# ER's for the Elderly



## HotelCo (Mar 16, 2011)

> Many hospitals run emergency rooms just for children. Now a few are opening ERs specially designed for seniors, without all the confusion and clamor and with a little more comfort.


Full Article


Does your area have one of these?


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## usalsfyre (Mar 16, 2011)

It's looks like a Press Ganey driven attempt to grab Medicare dollars. There's value in training in geriatrics and looking further into complaints (field providers take note of this, you can be a critical link here) but to open an entirely separate ED for "less hustle and bussle", softer mattresses, hearing aids and large print forms? It sounds like a fad to me.


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## Aidey (Mar 16, 2011)

The first thing I thought when I read about this is that they are advocating doing stuff that the patient's primary MD should be doing.


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## Sasha (Mar 16, 2011)

usalsfyre said:


> It's looks like a Press Ganey driven attempt to grab Medicare dollars. There's value in training in geriatrics and looking further into complaints (field providers take note of this, you can be a critical link here) but to open an entirely separate ED for "less hustle and bussle", softer mattresses, hearing aids and large print forms? It sounds like a fad to me.



That's kind of funny, we often ARE a critical link, but sometimes the chain ends there. The nurses dismiss you "Yeah.. they were sent out for abnormal labs but here's what I also found." they roll their eyes as "Yeah yeah stupid IFT people getting excited over nothing." and then complain that the patient doesn't need an ER. It's often not nothing, and we often have transported those patients more than once and know what their norm is, when they're not acting right, and if that "WNL" BP is anything near normal for them.

Sorry, sore spot. Ramble rant.


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## Anjel (Mar 16, 2011)

HotelCo said:


> Full Article
> 
> 
> Does your area have one of these?



We do! such a waste of space. st. joes dedicates like 15 or so beds to geriatric. And those will stay empty in perfect condition when there is 35 people in the lobby waiting to be seen. Keep like 5 for the old folks if you want to say "specialized in geriatric care"


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## Bon-Tech (Mar 16, 2011)

Afraid this trend is only going to get worse with the first major wave of baby boomers hitting retirement age and a projected 50 (55?) million seniors in the country by 2020. Surely, there is a need for this, but it shouldn't come at the expense of caring for others.


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## EMSDude54343 (Mar 18, 2011)

I think this is another example of 'looks good on paper'. Do we need Large scale ER's dedicated to this? Not really, if they take those changes that are made and apply them to the main ER then it will be better for every pt. Like doors instead of curtains, beds that are softer, recliners, it will ease the anxiety of all pts, not just elderly. Yeah rooms like the trauma bays and other specialty rooms may not get the new stuff, but most roooms sure. As for the amplifiers and large print forms, just have them on hand for the elderly, and have the personell on hand, they dont need a dedicated unit. Now for big retirement communities like that are near where i live (central florida) where the hosp is smack dab in the middle and 80%  of thier pts are elderly, sure have a dedicated elderly ER. Sounds to me like they are trying to set up an elderly pt primary care, not ER. and if they made those changes across the board for all pts seen, i think that the outcome would be better for all pts.
 In a time where health care costs are soaring, we should be looking at ways to do a better job, while spending less, i believe they can get the cost saving they are talking about by having after care programs and social workers, can be seen without adding a whole dept, especially one that may sit empty for long periods of time.


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## firetender (Mar 18, 2011)

*If this DOESN'T happen, God Help Us ALL!*

I don't know how many of you have really worked with the elderly but they really are under-served and so many in lower income situations, not at all. Add to that those who literally freeze in fear of getting absorbed into the Hospital environment. Those are the ones we never hear about, but pick up after they've been found dead in their hovels. They deserve a place of safety.

*Listen to your friendly firetender here because I'm predicting your future: You don't like IFT's now? Just wait! You will be inundated and I'll tell you why;*

_*We here in the West have done a good job of prolonging life. Unfortunately, we've done little to improve mobility, less to eliminate debilitating ailments and if you really look at it; MORE to encourage the treatment of chronic illness in institutionalized settings, in the process  encouraging dependence on hospitals and their ilk.*_

And you, my friends, are gonna be hauling all that flesh from here to there!

And the *best *place THERE could be for the elderly would be an intermediate facility that focuses on mobilizing social services and community support to manage a TRANSITION so *YOU *don't have to pick their fallen butts off the bathroom floor at 3 a.m.!

