Geriatric Emergency Department Accreditation for Rural Providers, with Kevin Biese and Natalie Elder

Organizations and resources mentioned in this episode:

• American College of Emergency Physicians
  • Geriatric Emergency Department Accreditation (GEDA)
• University of Vermont (UVM) Health Network
  • UVM Medical Center Geriatric Medicine
• Alice Peck Day Memorial Hospital, Dartmouth Health
• Geriatric Emergency Department Accreditation, New York State Cohort, Healthcare Association of New York State
• The John A. Hartford Foundation
• West Health
• Geriatric Emergency Department Collaborative (GEDC)
  • GEMCast Podcast

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

Today I'm speaking with Dr. Kevin Biese, Chair of the Board of the American College of Emergency Physicians Geriatric Emergency Accreditation program; he's an emergency medicine physician as well. Also joining us is Dr. Natalie Elder, who is a Clinical Assistant Professor at the Larner College of Medicine at the University of Vermont, and the Director of Geriatric Emergency Medicine for the Vermont Health Network.

We're going to be talking about Geriatric Emergency Departments, and the different levels of accreditation they can achieve. What is a Geriatric Emergency Department, and what are its primary goals?

Kevin Biese: I'll start with that. Thanks Andrew, for having Natalie and I on this podcast. [I] really appreciate it. Both Natalie and I have had the privilege of spending a lot of our career focused on improving emergency care for older adults. And there's a lot more to be done, and a lot of learning to happen, about how to be most helpful in rural settings. But what is a Geriatric Emergency Department? A Geriatric Emergency Department is a place where the staff has been trained and the facilities are better oriented to take care of complex, sometimes frail, older adults who need emergency services. It's a place, to put it simply, where if I had to take my mom, I'd feel comfortable that she was going to get care that makes sense for her, that's aligned with her goals of care. And that keeps in mind the fact that she is a now 78-year-old woman with some physical vulnerabilities, not the same as she was when she was 40. And that should be calculated as to how we do diagnoses and what kind of medications we use and how we care for her when she's there and what her goals of care might be.

So how do you reorient that experience to make it better for older adults? What it usually is not is a separate emergency department for older adults. So, most of the time it's about doing things a little different and a little better for the older adults when they come to the ER you already have. Natalie, I don't know what you'd add to that.

Natalie Elder: Yeah, I would agree. I think with the exception of maybe one or two emergency departments in this country, a Geriatric Emergency Department is not a separate space where we put all of our older adults, which, per the Medicare definition, is somebody over the age of 65. They are all integrated into our emergency departments. And it is just a way to make sure that you have the proper staff, procedures, environment, in order to best take care of an older adult who comes to the emergency department.

Andrew Nelson: What are some unique challenges that older adults might face in traditional emergency departments that Geriatric Emergency Departments aim to address?

Natalie Elder: So many. So I'll start with, I guess my favorite topic is that our emergency departments, a lot of them don't have windows. So sometimes you don't know what time of day it is. We are overcrowded, so a lot of our older adults, unfortunately, end up in one of our hallway beds, and it's just a chaotic environment overall and where there's not a lot of privacy or time to rest. So, a lot of our older adults who come to our emergency departments are [at] increased risk of developing delirium, which in itself can be a cause for morbidity for older adults, or a risk factor for later developing dementia, if they don't already have dementia. So I would say that is a big challenge with the way emergency departments are structured right now.

Another thing I will say is that our triage systems are not aligned to really single out older adults who might need immediate emergency care. There have been some studies that have shown that older adults can be under-triaged compared to other age groups. And in addition, you know, our triage scoring system does not have a specific geriatric-centered way of scoring people if they need immediate emergency care, versus they can wait a little bit. So, I would say those are for me big challenges that geriatric EDs do try to address. Kevin?

Kevin Biese: Yeah, I totally agree with everything that Dr. Elder said, Natalie just said. For those of us who have had the experience of going to the ER recently, most of the time it's pretty tough. I'm proud of the ER doctors and nurses I work with. My God, when I'm on shift, I feel stretched. I'm doing everything I can. It's like trying to put out seven fires at once with a cup of water. Like, I feel under-equipped to face all the things that are coming at us at the same time. So I am not slamming the ER doctors or nurses that I work with.

