Senior ED Program is a Winner By Almost Every Measure

To patients, the benefits of implementing a senior emergency department program like the one at Summa Health System are unquestionable. To CEOs whose hospitals or health systems are struggling for revenue, there may be hesitation.

Hospital and health system leaders are always on the lookout for ways to improve quality of care, patient satisfaction, and ED utilization. By those measures, the senior emergency department program being piloted at Akron's Summa Health System is an unqualified success.

But viewed through a financial lens, the cost benefits can be a mitigating factor—at least as long as fee-for-service healthcare maintains its strong hold on revenues and profitability.

That means the benefits from such a program can vary, depending on the business model of the hospital or health system that's using it. The fact that a senior ED program can reduce admissions can be a tough hurdle to clear for many top executives whose hospitals or health systems are struggling for revenue.

At Summa, which has its own health plan, the economic benefits can accrue to the health system as a whole even if they initially hurt revenues on the hospital side of the business. That's because the program has demonstrated that it can reduce hospital admissions. The decision to invest in a senior ED program must be studied carefully to make sure that hospitals aren't cutting their own financial throats by implementing them.

Long-Term Value
But if you believe that moving from volume to value generally will pay benefits for your hospital or health system as healthcare reform matures, developing such a program seems like a no-brainer. The benefits to the patient are unquestionable, given Summa's results. For improving patient care and satisfaction, it's a clear win.

But first, let's take a look at the program itself and the findings of a two-month study. Scott Wilber, MD, medical director of senior emergency care and director of emergency medicine research at Summa, says the health system has been thinking about adding a senior track to its ED for years. The idea germinated from the health system's ACE (acute care for the elderly) unit, which started in the 1990's, when Wilber was a resident.

"About five years ago, we started talking about the idea of a geriatric ED," he says. By fall of 2012, coincident with an $85 million, system-wide ED renovation program, the geriatric ED was operational.

Study Results
And the results are promising. Based on a two-month study comparing January 23–March 23, 2013 with the same period a year prior, the program:

• Significantly reduced admissions (4.3%)
• Increased observation status (1.7%)
• Increased discharge to home rates (2.4%)
• Significantly increased patient satisfaction scores
• Did not significantly increase ED revisits

The test group is surprisingly similar from year to year. There were

• 2,286 visits analyzed for 2013 with a mean age of 78 years
• 2012 data were drawn from 2,260 eligible visits, also with a mean age of 78
• Sixty percent were female in 2012 and 58% in 2013
• Only patients treated between 8:30 a.m. and 8:30 p.m. were studied

The senior ED is not so much a physical location as it is a program, Wilber stresses, adding that if seniors knew they were being directed to a separate facility based on age, many would probably resist such treatment.

"As my dad said to me when we were coming up with this idea, he wouldn't really want be in there," says Wilber. "The beauty is that for patients it's fairly transparent. So it's not a physical location, but a program."

That said, there are some physical differences in the rooms set aside for the senior ED, but along with the renovation of its EDs system-wide, Summa made the whole ED amenable to senior patients whose mobility and other functions may be compromised. Wilber and his team piloted the senior ED at Akron City Hospital, the system's largest, and they are now rolling its processes out to two other hospitals in the system.

Patients all come in through the same process, but seniors are triaged preferentially into beds that feature bedside toilets, nonskid floors, and appropriate lighting, he says.

Financial Impact
Of course, with fee-for-service payment still dominating, reducing admissions can have a negative effect on finances, says Wilber, but Summa as well as other organizations should keep their eye on what's best for the patient over short-term economic pain.

"At this point, we want to move toward value-based reimbursement and care delivery and yet we're not fully there. When we reduce readmissions, the health plan and ACO think it's great. But understandably, the hospital CEO doesn't think it's great," he says.

"I think that we realize that simply admitting every patient who presents to the ED who is older is not the best way to deliver healthcare moving forward. No matter how things shake out with value-based purchasing, we still have to make the commitment to the right care, at the right place, and at the right time."

Program Costs
Although Summa spent $85 million on redesigning and renovating its EDs system-wide, developing a senior ED doesn't have to require a lot of investment, Wilber says. And it's still a new program, but Wilber thinks Summa's results should push more senior executives and CMOs to investigate what it would take to innovate ED services at their own facilities.

"Around 30 organizations have developed [a] senior ED program similar to us," Wilber says.

Senior ED programs can take on a lot of different characteristics, but the physical plant is not the best part of the equation, he stresses. Instead, it's the alternatives for delivery of care that can provide the most benefit to the patient.

Wilber presented detailed findings of Summa's experience with the senior ED program in October at the American College of Emergency Physicians' annual conference in Seattle, and he and his team are putting together a white paper now that he expects will serve as a prescription for what developing a senior ED program will entail.

"The most important thing for leaders to know is that it is more than just changing the physical plant," he says. "Education and thought and planning on how to do things differently is where you get results. Across the country, ED physicians are ready to embrace this new role and each place will be a little different in how they do these things."