nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum 1

Older and Wiser . . .

Improving Care of Geriatric Patients

in the Emergency Department

Jeannie Burnie, MS, APRN, CEN, ACNS-BC

Nancy Doolittle, DNP, MBA, MSN, RN, NE-BC

Description of Clinical Problem

• 30% of Bethesda North’s 53,205 ED visits are patients 65 years

and older

• Of these, 61% are aged 75+ years

• 40% are admitted

• 21% return to the ED or are readmitted within 30 days

• For the 60% discharged, no formal process for coordination of

care occurred

Description and Scope of the Problem

• Aging of population and demographic shift creates:

– Increased challenges with complexities of providing

quality, patient-centered care

– Challenges to decrease readmissions

– Challenges to identify those

most at risk and better

coordinate care

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PICO

• With discharged geriatric emergency department

patients, does the implementation of a Geriatric Care

Coordination Team, compared to no Geriatric Care

Coordination Team, improve coordination of care,

decrease readmissions and return ED visits (who

return less than 30 days after ED discharge), and

improve patient satisfaction

Review of Literature

• Systematic reviews:

Hansen, Young, Hinami, Leung, and Williams (2011)

Rennke, Nguyen, Shoeb,Magan, Wachter, and Ranji (2013)

• Categorized interventions:

– Pre-discharge interventions

– Post-discharge interventions

– Bridging strategies

Review of Literature• A systematic review by Hastings and Heflin (2005)

• Interventions to improve outcomes include:

– Telephone follow-up

– Specially trained nurse/team in the ED

– Completion of comprehensive geriatric assessment

and risk screening

– Care Coordination Team

– Staff educational programs

– Home-based services

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Review of Literature• Randomized controlled trial by Saleh, Freire, Morris-

Dickinson, and Shannon (2012)

• Post-discharge transition program includes:

– Patient-centered health record

– Structured discharge preparation checklist

– Delivery of patient self-activation and management

sessions

– Follow-up appointments

– Coordination of data flow

Review of Literature

• Randomized controlled Trials:

• Koehler, Richter, Youngblood, Cohen, Prengler, Cheng,

and Masica (2009)

- Medication counseling

- Medication reconciliation

- Condition specific education

- Enhanced discharge planning

- Phone follow-up

Review of Literature

• Legrain, Tubach, Bonnet-Zamponi, Lemaire, Aquino,

Paillaud, Taillandier-Heriche, Thomas, Verny, Pasquet,

Moutet, Lieberherr, and Lacaille (2011)

- Medication review

- Education for self management

- Transition of care

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GAP Analysis

• Lack of multidisciplinary care approach

• No care coordination for discharged patients

• No geriatric risk identification

• Inconsistent pre-discharge, bridging, and

post-discharge interventions

Project Goals and Objectives

• Incorporate Triage Risk Screening Tool

• Implement a Geriatric Care Coordination Team (GCCT)

• Educate staff about GCCT and referral paths

• Increase geriatric care coordination/referrals

• Improve geriatric patient satisfaction

Project Team

• ED Nursing Director

• ED CNS Educator

• ED Medical Chairman

• Geriatric Social Work Navigator(s)

• ED Geriatric Resource Nurse(s)

• ED Pharmacist

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Methods/Metrics

• Step 1: SWOT Analysis

• Step 2: Fishbone Diagram

• Step 3: Team Member Analysis

• Step 4: Stakeholder Analysis

• Step 5: Triage Risk Screening Tool

• Step 6: Implementation of Care

Coordination Team

• Step 7: Audit Tool

Triage Risk Screening Tool (TRST)

• Identify risk of functional decline

• Risk of hospitalization

• Return to Emergency Department or Inpatient Admission

• Need for additional services

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Geriatric Care Coordination Team• Care coordination for patients

• Pre-discharge interventions

• Post-discharge interventions

• Bridging interventions

Outcomes/Metrics

• Number of care coordination referrals

• Readmission rates and return visit rates within 30 days of ED

discharge

• Geriatric patient satisfaction

Implementation Process

• Pre-discharge

• Bridging

• Post-discharge

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Pre-Discharge

• Triage Risk Screening Tool (TRST)

• Discharge planning

• Medication counseling

• Medication reconciliation

• Patient education

• Scheduling follow-up

appointments

Polypharmacy

• Defined as five or more medications

• Accidental overdose

• Medication counseling

• Medication reconciliation

Bridging• Transitioning

• Coordination of care

• Patient-centered discharge

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Follow-up

• Scheduling appointments

• Arranging transportation

Follow-up

• Follow-up telephone calls

• Post-discharge home visits

• Timely follow-up appointments

Implementation Barriers

• Challenging to educate all team members and effectively gain

buy-in

• Change is difficult and culture change very difficult

• Renovation delays and high ED volumes

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Discussion

February 2015 – May 2015 2014 2015 Variance

Inpatient Readmissions and return to ED visits for geriatric patients within 30 days of ED discharge (%) 20.37% 19.82% 0.55%

Overall geriatric patient satisfaction percentile ranking (%) 71.6% 86.5% 15%

Geriatric Care Coordination referrals (#) 0 1,868 1,868

Fiscal Year Data 2014 2015 Variance

Total # of discharged geriatric patients (#) 7633 8590 957

Outpatient follow-up visits within 14 days of ED discharge (#) 2,102 3,494 1,392

Outpatient follow-up visits within 14 days of ED discharge (%) 28% 41% 13%

Bethesda North Geriatric ED Project Summary - updated as 02/29/2016

July 2015-February 2016

Project Items FY 16 Year End Goal Updated 2/29/16

GNSW Consults 2424 2435

Community Resources Referrals 847 1065

Home Connections 21 28

Hospice Referrals 11 25

Home Care Referrals 14 44

Nursing Home Placements26

56 ROI= $96,448 ($1758 per OBV day saved)

Follow Up Phone Calls

438

Transportation Arrangements 128 72

ED Satisfaction on age 65 and up FY 14 76.7% FY 15 86.5% FY 14 76.7% FY 15 86.5%

Implications for Practice

• Better coordination of care demonstrated

• Impact upon inpatient readmissions

• Increased system revenue

• Increased geriatric patient satisfaction

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Questions

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