And yet from the patient experience standpoint, the majority of times if you go to the ER, you're not like, "Well, that was great!" You feel stretched, you feel exhausted. You feel like you waited a long time. You feel like maybe you were in an environment that wasn't very private. It was loud, it was noisy. Delirium is acute confusion in older adults. Heck, sometimes when I leave the ER after work, I feel delirious because it's such a tough place to be. All three of us on this line are relatively younger. We're not older vulnerable adults. I don't think any of us would qualify for Medicare, for example. You take everything we just said, and you make it an 82-year-old with some level of dementia and multiple comorbidities and frailty. And what for us just kind of stinks — makes for a really hard experience and a bad day and why did this happen — for them is dangerous and sometimes even deadly. And so, what we're aiming to address is to make sure that those who are most likely to not just suffer, but be harmed by the environment in which emergency care is often delivered — and frankly, a lack of deep knowledge of geriatric specific conditions and medications amongst emergency providers — that we don't hurt them. We know it's a tough environment. How do we tweak that environment and the learnings and the care that's delivered for older adults so we don't accidentally hurt those we're trying to help?

Natalie Elder: It's also important to realize that older adults in general just have increased needs when it comes to emergency department care. So we know that they spend a longer time with us. They require more imaging resources, they require more laboratory resources, they require more social work resources. They're more likely to experience adverse health events from being in the emergency department, and after being discharged from the emergency department. And they're most likely to be unsatisfied with the care that they receive in emergency departments. So that's just something that we know about older adult care in emergency departments.

Andrew Nelson: Have you seen that there are any different challenges for older adults, specifically in rural communities?

Natalie Elder: We have a lot of challenges. I think a couple of those are that we don't have enough training for our staff, our physicians, our APPs [Advanced Practice Providers], our nursing, our techs, about how to take care of older adults in the emergency department and what their specific needs are. There are difficulties with transportation, whether it's from the emergency department, home, or if they need to get transferred to another location for specialty care or a higher level of care. Those can often be delayed by quite a lot, which in itself may cause adverse effects, because people will be in the emergency department longer. We also have fewer resources when it comes to specialty follow-up. So at one of the locations I work at, we only have cardiology and GI [gastroenterology] one day a month, and that's it. That's all we get. Otherwise they have to travel over two hours to see these specialists and a lot of older adults just have difficulty with getting that specific follow-up. And therefore, we'll utilize the emergency department more, as their healthcare needs aren't addressed on an outpatient basis.

Kevin Biese: I will confess, I have worked mostly in larger urban or suburban big academic centers. But over the last several years, I've gotten to visit many rural hospitals. I want to start by saying, my goodness, what amazing places full of amazing people doing great work. And when we think about the needs of geriatric ER, sometimes when we think about the programs, we start from the premise of those of us who work in big centers, that we don't know our patients. I'll tell you what, in the Critical Access Hospitals I've gotten to go to, they know their patients. And it's a game-changer as far as what, the way they relate to them, what they can do for them. And I've gotten to work with some families that work in Critical Access Hospitals, and they don't talk about it as the hospital. It's their hospital. So there's a lot of unique strengths.

Having said that, everything that Natalie just said is of course true. Where I live in Chapel Hill, North Carolina, if I grabbed a golf ball right now and teed it up in my front yard and smacked it, there's about a 10% chance I'd take out a subspecialist physician, just walking down the street. I'd probably take them out. But, if I did that in the middle of Vermont, I'm probably not going to take out a subspecialty physician, because they're not falling from the trees there. And so you don't have the same level of expertise in the area. You don't even have the same number of providers, period ― physicians, nurse practitioners, PAs [physician assistants]. Transportation, I think we all know that is a huge barrier. And so how do you get the social resources that are needed to help take care of individuals that live in more rural communities? I do think there's some creative solutions to that. And I think in order to enact those solutions, we need to plug the ERs in more with more telehealth options, more transportation options. And because people are still going to come there when they need help, how can we connect them to ERs with the resources they need to get folks to the next stop on the way, even if it's bringing the information to them instead of moving them to the subspecialist that helps them get the care they need?

Natalie Elder: I just want to add, you are so right, Kevin. Sometimes when we get an EMS call, the nurses will know who the patient is based on the address. So it's like everybody does know everyone there. And I personally find that really special. It feels like you're taking care of a family. So that's really a big fun rewarding part of working in the rural environment.

Kevin Biese: And I'll confess, I'm still learning what I think needs to happen in rural settings, in order to make it better, in order to honor the sense of community that's been created and provide people with the care that they deserve without having to go two hours to find the cardiologist, for example, in Natalie's example. And I think that what needs to happen is that we really need to start building. We need systems that move the information to the patient, rather than the patient to the information.

