The primary goal of the project is to keep most geriatric patients at rural hospitals through telemedicine rather than transferring them to Dartmouth-Hitchcock Medical Center.
Telemedicine is the cornerstone of a Dartmouth-Hitchcock Medical Center geriatric emergency department (GED) initiative with four rural hospitals.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
In a partnership with West Health, Lebanon, New Hampshire–based Dartmouth-Hitchcock Medical Center (DHMC) has launched a three-year effort to build a "hub-and-spoke" model GED. Work to establish the hub at the medical center began in fall 2019 and is set to finish at the end of this year. Four rural hospitals will join in the effort as spoke facilities during year two and year three of the initiative.
"Most of the other accredited GEDs nationally are in more urban settings than ours. Related to that, we will be the first GED that uses telemedicine to extend central resources to rural spoke sites," says Scott Rodi, MD, chief and regional director of emergency medicine at DHMC.
The GED initiative is expected to be a threefold win. Older adult patients will benefit by receiving high-quality emergency department services close to home, the four rural hospitals will benefit from having fewer patients transferred to DHMC, and the medical center will benefit from being able to keep more beds open for high-acuity patients who generate higher reimbursement rates.
"The idea is to keep geriatric patients near home in their regional hospitals and to keep the most complicated cases coming to Dartmouth-Hitchcock rather than patients who are frail with simple medical problems and needing a lot of social support. If we can do that, we will provide better care and increase capacity at Dartmouth-Hitchcock for the complicated patients who need tertiary care and generate increased reimbursement," says Daniel Stadler, MD, director of geriatrics at DHMC.
How the rural GED will work
The GED initiative has five primary building blocks, Rodi and Stadler say.
1. Hub: The first step in the initiative is creating a GED at the medical center's emergency department.
Rodi says the organization is creating an area in the existing emergency department that will be generally dedicated to the geriatric population. Modifications to the space include larger clock faces, non-skid surfaces, and telephones that have a large keyboard. Telemedicine equipment will likely be cart-based.
"The project is much more about people and process than it is about bricks and mortar," Rodi says.
2. Staffing: Staffing the GED will include using new or "repurposed" personnel, Rodi says. Stadler will serve as a co-director of the GED with an ER physician, a new emergency department nurse will develop care protocols and implement screening tools, and new care management staff members will help establish community connections and bring local resources to bear for the geriatric population.
Rodi and Stadler are also creating a pool of geriatricians who will be on call for the GED at the medical center and via telemedicine when the spoke sites are activated. "We will have access 24/7 to a geriatrician who is part of this project," Rodi says.
3. Screening: At the triage level, screening tools are an essential process component of the GED project, Rodi says. "When a patient who is over 65 years old presents, there will be screening for dementia, fall risk, and other factors that will trigger additional actions such as reviewing the medication list or bringing home-care resources to bear depending on the screening tool that has been activated."
4. Accreditation: The GED at the medical center hit its first milestone in January, when the first geriatric patients received care at the GED. The next milestone for the hub site is gaining Level 1 GED accreditation status. "It's analogous to trauma certification. You have Level 1 trauma centers and now there are going to be Level 1 GEDs," Rodi says.
The accrediting organization is the American College of Emergency Physicians, and the spoke hospitals will be required to attain Level 2 or Level 3 GED accreditation.
5. Spokes: Criteria for selection as a spoke hospital features operating in a rural market, Rodi says. "In our area, many of the hospitals are considered critical access hospitals. Their financial viability is only possible because they get some preferential federal pricing for their services. Critical access hospitals are generally rural, with limited access to tertiary care. Almost certainly, our four spoke sites will be critical access hospitals."
In addition to geriatrician consults 24/7, the spoke hospitals will receive a range of services from the medical center's GED, Stadler says. Care managers will be well-versed in the community resources available near DMHC and the spoke hospitals.
"As another example, if a spoke hospital felt they could keep a patient if only they could get an endocrine consult or a cardiology consult, we are hopeful that we would be able to leverage telehealth to bring specialty consults to that hospital," Stadler says.
Modes of telemedicine communication will be telephone calls and video links, he says. "Whether we are on-site or not, we can pull in the son who lives in California, the daughter who lives in Chicago, and a member of the primary care team down the road all using telehealth. They can all engage in a meeting—we call it Brady Bunch technology because of all the faces on the screen. We're training care managers to facilitate those conversations."
The initiative is set to receive $4.5 million in funding over the first three years, with West Health contributing $3 million and Dartmouth-Hitchcock Health contributing $1.5 million.
"West Health is paying more in the beginning and Dartmouth-Hitchcock will be taking on more over time. The thought is that once the three-year period is over, Dartmouth-Hitchcock will fund the GED going forward," Stadler says.
Project managers will be monitoring several metrics, he says.
- Patient transfer rates from spoke hospitals
- The time that geriatric patients spend in emergency departments. "We know the longer geriatric patients spend in an emergency department the higher the risk of delirium, falls, and decompensation," Stadler says.
- Goals of care such as determining whether patient care is in concordance with advance directives
- Percentage of patients screened
- Percentage of patients referred to community resources
- Patient satisfaction
- Emergency department throughput for geriatric patients, which will help to determine whether low-acuity patients are being admitted for inpatient care at DHMC
"There is good data showing that when frail elders are cared for in quieter settings with their family around, they have better outcomes and spend less time in the hospital. When they come to busy tertiary academic centers far from home and far from familiar surroundings, they have a much higher tendency to get delirious and they generally have long hospital stays," Stadler says.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
At Dartmouth-Hitchcock Medical Center, a primary goal of a new geriatric emergency department is to boost care for patients at hospitals near their homes.
The geriatric emergency department at the medical center will provide a range of ED services via telemedicine to four rural hospitals such as 24/7 geriatrician consults.
For the medical center, the main source of return on investment from the new geriatric emergency department is maximizing beds for high-acuity patients.