Having lived in New York City for many years now, I’ve grown used to the blare of ambulance sirens. Still, when I hear one go by, I sometimes find myself saying a little prayer of hope that the patient onboard makes it OK through the insane city traffic.
These past few weeks, however, ambulances and emergency medical technicians (EMTs) were on my mind even more than usual. First, I received an inquiry from a geriatrician trying to develop an EMT intervention for the care of older adults and looking for the appropriate quality measures to use. I pointed her to Beeson Scholar Manish Shah at the University of Rochester, who has done innovative work in this area.
Then, I attended a meeting of a Community Action Board for a project led by the emergency department at Mount Sinai Medical Center: the GEDI-WISE program. The project aims to improve health and reduce costs for older emergency room patients
With an award from the Center for Medicare and Medicaid Innovation to develop the program, Mount Sinai is working in partnership with two other emergency departments at Northwestern University in Chicago and St. Joseph's in Paterson, N.J., to create "geriatric emergency departments" that can take care of the unique needs of older adults at each of the sites.
The three departments are utilizing a variety of interventions, including specially trained staff, care transitions programs, redesigned physical environments, and improved health IT. The project will evaluate which components might make the most positive differences for medically complex, frail older patients.
With carryover funds from their first year, the Mount Sinai emergency department staff was allowed to experiment even further. They saw an opportunity to improve their outcomes through EMTs, who play a critical role in our communities and in health care.
Many of Mount Sinai’s older ER patients utilize ambulance services to return home from their emergency department visit or hospitalization. The EMTs providing transport have direct contact with these patients and sometimes their caregivers, and they help people reenter their homes. EMTs also tend to be more representative of the communities they serve, often speaking the same languages and understanding their community's culture. So they’re in an excellent position to help address two vexing problems when discharging an older patient from the ER.
First, studies show that about 76 percent of people over age 50 leaving the hospital are confused about their discharge instructions, putting them at risk for bouncing right back. Second, 40 percent of people over age 60 fall within the six months after leaving the ER. When you consider the chaotic environment in the ER, these numbers become even more worrisome.
To help alleviate these problems, Mount Sinai developed a simple seven-item questionnaire that helps identify whether an older patient understands their discharge instructions. EMTs ask questions like, "Do you know what changes have been made to your medications?" and "Do you know how to set up your follow-up appointment?" All of the information is typically included on a discharge document, but by asking the questions, an EMT can help the patient find the information or make a call to the ER if it is clear that there are major problems ahead.
Falling is one of the main drivers of re-hospitalization and poor outcomes, so the EMT also asks to look around the older person's home to identify potential fall hazards. Another simple checklist helps the patient see what dangers might be there—cords, clutter, or throw rugs, for example. Mount Sinai will then follow up by phone to see if the patient has addressed his or her issues or needs further help.
Getting buy-in from the EMTs in this work is critical. Fortunately, Mount Sinai's transport contractor is eager to find ways to add value to their services and is working to embed applicable training and protocols in EMT orientations.
However, they aren't doing this for free. Mount Sinai's grant funds pay for EMT training and extra time at people's homes that might slow down service (roughly 10 to 15 minutes) and thereby increase costs. But what happens once the grant ends?
The point of the federal innovation award received by Mount Sinai is to develop different payment mechanisms that can support interventions like this, so long as they improve patient outcomes and reduce overall costs to Medicare. Hopefully, Medicare’s intention will become reality.
The principles at play here—utilizing all members of the health care team in commonsense ways to improve outcomes and reduce costs of care for older adults—are what we should support and push forward more generally, both in policy and practice.