So I'll give you an example. I work at the University of North Carolina Chapel Hill. And frequently we'll have people come from their smaller rural hospitals, say they fell and they bumped their head, and they have a very small possible amount of bleeding inside their head, like a subdural, which doesn't need an operation, which doesn't need anything definitive, which could be managed in another way. And this poor individual has now been put into an ambulance and driven three hours to UNC Chapel Hill, which means all of their family needs to come to UNC Chapel Hill to see them, which means they're far away from the people that they know, from the nurses that know where their address is and where they live and what they need. And they're in this new place only to have the specialist come by and be, "Well, nothing we need to do about that." And I say, "Well, what the heck?" Andrew, we're doing this podcast over some version of Zoom right now in three different states. In this world we live in, how is it that you have to get in, take this injured, older, frail individual, drive them three hours from their house to have someone with information look at the picture that came with them and say, "Well, you don't need to be in, you don't need a surgery." How is that not happening where they live, at the local hospital, which is their hospital, where the nurses know them?

Like, we have got to get better about moving the information, rather than moving the person, whenever possible. And when we move the person, it's because something can be done for that person that's consistent with that person's wishes only in the place we're moving them to. And if that's not the case, we shouldn't be doing it. Let's support the local rural hospitals to take great care of their community rather than setting up a system where they've got to ship them out all the time to get care that isn't always indicated.

Natalie Elder: I would say that's also a paradigm shift in our specialty as a whole that's going to be very difficult to make. Because I feel like we're trained, if we don't have a specific specialist, we need to get the patient to the specialist, you know? I think it would be a huge paradigm shift to keep somebody, like in Kevin's example, with a small brain bleed in our emergency department and just give them the information that they need from ourselves and not from the specialist who won't be doing much for them probably anyway. So, I'm hopeful that as a specialty, we can move towards that direction to minimize the harm that we're potentially doing to older adults.

Kevin Biese: And maybe Natalie, it can be done in such a way that the specialist can zoom in for a consult call right there. I'm not asking the ER provider at the local hospital make this decision in absence of them, I'm saying that the specialist can be available for this information and these decisions without moving the patient to the specialist. And that's the infrastructure that can be created to empower local hospitals and not force them to keep patients there ― not advocating for that ― there are times when the patient needs to move for their own well-being, but rather, what support can we give to local hospitals to allow patients to be treated there when it's appropriate and when it's possible. And we ought to be making our specialists and expertise and information available to be deployed at local hospitals rather than having the patient always have to move away from their own home state or home center to get that care, but not just forcing it on you, Natalie, that's not the point.

Natalie Elder: I will say, as an example here at UVM, we are able to consult our specialists over the phone. We don't have specific telehealth, but it's really helpful to just talk to them about a patient and see if there's anything we can do to just keep them where they are so that we don't have to do these very long transfers. So thankfully that is available to us, but I think telehealth would be a great next step.

Andrew Nelson: There's definitely more of a sense of connection that you'll often find in those rural spaces that I think everybody ends up benefiting from. I think that's really special. There are three levels of Geriatric Emergency Department care accreditation. Can you tell us what those are, and what kind of qualifications are required to achieve those levels?

Kevin Biese: So there's three levels. There's bronze, silver, gold. Bronze is a level that every emergency department in the country should be able to get to. I think of bronze as tilling the field, getting ready to plant great programs. So bronze, you need to have a champion nurse and a champion physician. I'm sure Natalie is a champion physician for one or more of the hospitals that she works at. And what that means is that there are advocates for the well-being of older adults on the team. Somebody thinks about it a little more and they're like, "Wait a second, we could be doing that different, or this probably isn't working. Or, how can we help our older adults?"

And then you need to have like some pretty simple stuff, 24/7 access to mobility devices. Back before we started the geriatric ED, I was told, "Oh no, you can't get a cane for that patient. We lock those supplies up at 5:00 PM." Like, "What do you mean you lock them up at 5:00 PM? Someone open the closet!" But they wouldn't because it was after 5:00 PM. So, you have to have 24/7 access to mobility devices. So now they do open the closet. You have to have 24/7 access to food; kind of "No duh," but like it should be happening.

And some basic education for your champions and some care processes in place. What are the care improvement protocols that you're doing to make life better? Things like making sure you're very careful about which medications you give older adults, that you get them up and help them move around when possible and appropriate, that you make space for care partners or caregivers in the ER. So like that they have a place to go. Lots of different things you can do.

