’ve made for these types of programs is that sometimes while you do increase ED length of stay, like if you, especially if you look at ED and observation care at the same time, when you front load this care in the ED or in the observation unit, you see less admissions overall and more eventual discharges and things just happen more rapidly.

For us at least here at UC Health when we place them in the observation unit and we have daily rounding of our case managers, PTs and OTs and we have specific geriatric order sets for those patients, we find that yes, compared to previously, those patients are have a longer ED length of stay, but then it cuts off two or three days of their hospitalization because we get them direct in directly into SNF or into home care or into palliative care or into hospice directly from our observation unit instead of bringing them into the hospital and working this out over a series of days.

So we have a specific no medical need for admission pathway within our ED here at UC Health. And so folks that were previously just admitted as a social admit like we couldn’t arrange their a safe discharge for them after a three or four hour ED stay, we instead now put them into the observation unit, bring in this multidisciplinary team and we’re way more successful at getting them what they need so they can go safely to home or to snf.

Alex 34:10

Erica, let me ask one more question on this while we’re on this thread. Liz, in your article you wrote, in your editorial that accompanied Lauren’s paper in Jags, you wrote about a concern about dumping and I wonder if you could explain for our listeners what that is and whether that’s a real world concern or more of a theoretical concern.

Liz 34:29

Yeah, and Lauren touched on this in her article too. But it’s, you know, it’s this perception by often the hospital administration but also other clinicians that once you create these studies suite of services that are really easy to access, patients just need to drop in whenever they want to the ED. Right.

They come at 11pm if they want. Then maybe folks catch on at other hospitals and in the community and then they start coming in on purpose to the ED because they know it’s way easier to arrange if I go to the ED than to see my PCP or to go to this other hospital. I don’t really know what to say about that. I can’t imagine that too many of our patients are like, I want to go to the emergency department now because it’s so comfortable and fun and, and.

Alex 35:20

There’S a five hour wait and filled with people with influenza.

Liz 35:23

Yes, and filled with people with influenza. So I have a hard time totally believing in that argument. But I have heard it. It’s out there. I don’t know what Lauren thinks.

Lauren 35:33

I also don’t think there are a bunch of 85 year olds on Reddit saying, hey, go to OSU. You can’t believe the care I got if are thank you but hasn’t been an issue so far. I think one of our main issues is really doing better education on capacity, on social vulnerabilities for older adult patients because I see a lot of them going to other hospitals and I’ve, I’ve had people come to with notes or being told that, well, that hospital won’t do capacity assessments or they won’t do legal guardianship or they refuse to do this and they, they shouldn’t. Every hospital has the capability of doing all.

Eric 36:13

How different is this from like geriatric EDs or is this the same?

Lauren 36:20

So the whole concept of a geriatric ED is still pretty nebulous. It’s basically saying an emergency department that focuses on the different psychosocial and medical needs of older adults and they can do it in different ways. So you know, as Liz described the program in Some of our community hospitals with pharmacists and physical therapists, therapists and case managers, that’s a geriatric ED program or a geriatric ED intervention. Typically they’ll involve multidisciplinary staff, they’ll involve medication management, but every one is slightly different, which makes it very hard to collate all the outcomes together. If you’re considering doing meta analysis on the topic.

Eric 37:04

But there’s no like, certification for, like, you have to meet, like.

Alex 37:08

But I think there is. There is different levels. There’s like silver tier and bronze tier. Gold tier, Exactly.

Liz 37:15

So the American College of Emergency physicians started certifying EDS as geriatric EDS, and I believe it was in 2019. And you had specific criteria that were in the bronze column. Silver or gold? Gold is like, you do everything. You make environmental changes to the ed. Non slip floors, grab bars, you have walkers to give out. And you also do these types of interventions like gap care or like Lauren’s embedded Social services. But every geriatric AD can choose among sort of a menu of different geriatric initiatives.

They do want a physician and a nurse that are really great educators and champions in that area. It does cost some money for hospitals to get this certification. So some hospitals will do all the geriatric things but won’t go through a certification because of that cost or because maybe there’s not a lot of health care competition. So they don’t really value putting that bronze badge out in front of their door. But many have gone through with that because they want to signal to patients in the community like, we’re here for you. We actually have specialized care for you. But you’ve seen one geriatric ED and you’ve seen one geriatric ed. They’re all different.

Eric 38:27

I’m wondering, are there other programs that you see either around the US or internationally, that you think, wow, like, these are other really good examples of embedding into emergency department to improve the care of older adults.

Liz 38:42

Yeah.

Lauren 38:43

So I was very fortunate to spend four months in Australia last year on a Fulbright award to Sydney, where I interviewed people from emergency departments all over Queensland and New South Wales. So those are two of the big territories. And learned what they were doing, which in many ways are far more advanced than what we’re doing for older patients here. Every single examples. Yeah, every single ED has a geriatric nurse who will help coordinate care. Many of them have whole interdisciplinary teams.

I talked to one, one nurse out in this very rural, middle of the bush, tiny hospital, and she coordinated care for all the older adult patients, you know, knows everybody in the community, would go out and see them in the nursing home or at their home after their ER visit and check on them, would arrange any social services they need. And if the patient comes into the er, they will call the nursing facility or they’re from, get collateral from the family, make sure we’re addressing all the families and nursing facilities needs as well.

