Public Health Emergency - Leading a Nation Prepared
Author: Brendan Carr, M.D., director, ASPR Emergency Care Coordination Center, and Aisha Hasan, policy analyst, ASPR Division of Health System Policy Published Date: 8/7/2015 4:12:00 PM
Category: Hospital Preparedness; Public Health Preparedness;
Mr. G is 92 years old. He’s at home Friday at 8 p.m. He suddenly feels nauseated, a tad dizzy, and a bit unsteady on his feet. He recalls when he felt like this before, the culprit was dehydration. But how can he be sure? His primary care doctor’s office is closed at this hour, so he calls 911. An ambulance takes him to the nearest emergency department (ED). After a few bags of IV fluid, the symptoms are gone, and he feels much better.
The diagnosis? Dehydration. But now it’s close to 3 a.m. The only person at home is his 87-year-old wife, and he does not want to bother her at this hour. So, he accepts his doctor’s offer to be admitted for the evening. With troubling results on standard blood tests, Mr. G’s one-evening stay turned into two weeks. As with a third of all geriatric inpatient admissions, Mr. G experienced a functional decline during his hospitalization. He reached a point where physicians recommended discharge to a rehabilitation facility to reverse the deconditioning that took place during those two weeks. Four weeks later, Mr. G was discharged to home after case managers set up home nursing.
How could this story have been different if a trained paramedic had come to Mr. G’s house and assessed him without bringing him to the nearest ED? Or, if he could have used his phone to video-chat with a doctor and been guided through steps that prevented a trip to the ED?
Acute unscheduled care can refer to new injuries or illness, as well as exacerbations of chronic conditions. When older adults get sick or injured, they seek care in doctors’ offices, urgent care centers, retail clinics, and EDs. There are over 500 visits to EDs annually for every 1,000 adults over 65 in the U.S., and this is expected to increase.
U.S. Census results from 2000 to 2010 indicate that the geriatric population increased at a faster rate than the total U.S. population; in 2010 there were more than 40 million Americans over age 65. In 2000, Americans over 65 made up 12.4 percent of the population; by 2030, this population is expected to grow to 72 million – 19 percent of the U.S. population. As people live longer, more active lives with more chronic medical conditions, we will likely see an increased demand for acute care and a need for better coordination of care across the healthcare continuum. By improving these everyday systems, we also better position our communities to withstand disasters and public health emergencies.
Effective care coordination for the aging population requires a team effort between emergency medical service (EMS) practitioners, primary care providers, EDs, and geriatric EDs, as well as new care delivery models, such as on-demand telemedicine and public health. The nation’s healthcare workforce must be trained to address the increasing demands of our country’s aging population in patient-centered models.
That’s where ASPR’s Emergency Care Coordination Center (ECCC) comes in: as a thought leader to develop and socialize policies that increase effectiveness of acute unscheduled care, including for older adults. The center leads the U.S. government’s efforts to drive change in the emergency care system. The country needs patient- and community-centered emergency care that is integrated into the broader healthcare system, high-quality, and prepared to respond in public health emergencies.
To expand the dialogue on acute unscheduled care for older adults, the ECCC led three interactive sessions at the Healthy Aging Summit ,
July 27-28 in Washington, D.C. During these sessions, policy makers, researchers, clinicians, educators, and public health practitioners from throughout the U.S. discussed acute unscheduled care for the aging population and how to catalyze a more tailored, evidenced-based care structure.
Participants talked about a quandary: novel, well-intentioned, healthcare delivery models, ranging from urgent care centers to telemedicine, are often more patient-centered, but run the risk of disrupting care continuity. So, careful care coordination is extremely important. A lot of older people have multiple co-morbid conditions, use more healthcare services, and take multiple medications. To support these unique needs, developing novel healthcare delivery models must make sure to be individually tailored, based on evidence, and well-coordinated across multiple care providers and settings of care.
Experts from the Icahn School of Medicine at Mount Sinai, University of Wisconsin, Aurora Health Care, WellMed Charitable Foundation, and the ECCC described the epidemiology of ED use and alternate models of acute care. Participants shared stories, including Mr. G’s, which demonstrated the need for a change in the way acute unscheduled health care is delivered to the elderly. Innovators in the field discussed their ideas, some of which are currently being implemented and studied. For example:
Telemedicine: In Rochester, New York, older adults with acute illnesses receive a “virtual visit” from physicians. These visits are facilitated by telepresenters (e.g. EMTs, nurses’ aides) who obtain objective health data, such as vital signs, images (e.g., of rashes), video (e.g., of movement), sounds (e.g., lung, heart) and labs results. Interventions can then be prescribed to treat the illnesses.
Geriatric EDs: In New York City, certain EDs have modified how care is structured and the process for care in order to introduce preventive medicine during acute care visits. A new interdisciplinary approach that includes social workers, pharmacists, an primary care physicians allows the ED to play a central role in coordinating care. This approach ultimately leads to fewer hospital admissions, decreased costs, and - most importantly - improved patient care.
Regardless of where care is delivered, it must meet older adults’ needs on their own terms. At least some of the time, those terms do not include a prolonged hospitalization such as the one Mr. G experienced. Substantial effort is being spent on avoiding visits to the ED whenever possible and this is important work. Moving forward, it is essential to focus on prevention, optimizing the experience in the care setting (ED or otherwise) and ensuring transition back to the usual source of care.
How is acute unscheduled care working for older adults in your community? What policies and recommendations should be included to ensure the best care for a specific population? How can the emergency care system be reformed to provide more patient-centered care? Comment on this blog or email us at ECCC@hhs.gov with your thoughts and ideas.
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