As you move up to silver and gold levels, you end up having more care management support you connect with opportunities for physical therapy, occupational therapy, pharmacy, et cetera. And the number of care processes that you have to do goes up dramatically from four in a bronze, to ten in a silver, to twenty in a gold. But basically, you educate the team a little bit more. You have certain champions, and you put in process consistent care processes that improve the care older adults get on a consistent basis in your year.

Andrew Nelson: It does seem like sometimes when we're trying to improve levels of care in whatever environment, sometimes there are common-sense things we find that need to be corrected, like having mobility aids locked up, or availability of food. You were talking about Critical Access Hospitals specifically earlier. Do you know at this time how many Critical Access Hospitals currently have Accredited GEDs?

Kevin Biese: Thirteen.

Natalie Elder: And I'm going to brag, the University of Vermont is four out of those thirteen!

Kevin Biese: Well done, Natalie and team! That's awesome.

Andrew Nelson: That's fantastic! That's really cool to hear. What are some of the rural-specific challenges to accreditation?

Kevin Biese: It is good that you asked that, and I'll ask Natalie to respond to it, but I just want to say, thirteen's a great start and four is awesome in Vermont at the University of Vermont, but there are over 1,000 Critical Access Hospitals in this country. So 530 or so accredited emergency departments of the 5,500 in the country. So let's say 10% of emergency departments are accredited as geriatric-appropriate ERs right now, which is awesome. Like, we've made great progress. Okay, that's great. But if there's 1,000 and some Critical Access Hospitals and only 13 are accredited, then that percent is like 1%. So my point is that like we are lagging behind in Critical Access Hospitals, specifically the question. And that by extension, I think that means we're lagging behind of being of service to rural hospitals. I know that not all rural hospitals are Critical Access, but I look at that, and I say, "Huh, are we really being as helpful as we can in rural America?" And if we are not, we are failing, because the percentage of older adults living in rural America is higher than in urban America, and we just need to be doing a better job in rural America. So, Natalie, what are some of the challenges to accreditation in rural America and how can we do better?

Natalie Elder: I would say the bronze level is such a low barrier of entry that if you are in a Critical Access Hospital and you don't have the GED accreditation yet, I think it's really important that you look into it because I think that it is very accessible pretty much to almost anyone. I think one of the main challenges was having a physician champion in the past. I believe that GEDA [Geriatric Emergency Department Accreditation] has addressed that. And now you can have an APP champion. Is that correct, Kevin? Yes. Okay. And really what you need is one physician or APP champion, you need a nurse champion. And those processes that we were talking about, all you have to do is write up half a page about how you're not going to put in unnecessary urinary catheters and how you have food around the clock, and you're going to feed people and just have access to canes and walkers. So, I think probably the financial cost might be a little difficult for some places. But I really feel it's important to get these devices just to help our older adults because we don't want them falling and coming back with more severe injuries. So I think probably having that physician part was a little difficult for some places. And the financial part is always going to be difficult, but in my opinion it's totally worth it and pays dividends later.

Kevin Biese: I think there's also a unique opportunity. So right now, talking with the Healthcare Association of New York State, there's a lot of interest in New York State for having more rural hospitals be able to become GED accredited. In fact, there's a bill in the New York State Senate to support hospitals for becoming the highest level of GED accredited, California's plan on aging is also including Geriatric Emergency Departments, as a couple examples. Many other states from all different parts of the country, including the middle of the country and from all different political dispositions, have made GEDs a part of their plan specifically for rural settings. And I think one way to get innovative about that is to work with like potentially local funders or your healthcare association of your state and think about, "Gosh, how could we get five or ten of our Critical Access Hospitals or rural hospitals to do this together?"

There's lots of ways to kind of collaborate on that, to leverage resources across different sites, to even ask for discounts from the accrediting agencies. At the end of the day, geriatric EDs are, yes, they're based in the hospital, but they're sort of like a social rights movement. They're like the fact that all of us should have care that's appropriate for older adults in our local ER, whether no matter where we live. And so I think there's an opportunity to work with like local government and healthcare associations to drive it across multiple hospitals in a region at the same time. And definitely we're seeing that in a couple states right now.

Andrew Nelson: Natalie, I think you touched on this a moment ago, but could you tell us a little bit more about what some of the benefits of GED accreditation are for rural hospitals?

