Comprehensive Geriatric Evaluation in the ED Facilitates a Smooth Transition to Skilled Nursing Facilities

Since Medicare was established in 1965, its beneficiaries have been required to complete a consecutive three-day stay in a hospital before receiving coverage for their nursing and/or rehabilitation care at a skilled nursing facility (SNF). However, over the past several years, Medicare has experimented under risk-based Accountable Care Organization (ACO) programs and Bundled Payment arrangements with waiving the three-day hospital stay requirement for patients receiving care from providers participating in these value-based contracts. As of January 1, 2018, the Cleveland Clinic Medicare ACO under a Track 1+, downside risk contract has leveraged the “SNF 3-Day Rule” waiver for eligible Medicare beneficiaries who receive a plurality of their primary care services from this ACO.

For patients, this waiver enables participating physicians to admit appropriate, need-based patients to an eligible SNF without the need for a prior three-day inpatient hospital stay. The SNF 3-Day Rule waiver applies to all traditional Medicare patients who meet criteria to receive short-term rehabilitative care from one of Cleveland Clinic’s contracted SNF partners.

Comprehensive geriatric evaluation in the ED offers multiple benefits

In cooperation with their colleagues from the Emergency Department (ED), Cleveland Clinic geriatricians Saket Saxena, MD, and Ardeshir Hashmi, MD, launched a pilot program with the goal to explore how comprehensive geriatric evaluation can facilitate a smooth transition of eligible patients directly from the ED to a SNF. The program ran for 15 days in November and December 2018.

“Throughout those 15 days we had a dedicated geriatrician present throughout the day in the ED (ED) to facilitate the transfer of eligible patients to a SNF,” says Dr. Saxena. “Out of the 64 patients we saw during the pilot, five were directly transferred from the ED to various SNFs after geriatric evaluation.”

Dr. Saxena says that the feedback about the geriatrician’s presence from both the ED physicians and patients was very positive. Patients who come to the ED are especially suitable for geriatric evaluation, because they often present with several comorbidities, utilize multiple medications, experience cognitive behavioral problems, have mobility issues and frequently lack an adequate social support system.

“As geriatricians we are best equipped to address these concerns and perform a comprehensive geriatric evaluation to make their transition from the ED to a SNF a smooth one,” he says. “As soon as the patient qualifies for the SNF 3-Day Rule waiver and after their geriatric evaluation, we will arrange for the SNF to accept a patient and provide a written hand-off detailing all of our concerns related to that patient.”

In the pilot program, geriatricians worked closely with case managers to identify and address all medical issues faced by the patients prior to their transition to a SNF. This approach ensured that the SNF physician who will be taking over the care of the patient was well-informed about the patient’s medical needs upon their arrival.

“While the ED physicians focus on addressing the patient’s acute issues, a geriatrician will evaluate any chronic medical problems and put together a comprehensive care plan for the SNF physician who will take over their care,” says Dr. Saxena. “This makes the transition better from the standpoint of everyone involved: the ED doctors, case management/social workers, SNF physicians and patients.”

One step further: a permanent plan

Based on the encouraging results of the pilot program, Drs. Saxena and Hashmi are now working with their colleagues on incorporating geriatric evaluation in the ED on a permanent basis.

“We have ongoing conversations and are putting together a permanent plan for the involvement of geriatrics in the ED,” he says. “Due to changing demographics, we are increasingly seeing older patients in ED setting.”

Managing older patients in the ED can be especially challenging, because navigating the fast-paced setting of the ED and understanding what is going on around them can be very difficult for an older, frail person who might also have cognitive challenges.

“Sometimes, the stress of the ED environment can precipitate additional medical issues such as agitation and delirium,” says Dr. Saxena. “Therefore, we are also working on developing effective communication strategies for the physicians to utilize when communicating with patients and their caregivers.”