But it's going to be worse than that. If there is a way to make money out of it, entrepreneurs will CREATE even more institutions to house and care for this wave of "Consumers".

_*Perhaps something you're NOT noticing is that these new institutions will thrive because family links have largely been broken. My generation put a whole lot of our parents in Nursing Homes. You will not be any more generous with us. It's our own damn faults, we modeled selfishness to you!*_


And you, my friends, are gonna be hauling all that flesh from here to there!

I'd advise you to start studying up on geriatric diseases because if you do much emergency intervention, that's where it's gonna happen. The proportion of time you spend saving lives will dwindle as you find yourself learning how to better ease the pains and complications of increasing lifespans.

I hope you understand I'm not laying a curse on you. Rather I'm trying to make you aware of the EXPANDED role you will be called on to fulfill. This could land you back in a healing profession; what a Trip!

(The opinions expressed here do not necessarily reflect the views of EMTlife or its Community Leaders or participants. It's a firetender thing.)


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## EMSDude54343 (Mar 18, 2011)

firetender, I think I made my point incorrectly. I do understand that the elderly need more specialized care, and are in need of the after care services, and should over all be better taken care of. I just feel that the changes that are being made for the eldery should be made across the board, and not 'just' for the elderly! I believe that if we did away with the whole stabilize and relaese aspect of emergency medicine and made after treatment care more readily available and accesable for everyone including the elderly, that overall pt health would increase and we would see less return trips for pts.


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## Aidey (Mar 18, 2011)

To repeat myself, theose things should fall under the role of the primary care physician. If it isn't being done, get a new GP, don't redesign ERs. What is being described is not an ER, it is a geriatric outreach, social services and respite center. 

What it boils down to is a place to stick gomers so they aren't taking up ED beds. If you read between the lines they are talking about gomers. The non-gomer elderly or gomers with actual acute problems will still go to the normal ED.


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## firetender (Mar 18, 2011)

EMSDude54343 said:


> firetender, I think I made my point incorrectly. I do understand that the elderly need more specialized care, and are in need of the after care services, and should over all be better taken care of. I just feel that the changes that are being made for the eldery should be made across the board, and not 'just' for the elderly! I believe that if we did away with the whole stabilize and relaese aspect of emergency medicine and made after treatment care more readily available and accesable for everyone including the elderly, that overall pt health would increase and we would see less return trips for pts.



I happen to agree with you in that in order for ambulance service to perform its rightful function it needs to be able to get people to where they need to go. In order for that to happen we need to develop places OTHER THAN ER's to get them to. We're putting all our fractured eggs into one basket, when Humpty-Dumpty needs the most attention! 

(Was that bad or what?)

And to AIDEY:



> ...What is being described is not an ER, it is a geriatric  outreach, social services and respite center.



You're absolutely right, and if we are going to help the people that need us, this is one of the places we need to bring them to.



> What it boils down to is a place to stick gomers so they aren't taking  up ED beds. If you read between the lines they are talking about gomers.  The non-gomer elderly or gomers with actual acute problems will still  go to the normal ED.



You're talking like the ER is sacred. As if people in need of other than emergency treatment are leprous. They are GOMERS - Get Out Of My Emergency Room! What they REALLY are are PINPs: Patients In Need of Placement!

The system is going to adapt to the fact that handling emergencies is only a small part of what we do these days, and that people who are NOT in emergencies do not need to be referred to as if they were burdens.

I think it's time to stop thinking we're still Johnny and Roy. It's a different world out there, the character of our patients have changed, the institutions we bring them to have evolved and in some cases de-volved and we're at a crossroads: We need to re-design the whole system, and this firetender thinks it's from the ground up; and that means you're going to have to broaden your horizons and build your profession to support what you actually do rather than what you hoped would be.


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## Aidey (Mar 18, 2011)

I still firmly believe there are better ways of going about reforming the system than reappropriating ER services. I maintain that what is being done in the elderly ERs should be done by the GP. If a hospital wants to gave a geriontologist on call for the ER, awesome. But the pts GP should be the primary coordinator of care and services. The patient's GP and primary phamacy should be checking for medication interactions. The GP should be assessing the patient's general wellbeing and home status.

This may mean GPs need to start having social service coordinators on staff who can help organize this stuff and do home visits to assess the patient's home. 

