“SENIORS ONLY” Emergency Rooms – Why not in Maine, or elsewhere? By: Brett Seekins

Health care providers have been confronted with a number of challenges the last few years: The Affordable Care Act, reductions in payor revenue, a recovering economy, diverse consumer demands, litigation worries and HITECH. Not to mention transforming operations and policy that will improve quality, reduce cost side bloat and enhance the patient experience. As much as we talk about reducing readmissions, the game in town is to reduce the “admission.” So we're going to “case manage” and “community care transition” and “patient center medical home” would-be acute care admits back to their homes with services designed to keep them there. Policy worthy of merit given the aforementioned challenges. But what about our seniors? It has been well documented that Maine is the oldest state in the country. Aging is our future. As we plan, strategize and design health systems for the future, to be successful, we must rethink care treatment for our seniors. Arguably, seniors are most at risk for acute care admissions and readmissions. Developing successful plans of care for this demographic can be complex and inconstant. What might be working one week doesn’t the next; readmission and penalty. A prescribed secondary medication might be ineffective and counterproductive to the primary; readmission and penalty. During triage, a senior may not tell you their whole ‘story’; readmission and penalty. Now consider what a trip to the Emergency Room entails for our seniors. A sometimes dark, noisy and lengthy experience awaits registration and triage. This can lead to confusion, anxiety, restlessness and an inaccurate care plan; readmission and penalty. Seniors tend to travel in small circles, now they’re in the company of strangers and an unknown environment. This can be threatening. Imagine an experience where a senior visits an ER, registers and is then ushered to separate quarters to a ‘Senior Only” intervention? What would await them?

• A large, warm, well-lit non-glare, soundproofed room • Larger private patient examination rooms • Soft padded flooring for better stability and traction • Sidewalls with grab rails for safer better transport and mobility • Well cushioned, reclining seating to provide support and comfort • Reading material and all health related documents with a larger type font • Heated blankets • Enhanced communication systems for those that are hearing and/or vision impaired

As we analyze a traditional visit to the Emergency Room vs. triage in a Senior Only design, we can ask the following questions:

• Which setting is likely to produce the most accurate evaluation? • Which setting is likely to develop the most accurate and achievable plan of care? • Which setting is likely to advance patient responsibility discussion? • Which setting is likely to prevent the admission? Or, the readmission?

If we answered a Senior Only Emergency Room for all of the above, then we can assert that this experience has the potential to also improve quality, reduce cost, enhance the patient experience, reduce unnecessary

admission, reduce readmissions and penalties, prevent over-institutionalization, affect and improve patient responsibility and understanding — all leading to the best, most accurate and achievable plan of care. Upon design of the site, staffing is critical. Experienced geriatric nurses and physicians should be on staff or at least on-call. These professionals are specially trained in understanding and assessing senior care issues, asking the right questions and drawing out answers, conducting mental, behavioral and physical functioning examinations and conversant with family care givers, companions and Primary Care Physicians. One of the keys to developing accurate care plans is getting all the information you can about the patient upon the initial consultation. In a traditional Emergency Room setting, it’s quite possible this won’t happen; particularly if your senior patient has been sitting a long time, is cold, and is hungry and is thirsty. In this instance, when this person is finally evaluated, they just want to go home. You possibly won’t get the whole “story”. Result: Inaccurate plan of care; readmission and penalty. There were just over 50 Senior Emergency Rooms, or sometimes called Geriatric Emergency Department Intervention Rooms, in the country in 2014 with another 150 or so ER-like care centers specific to this demographic. Seniors represent 25% of ER visits world-wide making this potential, at the very least, something to study or pilot. Actual cost savings from this specialty focused triage is becoming more available as this trend reaches scale. The cost side dependency is related to the unique capital investment a hospital would need to make to retrofit and / or develop a Senior Emergency Room. As we continue to explore designs that achieve the strengths and balance of the “triple aim” a Senior Emergency Room could well be worth that investment in Maine, given our aging population. Brett Seekins is a Senior Manager with BNN’s Health Care Management Services division and directs the long term care practice for the firm. Brett is also Chairman of the Cape Elizabeth Senior Citizen Advisory Commission.