Natalie Elder: Okay. So first I'll say obviously, improving the care we give to older adults, that's pretty much the overarching theme here. But really, just having that enhancement in policies or protocols or personnel and having that equipment available is important, and part of providing good care. And there has been some data out there that shows that from a Geriatric Emergency Department, given everything you have in place, there's potential to reduce admissions to the hospital and therefore reducing skilled nursing facility admissions that might happen from a hospital setting. And I think also in a way it's as Kevin was saying earlier, it gives somebody a choice of where to go for their emergency care, just gives them an informed decision about where they're going. So, saying, "Hey, my mother will probably get better care here, given the personnel and the policies that are available at this geriatric ED versus a place that doesn't have one."

Kevin Biese: Yeah. You know, I'd add to that, there's several examples, but one of them is also in New England, Alice Peck Day [Memorial Hospital] is in New Hampshire. They're a Critical Access Hospital that achieved gold-level geriatric ER status. And on the way, a few things happen. One is, they know that their patients are getting better care, and they're very proud of that. That's obviously the most important. In addition, it was important to them actually to increase their ER census. A lot of big academic centers are like, "That's not what I want to increase." But a lot of smaller community hospitals like, yes, they want to be the place you go if you need medical help. Well, they nearly doubled their ER census over those three years, and two years in a row, they've won the highest level of PressGaney award that's available, period.

So the highest level of patient experience award. They got the highest patient experiences possible for emergency departments, and received an award two years in a row from PressGaney. So they know their patient experience has gone way up. Not surprisingly, their patient volumes have gone way up. Their hospital as a result is functioning better financially, and they feel better about the care that they're giving. It can be transformative because I think all of us know, "Gosh, we really could do better by older adults," but it gives you a program and specific milestones to go to, to come together and say, "This is what we're going to do. We're going to do this better." And that can be transformative.

Andrew Nelson: In terms of establishing and maintaining a GED's performance in terms of accreditation, what specific data or metrics do you use and how do you gather that information?

Natalie Elder: I guess it depends on which accreditation you're going for. So I will speak to the bronze level. You really just have to show in whatever way you can that your policies are being adhered to. So whether that's looking back, for example, on which patients got urinary catheters and making sure that they were for indications that are appropriate is totally fine. And as you go up the silver and gold there are a lot more metrics that you need to keep track of. And I'll let Kevin talk to those.

Kevin Biese: And I'd reiterate what Natalie just said, because I helped create the program and it's intentionally flexible, especially at the bronze level. We don't want, especially smaller hospitals to be like, "My God, I can't hire a new data person to figure out and meet all these standards to get this done." We want it to be doable. We want you like, "Hey, we're going to do a better job. We're going to really pay attention to who gets which medications. And we're tracking that." However you track it is good enough with us because we're not the police officers. We're trying to encourage better behavior, not judge you or give you an exact grade on it. Once you get the silver or gold, we did want to have slightly higher standards because we really wanted to be able to say with some level of certainty, "Yep, this hospital is reaching those high plateaus." And those sites create a data dashboard.

The majority of the data dashboard is about completing the programs you said you've set in place. So let's say you're going to screen, let's say you're going to do a medication reconciliation. You look at all the drugs a patient takes and line them up and make sure they're getting the right doses. And is this happening in the right place? You're going to do it for all your patients over age 65. Well, we're going to require that you keep track that you say, "Okay, we had 20 patients over age 65 yesterday and 18 have got this, that's 90% yesterday." And you keep track on a monthly basis. All of these care processes create a data dashboard, and then you have to have at least three, and if you're gold, five outcome measures of ways that this process has resulted in better outcomes for your patients. So it could be like less adverse medication reactions, less times somebody got the wrong medication and everything went wrong. That'd be one way of tracking that.

But for bronze, it's very flexible. It just says, "What are you doing better and how do you know you're doing it?" And for silver and gold it says, "What's your data dashboard and how is that actually improving care?"

Andrew Nelson: It's an interesting point you make about wanting to make the bronze tier accessible so it's less intimidating. It's easier for people to get a toehold in that system, and then build from there in terms of developing and increasing levels of care.

Kevin Biese: Right. Especially because when we started, and still today, I can make arguments to you as to why this program would be financially beneficial to your hospital, and I can make good arguments. There's lots of reasons we can talk about, but I can't offer that Medicare is going to pay you more money if you do this today. So if it was out of the gates, if it was like, "Well, you need to hire three new people and need to get a new computer system," and people are going to be like, "That sounds great. And while I'm at it, I'll pick up our Ferrari at the local shop." I mean, it's not going to happen. We live in the real world, so what can we work with today that encourages better care? And then how do we build on that?