I forsee that these ERs won't coordinate with the pts GP any better than happens now, rendering most of what they do pointless. We need to advocate that the GPs of these patients step up and manage their care rather than creating an even more complicated and fractured system.

I am aware that EDs are no longer only for emergencies. However acting as geriatric case managers is far outside of the realm of emergenct, acute or urgent care.


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## usalsfyre (Mar 18, 2011)

Not to mention that outside of a surgery table, an ED bed might be the most expensive place in healthcare to park someone.


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## firetender (Mar 18, 2011)

*It's all about the numbers.*



Aidey said:


> I am aware that EDs are no longer only for emergencies. However acting as geriatric case managers is far outside of the realm of emergenct, acute or urgent care.



I'm not disagreeing with you. My point is the VOLUME of elderly in need of NOT-QUITE emergency care is going to be so massive it will completely bog down the Emergency systems we have in place today.

Right now EMS is bogged down as it is but that doesn't change the patient's need to get SOMEWHERE. There's nowhere OTHER than the ER now, and that is just NOT cost-effective because they are set up to handle emergencies and that's not what the patients are needing; they ARE needing Case-Managers.

It's not going to happen with individual GP's. There are too few, primarily because that ain't where the money is. The only solution is to set up facilities that can handle sub-acute care and also "tend-to" the needs of the growing elderly population.


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## Veneficus (Mar 18, 2011)

Aidey said:


> To repeat myself, theose things should fall under the role of the primary care physician. If it isn't being done, get a new GP, don't redesign ERs. What is being described is not an ER, it is a geriatric outreach, social services and respite center.


 
I have to disagree with this.

The GP system in the US is broken beyond repair. 

I could not possibly hope to describe the extent of it here, and all the halfassed measures to plug the leaks are largely a waste of money that just complicates the problem rather than simplify it.

But let's have a small look shall we?

The elderly have no money. So paying out of pocket for care is basically out. Even with Medicare/medicade the deductables and copay is often inhibitory.

Then there is transportation. Rather the lack of it. Often the elderly don't actually meet the bed confined criteria to have the local IFT transport them to the doctor. So they are going to have to pay for that. 

Not to mention buy medications and pay for medicare part D. Oh, and food on the table, heat/cooling, electric, and all those things that keep going up higher than their "fixed" income. (fixed like a dog maybe) 

Lack of mobility, lack of money inhibit access to care. But 911 to the ED for primary care is very accessable. 

For years probably decades the ED has morphed as the center for primary care. Mostly out of need than design. However, the available treatments and knowledge to properly provide primary care had not evolved along with the mission. 

Then there is the midlevel provider making things harder and adding completely unnecessary cost. Somehow find the money/transportation to go to your local NP/PA which generates all kinds of administrative costs to be refered to a doctor when you don't fit the protocol. Now you have to pay and find transportation to this doctor. Who doesn't know anything about you at all. Has to work you up from the start, with not only diagnostics but administrative costs. 

Even if you go to the doctor first. If you can get an appointment before you wind up in the ED, often times to even stay economically afloat these doctors have thousands of patients. So many they can't even remember what medications you are on or need refilling many times. Health promotion/prevention out of the question in your 8 minute appointment. If you can find one that has an opening for a new patient. Most also do not have diagnostics in house. Compounding the transportation problems.

After primary care looks at you, you are often on your way to a specialist, which is going to put the exact same burdons on the patient as the other previous providers. Especially when they are managed by 4+ specialists none of which are proficent at being a PCP because all they learned was their specialty.

Now let's think about the actuall doctor's office. Small, uncomfortable chairs. No food, possibly some water, inadequete restroom facilities for the need. Fill out the 6 point font forms that even my hyper accute vision can barely read  about things they don't understand. Sit for hours in chairs that cut off circulation to their lower extremities, cause pain in their kyphotic spines, and then there is the stress of the actual rushed meeting with the doctor. Concluded with leaving more afraid, confused, and with more economic nd transport concerns. Probably with a rapid fire list of instructions they don't understand and highly stressed that they will be yanked from their homes and be institutionalized as soon as some 30 year old figures it will be easier to fill out the referal to social services because they can't take care of their "basic needs" in the effort of expiditing "better care."

