EXECUTIVE SUMMARY

Researchers are testing whether telemedicine can be used to help EDs at small, rural hospitals deliver the kind of high-quality geriatric care spelled out in the American College of Emergency Physician’s new Geriatric Emergency Department Accreditation (GEDA) program. Under the three-year research project, Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH, will be providing geriatric support and expertise to four rural hospitals through a mature telemedicine program already in place.

One aim of the program is to enable senior patients in rural areas to receive high-quality geriatric care in their local EDs rather than face transfer to larger hospitals that may be far away.

Under the approach, geriatricians, case managers, social workers, physical therapists, and other specialists will be available via telemedicine hookup to the rural hospitals participating in the project.

Program developers will help the four hospitals work toward achieving level 2 accreditation in the GEDA program.

Investigators also will be monitoring a blueprint that will allow other parts of the country to deploy geriatric expertise and support services to rural EDs in a sustainable way.


Currently, there are more than 100 U.S. EDs that have achieved some level of credit through the American College of Emergency Physician’s (ACEP) Geriatric Emergency Department Accreditation (GEDA) program. That means these EDs have taken specific steps to better meet the needs of older patients who present to the ED according to Geriatric Emergency Department Guidelines, a set of consensus-driven guidelines established in 2013.

However, recognizing that smaller, rural hospitals often do not have the training or resources to meet GEDA standards, researchers are determining if telemedicine technology can be leveraged to make this accreditation available to these facilities.

Further, is it possible for many older patients to receive needed care in their own communities rather than face transfer to larger, tertiary care hospitals that may be far away?

Lebanon, NH-based Dartmouth-Hitchcock Health and West Health, a group of nonprofits that has long been focused on programs and interventions to help seniors receive high-quality, cost-effective healthcare in their own communities, have teamed up to find out.

Scott Rodi, MD, interim section chief and regional director of emergency medicine at Dartmouth-Hitchcock Medical Center (DHMC), says the first step is for the DHMC ED to become a level 1 geriatric ED under the GEDA program, the highest of three levels of accreditation offered. However, he also notes that the Dartmouth-Hitchcock Health System already has a mature telemedicine network in place that will be used to support the delivery of high-quality geriatric care at the participating rural hospitals.

“In each of years 2 and 3 of the project, we plan to bring on two rural [hospitals] so that by the end of the project we will have at least four rural hospitals that are part of our system,” observes Rodi, who is serving as the principal investigator and local champion for the effort. “The point of the project is to actually study [this approach]. If it turns out to be a useful and feasible model, we would hope to expand it to more sites.”

Kevin Biese, MD, FACEP, MAT, associate professor in the division of geriatric medicine and co-director of the division of geriatric emergency medicine at the University of North Carolina, is heavily involved in helping set up the program at DHMC. He also will work with the participating rural hospitals once they are selected.

Biese has taken a leading role in establishing the GEDA program, and works part-time for West Health. “I am sharing with [DHMC] specifically the best practices from the best geriatric EDs in the country. There are now 107 geriatric EDs in more than 25 states. I have been able to visit all the level 1 sites,” he reports. “I am sharing those best practices and helping DHMC learn from the experiences of others as to how you take excellent emergency care of older adults. I am innovating with [DHMC] on how we can make those same services available via telehealth to their partnering rural and critical access hospitals.”

Biese notes that providing the kind of medical care and social supports that older adults often need when they go to the ED requires a lot of expertise. This not only applies to doctors and nurses, but also social workers, case managers, pharmacists, and physical therapists.

“Frequently, complicated patients with complicated medical problems are transferred to big medical centers like DHMC, and then they are far from home,” he says.

Spending time away from family can be hard on patients and loved ones. This project leverages the telehealth network already in place in the Dartmouth-Hitchcock Health System to essentially “beam out” that multidisciplinary care team to the EDs at these smaller, rural hospitals. Thus, many of these patients may access the care they need closer to home, Biese shares.

In the first year of the project, most of the ED staff at DHMC will receive some geriatric training. However, Rodi explains there also will be new resources brought on specifically for care management and social work that can be dedicated to the geriatric population.

He also anticipates adding geriatricians who can provide physician-to-physician support or advice. “When we get to the point of adding hospitals, if they are looking for help connecting to their community or help screening a patient, or they want the advice of a geriatrician, those mostly new resources will be in place to provide that support, typically through telemedicine,” he says.

Rodi adds there will be both a geriatric medical director and an emergency medicine director for the project. These leaders will make some on-site visits to participating hospitals.

“We will be on site to help each site identify which screening tools they want to implement ... and which policies they want to put in place,” Rodi observes. “A geriatrician will be on call 24/7, but the geriatric medical director and emergency medicine medical director will also be available to help in a scheduled way.”

One goal of the three-year project is to enable the four participating rural hospitals to achieve level 2 GEDA certification. “Our thinking is that without a project like this, it would be very difficult for a small, critical access hospital to achieve level 2 status,” Rodi explains.

Beyond helping these facilities achieve accreditation, investigators will be tracking a range of metrics to gauge the overall impact of the program. These metrics may include length of stay, hospital charges, rates of various screenings, urinary catheter use, perception of avoided transfers, and concordance with advance directives.

Other metrics could include hospital-acquired delirium; patient and family satisfaction; rates of polypharmacy; use of physical or chemical restraints; rates of falls; and consultations with physical therapists, geriatricians, and palliative care. “We are developing a score card ... but the overarching goal of that will be to decide whether clinically this program has an impact that is valuable to the community,” Rodi shares.

He adds that analysts also will be assessing whether there is any financial impact for participating hospitals, and whether offering these services is cost-effective for DHMC.

There will be no fees assessed during the three-year research phase, but there will be some requirements, Rodi notes. “The principal things we will be asking for is that they have a local champion who is interested [in this area], will work with us to develop their screening tools, and help us gather data locally,” he explains. “Most of these sites will not have an electronic medical record that we can access. We will need help from that person on site who will be the champion.”

Ultimately, researchers hope to determine whether this program can deliver a return on investment (ROI) for small, rural hospitals. “It is conceivable that if there is an ROI, we might [eventually] discuss fees for sites that have access to the resources that are being paid for centrally,” Rodi explains.

Biese envisions a program that will endure well beyond the three-year timetable of this research project. “We are not just doing a grant-funded program that should go away when the grant goes away,” he stresses. “We know if critical access hospitals are able to keep patients and treat them appropriately there, then that will make those hospitals more sustainable. Keeping rural hospitals in America open is critically important.”

Further, Biese observes if DHMC can dedicate its high-intensity beds to patients who need services that can only be provided in tertiary medical center like theirs, that is more financially sustainable for the health system.

“As we are tracking the clinical impact of this, we will also be keeping an eye on a blueprint that will allow other parts of the country to deploy these types of services in a sustainable way,” Biese notes. “The closer to home you can get care, the better.”

(Editor’s Note: For more information about the GEDA certification program and process, please visit: http://bit.ly/2JWhqvG. For more specific information about the Geriatric Emergency Department Guidelines that were created in 2013, please visit: http://bit.ly/2PPWold.)