GAP-ED Project: Improving Care for Elderly ED Patients
Older adults in the ED setting are a vulnerable patient population who frequently present with complex conditions and are at an increased risk of return visits, unnecessary hospitalization, prolonged suffering, and death. A review of ED admissions data at Long Island Jewish Medical Center (LIJMC) identified a large elderly population with multiple revisits for non-emergency medical care, visits that aggravate the morbidity and mortality of these vulnerable patients.The Geriatric and Palliative (GAP) Division and ED at LIJMC implemented a multidisciplinary GAP-ED Team, delivering geriatric and palliative expertise to the ED with the goal of decreasing revisits and hospitalizations and improving patient satisfaction.
We aimed to improve resources available to older adults in the ED by providing comprehensive geriatric and palliative care assessments, holding conversations on advance directives/MOLST and Goals of Care, linking patients to community resources, and coordinating care upon discharge. Furthermore, we intended to demonstrate improved care quality by reducing 30-day ED revisit and 30-day hospitalization rates by at least 10% and by documenting improved patient and caregiver satisfaction.
The GAP-ED Specialist, a geriatric social worker, identified eligible patients in the ED who met inclusion criteria. Criteria included patients who were: at least 65 years of age, community-dwelling, discharged home after the ED visit, and had medical or social co-morbidities that put them at high risk of recidivism based on reviews of published predictive tools and expert experience. The GAP-ED Specialist provided an assessment of needs focusing on medical conditions, medication reconciliation, psychosocial needs, and Goals of Care. The Specialist also connected patients to community-based resources that fit the patient's needs.Patients received follow-up phone calls regarding their ED visit at 3, 7, and 30 days post-discharge. Five weeks post-intervention, a satisfaction survey was administered to patients or their family members.
From November 2, 2015 to January 31, 2017, 370 patients met the established inclusion criteria.. Advanced directives were established for 96% of patients (356).There was a reduction in 30-day revisit rates to 22.5%, and in hospitalization rates from 53.4% to 32.0%.157 GAP-ED patients have been surveyed post-discharge. 91.4% responded that the Specialist was helpful in providing support and resources. 85.7% responded that all ED's should have the GAP-ED initiative. Patients and families have been extremely appreciative of the assistance and focus on their specific needs and have used the GAP-ED Specialist as a resource post-discharge, improving communication and turnaround time in delivering services to patients.
The significant reduction in 30-day ED revisit and hospitalization rates suggests the GAP-ED Team improved the quality of care and post-discharge outcomes for at-risk elderly patients. Reduction of non-emergent ED use concurrently reduces the dangerous complications often experienced by older adults while in the hospital. Decreased non-emergency patient volume also decompresses the ED and conceivably has downstream effects to improve care for all ED patients.
Furthermore, the emotional support provided to patients and their caregivers leaves a lasting impact and improves their healthcare experience.
- Natalie Sohn
- Medical Student
- Division of Geriatric and Palliative Medicine, Long Island Jewish Medical Center
- 270-05 76th Avenue
- New Hyde Park, NY 11590
- Nancy Kwon, MD, MPA
- Regina Roofeh, MPH
- Tara Liberman, DO