And what's fun about doing this type of work is now that five hundred and thirty hospitals have done this work, now we get to talk with CMS and government agencies and insurance companies and say, "Here's why you should encourage this. Here's why you should be supportive of this." So then you can actually begin to build in some level of support or regulation like the CMS Age Friendly [Hospital] Measure that we helped write that helped to really begin to up the game for everyone across the country. But especially when starting, it's not like everybody working in hospitals is bored right now. They feel incredibly strapped. Or as Natalie said earlier, they're financially kind of stretched already. So we had to work with what we had and build from there.

Andrew Nelson: Sure. For rural hospitals that are attempting to become accredited as GEDs or are wanting to achieve higher levels of accreditation, what types of support or resources are available?

Kevin Biese: So I am a big fan of the GEDC, the Geriatric Emergency Department Collaborative. GEDcollaborative.com has been grant-funded by both West Health and John A. Hartford, the two largest philanthropic organizations in the country dedicated to improving aging and improving the care of older adults in this country.

And there's all kinds of resources on there. So there's implementation toolkits, there's educational programs, there's educational programs with continuing medical education. Because you have to get a certain number of hours of class basically as nurses and doctors. And so it counts for that. There's podcasts, because ER providers, none of us read really ― I'm being a bit flippant ― but we all listen to stuff when we're working out because we're that kind of people. And so there's podcasts, you know, we're on a podcast now, but GEMCast is the Geriatric EM podcast. There's webinars that we put on every other month where we have about 200 folks from around the world talking about best practices. I'm sure Natalie's spoken on our webinars and podcasts and stuff before. So there's just tons of stuff there. It's free because people donated money to help us create it. And so, check it out. Super helpful.

Having said that, GED Collaborative also has done consulting engagements is totally not-for-profit, but like we've worked with groups with healthcare systems, state agencies, for example, San Diego County said that every ER in their county should become a geriatric ER. Unless you're a pediatric ER. You're either a pediatric ER or you're a geriatric ER. And so they hired GEDC to come in and help train up the hospitals to do that. So there's ways to get even more help than that. But start with just the website, GEDcollaborative.com. We've got lots of stuff on there to help unpack this riddle.

Natalie Elder: And I will say, I'm obviously not sure about the rest of the country, but here as Kevin was mentioning earlier, there's the Healthcare Association of New York State, which has been super supportive and has great resources for anybody in New York State. And they even help us here in Vermont as well. And they've been fantastic to work with.

Kevin Biese: Yeah. So if you happen to be connected with or work for or with your state healthcare association and you think, "Maybe we'd want to do this in our state," please reach out to me or Natalie or, we'll help get that connected, because that's something, it's a great way for a region, whether that's a county or a state to say, "This is important to the people of our region, our county, or our state, and we want to get this done." So we'd be happy to help.

Andrew Nelson: Earlier I asked about some of the challenges that older patients in rural communities can face when they're trying to get care. What are some common challenges for providing GED care in rural environments?

Natalie Elder: So I'll start as a general, right? Providing emergency care to older adults is challenging in a number of ways. I'll say the first one is that they have very non-specific complaints and sometimes it's difficult to parse out what they are here for and what is really going on, if it's more medical or social and just figuring out what their needs are. And I would say also kind of knowing where to stop, saying "Is this something that you would want that would be beneficial to you and the life you're living right now? Or are we focusing more on different challenges or just making you more comfortable?" So I'll say, I think that's just in general providing care to older adults. Sometimes it's just hard to figure out what's going on, and that's okay.

But I'll say, especially in the rural setting is really, I'm sure this comes up tens of trillions of times, it's really the lack of resources, right? So in some of our rural EDs, it's just a physician and two nurses and a tech, and that's it. I don't have access to a pharmacist on site. There's somebody offsite who checks our meds, et cetera, but if I want to discharge somebody with a medication, I can't really ask somebody sitting next to me, "Hey, is this okay?" But I'm going to have to make that extra step of making that phone call to the pharmacist who's offsite.

Obviously we talked earlier about coordinating care after discharge from the emergency department and also coordinating care to get home visits to people in rural states. Everybody's home is so far away from everything. So, it's really challenging to get people to come out to somebody's house because it might be a really long drive. And the social isolation is also a big thing here, I would say. So those are just a couple of things, I think.