Now in all of this, there is no continuum of care and despite the BS propaganda that technology is somehow going to solve the issue of this lack of continuity and fix everything is just that, BS. Another American attempt to solve the problem by throwing technology at it rather than actual hire more people and reduce the wasteful excesses in the system.

Simple systems work better. The ED attached to a hospital is the better answer. A ride to and from provided. All diagnostics available. Need tests over time or have it all done at the 1 stop shop. Spend the night. Have some nurses take care of basic needs like bathing which is often difficult at home. Perhaps a nutritionist to plan your meals for you. A physical therapist to teach and coach some excercise. 1 set of papers. 1 computer system. Doctors come to you.

So come to the ED. If you can be maintained or problem solved and discharged, perfect. Need 10 specialists? On site. Not perfect but better coordinated care. 

Cheaper? Better? Yes

The way things were done in 1970? No.

Welcome to 2011.


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## Aidey (Mar 18, 2011)

So, in short GPs can't afford to change, so they are passing the costs on to larger entities (the hospitals). 

Both systems are equally inadequate right now. My argument is that it would be better to change the GP system rather than the ED system. An absurdly high amount of money is spent by Medicare/Medicaid in the last few months of a patient's life. This tells me that the patients are not being managed properly far before they get to the hospital. A hospital playing catch up is never going to be able to do as good of a job as a system the patients are participating in before there is a problem. 

ERs are no more comfortable than a GPs office. You get a bed, maybe a TV (without a remote control), you might get food, maybe, eventually, and if you do there likely will be no one to help you eat. There is one bathroom for every 10 beds, and getting a camode requires someone having enough time to help you. The ER MDs instructions are going to be delivered in a hurried manner, with the RN left to give the patient the paperwork. Which frankly, is rather useless. 

Hospital discharge paperwork usually includes a one or two line description of the problem, along with a few page print out that looks like it came from 7th grade health text book. It gives no explanation of what was actually done for the patient at the hospital. 

I see my GP and I get a 2+ page sheet that lists what I was seen for, what my vital signs, height and weight were. What medical conditions I have, what medications I'm on, what I'm allergic to, and what Rxs I have pending at the pharmacy. Any up coming appointments, lab/imaging tests or treatments (like if you are getting a series of shots it says when the next one is due). 

You tell me which one is more helpful. 

When it comes to prescriptions if the in house pharmacy is open, and has the medications available, there is no one to take you there, especially if you are WC bound. That means there will be a delay in getting your medications because you will have to wait for someone to get them for you once you are discharged. You will likely be sent home by ambulance, which is not necessary, leading to billing problems down the line. If you are lucky they will call a WC taxi for you rather than an ambulance. 

Imaging tests may or may not be performed. Depending on the situation you may instead be given instructions to follow up with your primary MD for further testing. I've encountered this twice personally, and have often seen patients who have discharge orders to return for an outpatient imaging appointment or to schedule the test through their GP.

Frankly, there are just as many problems with utilizing the ER for these patients as there is going the GP route. I think it would be significantly easier to reform the reimbursement for outpatient services rather than continuing to hemorrhage money through hospital systems. There should be incentives for the listed primary care MD to keep people out of hospitals. 

The ED is only more efficient if all of those services and people are available. Depending on the size of the hospital and how busy it is the specialist/consultant needed may not be there at all, or may not be available for some time. There is also no guarantee that you will have consistent care by the same person by utilizing those services through a hospital. 

I think I get my feelings from working in dialysis and seeing how that system works. It is an outpatient service, and the social worker, nutritionalist and MD all come to you, with the goal of managing your care and keeping you out of the hospital. Labs are drawn while you are there for treatment. Transportation is coordinated. The only thing left out is meds. 

If the system 95%+ reliant on Medicare and Medicaid can get it figured out, I'm pretty darn sure it can be applied to GP care.


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## Veneficus (Mar 18, 2011)

Aidey said:


> So, in short GPs can't afford to change, so they are passing the costs on to larger entities (the hospitals).
> 
> Both systems are equally inadequate right now. My argument is that it would be better to change the GP system rather than the ED system. An absurdly high amount of money is spent by Medicare/Medicaid in the last few months of a patient's life. This tells me that the patients are not being managed properly far before they get to the hospital. A hospital playing catch up is never going to be able to do as good of a job as a system the patients are participating in before there is a problem.



That is basically the trouble. 