Eric 39:51

Is this because, like, everybody thought, hey, this is really good care. Is there like a national or mandate, like, to. To do this type of care?

Lauren 39:59

It was. So a group led by EJ Morrison in Brisbane did a pilot and said, hey, this really improves care. And so the government, remember they have a national health system, said, okay, well, then let’s do it everywhere. So they give every ED money to hire and start these programs. And, and we’re talking to trainees, so residents, emergency medicine residents and faculty. I would say, you know, so what would you do if the nurse is not there?

And they’d say, oh, well, we keep them till the morning, till the nursing team is there and can help us with all this stuff. I was like, you don’t just, you know, in the us, most hospitals don’t have these nurses and you just send them home. How would you do that? They wouldn’t have everything they need. So it was amazing to see over just five or so years of having these care teams in every er, how the culture has changed to recognize how important they are.

Eric 40:54

Liz, any examples from your perspective?

Liz 40:57

Yeah, I. I mean, I spent a lot of my childhood in, in Germany and then I did medical school in Israel, which were both, you know, had universal healthcare. And I will say, like, just reading over manuscripts from other countries, there’s some really, really great work being done for our older adults. Wraparound services seem to be more robust in these countries where there’s universal health care, where let’s fee for service, which makes a lot of sense to me.

And so when I read, when I read those studies, when I review those studies, it does make me, you know, hope that we can inch towards that with some of these programs that are being initiated just because it’s the right thing for patients, but might not be well reimbursed at this point in time. So I think we have a long way to go.

Alex 41:44

Yeah, okay.

Eric 41:45

I know we got a long way to go. Oh, go ahead.

Lauren 41:48

It gives us hope. Because when I talk to people and say, oh, there’s no way my hospital will ever do that, or that’s way too hard. This is just routine care in many Places around the world. We’re the ones that are behind.

Eric 42:00

So let me ask you this, because my backup plan is I’m applying for a German citizenship, but just in case my backup plan fails.

Alex 42:07

It’s true, dear.

Eric 42:08

It is true.

Alex 42:09

He actually is doing that.

Eric 42:11

Like, if you had a magic wand to make one change, to get closer to kind of what you think the gold standard is, what would you use that magic wand on to change the care for these older adults?

Lauren 42:25

Lauren, I think a way that we are headed towards disaster is our lack of home health care and home caregiving support. So if I could change something, I would change that because then I would know when I send my patients back home, they would still get the care that they need.

Liz 42:42

Yeah.

Alex 42:43

And it’s that daily sort of care with activities of daily living that home healthcare would provide.

Liz 42:47

Yeah.

Eric 42:48

Thanks, Liz.

Liz 42:49

I would try to break down the silos between some of these really fantastic community programs that are out there and health systems so that if we identify risks in the ed, fall risk or other social risks, social deterrence of health, it would be much easier to clearly communicate with those programs, link those people directly to those programs and make some of this happen. That hasn’t been able to happen in the. In the outpatient setting. But in the meantime, we’ll continue our work in the ed.

Alex 43:19

But can I ask another question? Have you seen the Pit?

Liz 43:23

Yes.

Alex 43:24

Yes. Okay. How would you rate the quality of the Pit in terms of depiction of older adults, people with serious illness, the interactions they have?

Eric 43:34

What color are they on the Jerry? Bariatric? ED Bronze.

Alex 43:40

Yeah.

Liz 43:40

I think the Pit is very realistic in terms of what you may see in the typical ED in the United States and.

Eric 43:50

Yeah, but no med student is doing what they’re doing on the pitch.

Liz 43:54

No, that’s it. I. I think the procedures are pretty awesome and they’re more few. They’re few and far between the show, but it’s otherwise really realistic. It’s depiction.

Eric 44:05

All right, Lauren, you agree with that one?

Lauren 44:08

I honestly haven’t seen it yet, so.

Alex 44:11

I’ve only watched a few episodes, but I was impressed. I did hear that they actually consulted with some, like, experts in geriatrics and palliative care. Community. Have you heard that too?

Liz 44:20

I didn’t hear that. I knew they had. They have good ED docs advising them.

Alex 44:24

Yeah.

Eric 44:26

Okay, Alex, bring us home with some gravity.

Alex 44:28

All right, here’s a little more. Let’s see if I can stop playing. I’ll cut you off twice as much.

Speaker 5 44:37

Ain’T twice as good, and can’t sustain like one half could it’s wanting more that’s gonna send me to my knees.

Speaker 5 44:57

Gravity or stay the hell away from me

Speaker 5 45:07

oh, gravity is taking better men than me how can that be? Just keep me where the light is Just keep me where the light is Keep me where the light is.

Liz 45:32

Come.

Speaker 5 45:32

On Keep me where the light is Come on Keep me where the light is Come on Keep me where the light is Is.

Eric 45:54

Lovely. Laura and Liz, thanks for being on this podcast.

Liz 45:58

Thank you so much for having us.

Lauren 46:00

Yeah.

Eric 46:01

And we will have links to all the articles we talked about in our show notes and thank you listeners for your continued support.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/