Kevin Biese: No, absolutely. I think the one piece I'd add, in general, those of us who trained in emergency medicine, like if I'm working in the ER any given day, I've got to be ready for like 15 things to come in at the same time. And the only way I manage 15 or 20 people at the same time, because they don't make appointments — they don't come like one, and then I see the next one, and then I see the next one. It's like, "Oh gosh, here they all come." I try and figure out what's the actual complaint, and then what's the algorithm for treating that? Like, "Oh, you have chest pain. Oh, I'm worried you might have a heart attack. So I know what to do now." It's like, okay, do this, this, this, this. Natalie and I would know exactly what to do. Once we get to that point, there's like this whole chart basically of, so then the next one it's like, "Okay, you got shot in your right calf. Okay, I know what's in the right calf, I know what to do."

But older adults are amazing. Natalie and I are both geriatric emergency medicine specialists because we love older adults, but it is not nearly as simple. First of all, it's oftentimes chronic conditions that have been present for a long time exacerbated by sometimes worsening medical and sometimes social. Sometimes the daughter just can't manage taking care of her mom anymore and that's nobody's fault. But there isn't like the algorithm for managing that in the same way. And so really the whole structure of managing an ER doesn't really work for complicated older adults most of the time. And so we need a different way to approach patients that starts with different questions and that's what we're developing here. You add that in a rural setting with less people on the team, less external resources immediately accessible, and I imagine it just gets really hard to do the job that you want to do for your patients each day.

Part of the advantage of the geriatric ED program is it gets this conversation elevated, it gets this conversation going on in government circles, in company circles. I was on the Zoom with a board member of one of the largest health insurance companies in the country earlier today. Once we get momentum and you start to have these conversations, part of the advantage, because we can't fix all of that just by getting a bronze level certificate for your ER, but by having all this momentum, then we start to have this conversation at a national level and we can begin to say, "Hey, wait a second, what do we need to be doing to get the right care available for older adults in all settings, including, especially rural settings."

Andrew Nelson: You both mentioned earlier how care in rural communities kind of organically tends to be more personalized because people know each other. Can you talk about some other ways that Geriatric Emergency Department care can specifically be tailored to the needs of individual communities?

Kevin Biese: I'll give you one example that I'm familiar with, and then that gives Natalie some time to come up with better ones. But one, if you had Kristie Foster, who's the nurse champion for Alice Beck Day Critical Access Hospital on this line right now, she would immediately start talking about her phone call follow-up program. So Kristie has herself, and then eventually there's other people working with her, calls almost every older adult that goes to Alice Beck Day Hospital's ER, and then goes home. And she does this to help make sure that people got the medications they needed and were able to get follow-up. And she started to notice patterns about who couldn't get their medications, or what medications they couldn't get, or which doctor's offices they could get follow up and which they couldn't. And then she was able to start addressing those.

So one very potent intervention is some sort of follow-up for patients after they come to the emergency department when possible, which is usually done via phone. If nothing else, even if the patient didn't have any specific needs, they feel cared for that someone reached out and took that extra step. And it begins to figure out where the cracks in your social support network in your community exist for patients just after they came to the ER so that then you can begin to address them. And she actually got her docs to take on more primary care patient portfolio and got some system changes, because she was able to say, "Look, I called 50 people and 30 of them had the same problem. We need to do something." So that's one example of an intervention that fits in all centers but absolutely works in rural center communities as well to begin to help take better care of patients and figure out how to redesign your local ecosystem of care to meet their needs.

Natalie Elder: We're not that advanced yet. I'll say that I have heard other rural emergency departments having access, as we were talking about earlier, to telehealth, specifically like geriatrician consults or pharmacist consults via telehealth for patients while they're in the emergency department. And I think that is totally amazing and a great way to bring the specialist to you, versus bringing you to the specialist. So I think there's a great role for telehealth. We already sort of do it with our stroke, right? We have that physician and the robot kind of thing going on for all of our stroke patients, but I feel like there's such potential to expand that and integrate that for a lot of our specialists or consultants to see our older adults where they're at. So I think that would be another great thing to have in the future.

Andrew Nelson: We really saw an uptake in telehealth during the pandemic. There was a greater need and a greater incentive. We've just seen the huge positive impact that it's had on rural patients since then.

