Expanding ED Services to Meet the Needs of An Aging Rural Population

Since 2019, Cleveland Clinic’s Main Campus has been home to a specialized geriatric emergency department (ED) designed to provide older adults with the comprehensive services demanded by their unique medical and psychosocial requirements. The facility reflects a growing national awareness among geriatricians and emergency physicians of the need to appropriately address the complex acute concerns that often affect elderly patients.

Despite the national shortage of geriatric medicine specialists, the “increasingly robust” program has continued to grow, says Cleveland Clinic geriatrician Oliver G. Ancheta, DO, MS, MPH. Population data further supports the importance of expanding geriatric emergency care in community settings. According to the 2020 U.S. Census, approximately 10,000 baby boomers turn 65 years old every day.

Overcoming limitations

Although Main Campus is well-sourced to manage an older population, community hospitals – including those in Cleveland Clinic’s healthcare network – are staffed with fewer geriatricians, he says. As a result, older adults who seek care in rural and suburban EDs may have limited access to certain tests and treatments.

“The standard ED is designed for rapid turnover, but older individuals often present with complex issues like polypharmacy concerns and dementia, which don’t fit well into that framework,” Dr. Ancheta explains. “Geriatric patients require substantial attention and resources that standard EDs are not necessarily designed to deliver.”

In November 2023, Dr. Ancheta and his colleagues Saket Saxena, MD, and Anatoliy Goykhman, MD, set out to expand emergency services to community hospitals “as a way to meet older patients where they’re interacting with medical care the most – in rural areas,” he explains.

The pilot program was launched at Avon Hospital, a 126-bed suburban facility whose emergency department was struggling to meet the needs of a large population of geriatric patients.

Equipped with very limited specialized resources, Avon Hospital also provided another compelling challenge: Many of the older patients seen in the ED were reluctant to travel to Main Campus for follow-up appointments. “The hospital’s rural location provided an important opportunity to reach those patients and engage them in their own care,” Dr. Ancheta explains.

Getting started

The first stage of the pilot project involved teaching Avon’s ED providers how geriatric patients were approached at Main Campus using the four Ms: mentation and delirium management; medication and polypharmacy issues; mobility and fall risks; and what matters most, or disposition planning.

Delirium and confusion were highlighted as major points of concern, Dr. Ancheta says. “Older patients who present to the ED with confusion or altered mental status are often admitted – and we know that remaining in the hospital may do more harm than good,” with documented risks that include falls and cognitive and functional decline.

On the other hand, patients who are evaluated by a geriatrician in the ED are more likely to be sent home with plans for outpatient care. “That improves the likelihood of a good outcome and substantially reduces medical costs,” he says.

Emergency providers were also given information on community resources, including the Alzheimer’s Association and the National Council on Aging. “These connections can help guide ED providers when a geriatrician might not be available,” Dr. Ancheta says.

The importance of education notwithstanding, the biggest challenge at Avon remained its limited geriatric-specific resources, he says, which the team addressed by creating a new role. By introducing “hybrid” geriatricians, who saw admitted patients at Avon as well as select ED patients who had been identified as being likely to benefit from a specialist evaluation. “The model gave us an effective way of maximizing the tools we had available,” he adds.

Charting a new course

Dr. Ancheta says he is encouraged by his team’s initial progress and pleased to see the hospital’s ED providers become increasingly comfortable managing geriatric presentations and making appropriate dispositions.

“We’ve discovered that there are ways to circumvent many of the obstacles that stand in the way of managing a geriatric ED,” he says. “Even with limited resources, we’ve found simple workflow adjustments can be very effective, especially when paired with staff education and age-friendly modifications to the physical facility.”

The program also helped Avon Hospital earn Level 2 Geriatric Emergency Department Accreditation (GEDA) from the American College of Emergency Physicians. (All Cleveland Clinic’s Northeast Ohio EDs currently hold at least Level 3 GEDA accreditation. Main Campus holds Level 1.)

Inspired by a virtual presentation Dr. Ancheta provided at the 2024 Annual Scientific Meeting of the American Geriatrics Society, hospital networks outside Cleveland Clinic have also expressed interest in adopting the hybrid staffing model, he says.

“Fortunately, our work has piqued the interest of other hospitals challenged with managing our country’s aging patient population,” Dr. Ancheta says. “Unfortunately, one size does not fit all, and ED processes must evolve to meet the complex care requirements of older adults. That kind of commitment is a cornerstone of Cleveland Clinic care.”