Yale New Haven Hospital System’s Bridgeport Hospital www.bridgeporthospital.org located in Connecticut has established a Geriatric Emergency Medicine Service called GEMS www.bridgeporthospital.org/geriatrics/gems/default.aspx in the hospital.
The problem is that seniors account for a significant share of ED visits. Most EDs have staffing levels and resources to address only the specific acute issues facing a senior patient and are not equipped to identify or address the often-complex and multifaceted medical and nonmedical needs that may have precipitated the visit.
As a result, seniors often spend a long time in the ED which contributes to overcrowding and backups. Also, seniors tend to have poorer outcomes after discharge, including repeat ED visits along with inpatient admissions.
To initially develop the GEMS program, the medical director of the hospital’s geriatric program started planning and hired one Advanced Practice Registered Nurse (APRN) to be based in the Emergency Department (ED) for the initial launch. The APRN was to conduct formal comprehensive assessments on ED patients over the age of 65 who are at risk of poor post discharge outcomes.
The first step is for an APRN to assess the situation for an elderly patient in the ED. The next step to take is to give the relevant information to ED-based clinicians and care coordinators and to hospital-based staff if the patient is admitted. Next the information is given to community-based primary care providers and to others if they are involved in caring for the senior after discharge.
After the patient is discharged from the ED, the APRN will call the patient’s primary care physician involved in the care of the patient to highlight issues important to post discharge care concerning medication changes, care recommendations, and other specific relevant issues.
The APRN will also call other providers involved in the ongoing care of the patient to make sure they are aware of the ED visit and relevant findings from the assessment, including supervisors in home health agencies plus nurse managers in assisted living facilities and nursing homes.
The program worked reasonably well for several years, although resentment existed among other ED nurses who felt that the APRN carried a lighter load than they did and felt that her job was to educate and advise rather than deliver hands-on care.
They also thought that the APRN did not interact as much with ED-based clinicians as program leaders had hoped. The GEMS director eventually hired an APRN as part of the geriatrics section but no longer based in the ED, to provide consultative services to the ED. This meant that the APRN’s services could be billed to Medicare as consultation fees. Program leaders then launched a modified version of GEMS to address problems with the initial model.
The results of the study show that the GEMS program has to be designed with specific organizational and community goals in mind, have stakeholder support, be based within geriatric services, integrated into the existing workflow, and very importantly experienced nurses need to be hired.
It is also necessary to monitor and share information on the program’s impact. Information needs have to be evaluated and shared with key stakeholders to demonstrate the program’s positive impact on wait times, repeat ED visits, readmissions, costs, and patient satisfaction.
As the program progressed, GEMS reduced ED wait times and readmissions, increased the volume of Medicare patients that could be seen in the ED and hospital, found higher patient satisfaction along with a very high levels of accuracy related to chart documentation and medication reconciliations.
Go to www.bridgeporthospital.org/geriatrics/gems/default.aspx or email Gina Calder, Executive Director, for Clinical Services Bridgeport Hospital at gina.calder@bpthosp.org or go the AHRQ Innovations Exchange at https://innovations.ahrq.gov for more details on the case.