Prescription for Change

How St. Joseph's redeployed ED staff to meet geriatric patients' needs

by Virginia Hite and Taylor Hurst

Editor's note: This story is the third post in a three-part ED series, where we featured stories and resources on ED efficiency. If you missed our last post on our Avoidable ED Utilization Assessment, check it out here.

Each year, 22% of geriatric patients use the ED at least once. Yet despite high utilization, ED staff often struggle to assess and address geriatric patients' unique care needs, leading to avoidable admissions, adverse outcomes, and poor patient experience.

Here are the 15 tactics to reduce avoidable ED utilization

Leaders at St. Joseph's Medical Center transformed part of their existing ED into two 10-bed geriatric units to avoid unnecessary admissions and improve overall experience. In addition to physical renovations such as non-slip flooring and thicker mattresses, they decided to create a specialized team trained to meet geriatric patients' needs.

Creating a core geriatric team in the ED

St. Joseph's core geriatric team includes two physicians, four nurses, two nurse navigators, and one patient liaison. This team's primary goal is to ensure that geriatric patients receive tailored support during their stay in the ED—and that nothing falls through the cracks. 

Three ways the core geriatric team improves care

St. Joseph's taps into its core geriatric team to consistently deliver timely and appropriate care to geriatric patients. Below, we've highlighted three ways that St. Joseph's deploys its geriatric core team to improve efficiency and experience.

  1. Streamline triage to maximize resource efficiency among older patients

    Nurse: Uses the five-level Emergency Severity Index (ESI) as an ED triage tool—geriatric patients can be assigned only to levels one, two, four, and five to more clearly prioritize elderly patients—and performs geriatric-specific clinical assessments to inform care plans.

  2. Use ED-based assessments to initiate cycle of palliative care and comfort services

    Nurse and Nurse Navigator: Connect with the patients' caregivers, primary care physician (PCP), and specialists for consultation as needed. Specific diagnoses (e.g., cancer) and the presence of unmet palliative care needs will initiate a palliative consult.

    Physician: Rotates through geriatric ED and leads the care team in complex care decisions.

    Patient Liaison: Focuses on maximizing patient comfort, which can include providing reading glasses, warm blankets, and pillows. This position does not need a clinical background; St. Joseph’s uses a trained layperson.

  3. Post-discharge support geared to help seniors maintain quality of life

    Nurse Navigator: Coordinates needed support services (e.g., adult day care, home health aide, walker, Meals on Wheels) and notifies case manager of more complicated concerns (e.g., elder abuse) prior to discharge. The navigator also ensures the patient is seen by a PCP within seven days post-discharge, and calls each patient four times (1, 3, 7, and 40 days post-discharge) to reassess conditions and schedule needed care.

Redeploying geriatric ED staff is key to reducing inpatient admissions

Since St. Joseph's opened its geriatric ED in 2009, inpatient admissions decreased 24%, from 54% to 30%. While St. Joseph's was an early mover in the geriatric space, not every organization has the resources (or buy-in) to create a geriatric-friendly ED. However, one of the low-budget ways you can start to tailor support to your geriatric ED patients is to train a subset of providers to anticipate—and serve—the needs of your geriatric patients.

Looking to improve quality and patient experience elsewhere in your organization?

The Physician Executive Council is currently conducting new research on the link between patient experience and clinical outcomes and we would love to include your perspective. If you're interested in participating, e-mail hitev@advisory.com to schedule an interview.

Make your patients healthy and your ED happy with community paramedicine

For organizations assuming population health risk, top priorities include reducing the rates of avoidable ED visits, avoidable admissions, and readmissions. But most organizations don't have all the staff they need to engage patients and support robust care management.

Our infographic explains how community paramedics can help extend the care team to prevent avoidable visits to the ED.

Download the Infographic