Aidey said:


> ERs are no more comfortable than a GPs office. You get a bed, maybe a TV (without a remote control), you might get food, maybe, eventually, and if you do there likely will be no one to help you eat. There is one bathroom for every 10 beds, and getting a camode requires someone having enough time to help you. The ER MDs instructions are going to be delivered in a hurried manner, with the RN left to give the patient the paperwork. Which frankly, is rather useless.



Perhaps to you the paprwork is useless, most patients i see want as simple of explanations and instructions as possible. It is quite different being a healthcare provider. The information I would expect might even be more than you do. 



Aidey said:


> Hospital discharge paperwork usually includes a one or two line description of the problem, along with a few page print out that looks like it came from 7th grade health text book. It gives no explanation of what was actually done for the patient at the hospital.



It is that way on purpose. 



Aidey said:


> I see my GP and I get a 2+ page sheet that lists what I was seen for, what my vital signs, height and weight were. What medical conditions I have, what medications I'm on, what I'm allergic to, and what Rxs I have pending at the pharmacy. Any up coming appointments, lab/imaging tests or treatments (like if you are getting a series of shots it says when the next one is due).



That is great, but it is not a majority or even a large percentage of what most GPs do now. Either yor insurance is really good or you have the money to pay cash, but GPs serving primarily medicare don't have the time nor the resources to do that. 



Aidey said:


> You tell me which one is more helpful.



Depends on if you are a doctor or if you didn't graduate highschool. 



Aidey said:


> When it comes to prescriptions if the in house pharmacy is open, and has the medications available, there is no one to take you there, especially if you are WC bound. That means there will be a delay in getting your medications because you will have to wait for someone to get them for you once you are discharged. You will likely be sent home by ambulance, which is not necessary, leading to billing problems down the line. If you are lucky they will call a WC taxi for you rather than an ambulance



That is no different than a PCP office. But at the hospital there is at least an oppoortunity.




Aidey said:


> Imaging tests may or may not be performed. Depending on the situation you may instead be given instructions to follow up with your primary MD for further testing. I've encountered this twice personally, and have often seen patients who have discharge orders to return for an outpatient imaging appointment or to schedule the test through their GP.



Yes, this is a common practice, but it is slowly changing. Most ERs are not set up to handle primary care even though it is a majority of their case load. The Geriatric ER is a step towards changing that. Medical systems in any country take years to change. Even when you know what is better.



Aidey said:


> Frankly, there are just as many problems with utilizing the ER for these patients as there is going the GP route. I think it would be significantly easier to reform the reimbursement for outpatient services rather than continuing to hemorrhage money through hospital systems.



It is not easier to reform the GP route, that is the issue. One of the problems is a viscious circle. Hardly anyone goes into GP anymore because there is no money in it. Some even go bankrupt and their credit is destroyed. But even if you offered more money, it takes more than a decade to train physicians. Not to mention there has to be an affordable way to pay for the outrageous malpractice insurance.



Aidey said:


> There should be incentives for the listed primary care MD to keep people out of hospitals.



Keeping people out of the hospital is easy. Just send them home to die.

The incentive needs to be based around health promotion, which there is absolutely no political will for. No time to do it because a GP needs to see 150people + a day to stay in the black. 




Aidey said:


> The ED is only more efficient if all of those services and people are available. Depending on the size of the hospital and how busy it is the specialist/consultant needed may not be there at all, or may not be available for some time. There is also no guarantee that you will have consistent care by the same person by utilizing those services through a hospital.



I didn't say it wss going to be consistent. Only better than what it is now.



Aidey said:


> I think I get my feelings from working in dialysis and seeing how that system works. It is an outpatient service, and the social worker, nutritionalist and MD all come to you, with the goal of managing your care and keeping you out of the hospital. Labs are drawn while you are there for treatment. Transportation is coordinated. The only thing left out is meds.



Yea, and they keep people out of the hospital that should be there. Or they do absolutely stupid things like not administer antibiotics that are indicated and the patient winds up in the hospital with almost impossible to treat wounds leading to amputations. 

Strong work there. 



Aidey said:


> If the system 95%+ reliant on Medicare and Medicaid can get it figured out, I'm pretty darn sure it can be applied to GP care.



The question is should we sustain hemodialysis? For how long? In who? In most patients in prolongs life, but diminishes quality of life. At a cost of billions per year.


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