Kevin Biese: Absolutely. I work in a big academic medical center and sometimes if they're not using telehealth, you'll see older folks come in and they'll come from like two and a half hours away and then they got to try and park in this lot that's a quarter mile from where they're going. And they're trying to find their way in like this labyrinth, huge thing, healthcare system all to go talk with some really smart provider doctor, whoever who's like the hematologist who's going to talk to them about their blood tests so that then they can get back in their car once they can get back to the parking garage and drive back two and a half hours. There is no reason for that not to happen over telehealth. There is a lot of the inefficiencies that are built into that, and the suffering we cause on older adults. So anyways, let's continue to leverage communication technology rather than cut it off, particularly for those who live in rural America.

Natalie Elder: And I will also say I'm not an expert in this at all, but I do feel like there's a good role for AI to play as we develop into the future. And to just by placing some data points here and there for a model to predict who's going to be at higher risk than someone else, or who's going to have greater needs that we might need to address. So, I am excited about that happening and looking forward to that in the future.

Andrew Nelson: Yeah, it seems like there's a lot of exciting potential there as well. I was talking to somebody for this podcast a few months ago, and they were talking specifically about using AI models for analyzing lab results and finding that was very helpful.

Kevin Biese: Yeah, the potential for technological advance in the care of complex patients like older adults is staggeringly promising. And we need to continue to adapt and evolve so we can work smarter, so that our processes can get better and as a result our patients will benefit. Lots of potential there.

Andrew Nelson: How do you navigate the challenge of balancing overall emergency care needs with geriatric- specific care in rural Geriatric Emergency Departments?

Kevin Biese: I think, you know, a lot of really good geriatric care and in general care comes down to what matters. But let me give you an example. Patient examples are always the best. It always matters what matters to you. But if I fall off my bike today and break my arm and go to the ER, and I see Dr. Elder in the ER, she's going to assume correctly that what matters to me is that my arm's broken and that it really hurts and that I need to know how bad it's broken and I need pain medicine and do I need surgery? She doesn't really have to have a long drawn-out conversation about that, [it's] kind of obvious. But if I am 82 and I have stage four cancer and I am in pain and I'm trying to decide whether I need to come into the hospital or maybe go to the cancer hospital and I'm in between chemotherapy, there's a lot more to figure out about what matters to me in that conversation, and to make sure that the things that Natalie does to me, or for me, or with me as my doctor in that scenario are aligned with what I want. It's a different way of practicing emergency medicine. I mean, we should all be focusing on what matters, but these questions become much trickier and much more involved. And so it takes a little bit of a pause and an asking and an inquiry and maybe in that there's a little bit of tension between that and the way usual emergency medicine is practiced. But it really comes down to being an even better listener and making sure that what we do aligns with what our patient needs.

Natalie Elder: I'll say also with what their family needs, I will say that I feel like the patients who feel like I have been a good doctor to them are the ones that I sit down and listen to. And that always, that's like a common theme. It's like, "Thank you for taking the time to listen because nobody else has." And so it's really like taking a pause and seeing what's important to the family as well and working with them together as a team versus like working alongside or against them sometimes.

Andrew Nelson: Looking forward, where do you see the future of Geriatric Emergency Departments headed? What kinds of possibilities do you see? And are there plans for more widespread implementations across other hospitals?

Kevin Biese: I'll share my own goal. This is going to sound counterintuitive. In 10 years, I hope the Geriatric ED Accreditation program doesn't exist because if I fall off my bike on my way to wherever and I go see Dr. Elder and she treats my arm and because I broke it and does whatever, no one gives her a special stamp, because of course that's what you do. Kevin fell off his bike and he needed, well, if my mom comes to your ER and you screen her for delirium because she's older and has some things, that's what you should be doing already. The future of this program lies in elevating the standard of care so that all of us, no matter what ER you live by, can know that that ER is equipped and supported in and educated in taking the best care possible of older adults. We're getting there, but we're not there yet. That's the goal. I want to be obsolete in 10 years because being a geriatric emergency medicine doctor shouldn't be a specialty, really. Because it turns out a lot of people that need emergency care are older, and all of us who work in the emergency department should be well equipped to manage their care.

Natalie Elder: I obviously agree with Kevin, and I think it's no secret that there's a lot more older adults. Pretty much every day I think we gain 10,000 new 65-and-over people, and we all know that the disease burden increases when you get old. That's just what happens when you age. And so my hope is just like Kevin said, is that it will become the standard of care, to give good care to our older adults. And my hope is that healthcare systems will appreciate the resources that are needed to do this and will prioritize them.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Dr. Kevin Biese, Chair of the Board of the American College of Emergency Physicians Geriatric Emergency Accreditation program, and Dr. Natalie Elder, Director of Geriatric Emergency Medicine for the Vermont Health Network. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health.