Human connection can be more powerful than drugs.
As an emergency physician who cares for older adults, I see this every day. However, my conviction in the healing power of human contact was solidified as a grandson who struggled to find appropriate care for my own grandmother in the last years of her life.
In 2010 my Grandma Margaret was at a rehabilitation facility in New Jersey recovering from pacemaker surgery when she fell. Prior to her fall, she had mild dementia but normal mobility. The local emergency department that evaluated her after falling quickly released her back to the rehabilitation facility with a clean bill of health even though she could not walk. Several days later, she still was not walking and in severe pain. Grandma was taken back to the hospital to be reevaluated. This time, she was diagnosed with a pelvic fracture. Grandma’s fall and broken pelvis precipitated her rapid decline, but her missed fracture could have been avoided.
My interaction with the health care system was always as a clinician, but experiencing it from the caregiver's perspective made me realize health care needed to do better when it came to caring for our seniors.
Older adults in the emergency department generally have more complex medical conditions and care needs than younger patients. They need more time and attention than other age groups, a luxury not always afforded in a typical emergency department. When they arrive scared and alone like my grandmother did on her first trip to the hospital, the care needs increase. Her dementia, coupled with the pain she was experiencing, most likely made the ambulance ride and hospital visit even more stressful and confusing. The bright lights, beeping medical machines, and unfamiliar faces compounded her anxiety. And no one was there to hold her hand or talk with her. No older adult should ever have this type of disorienting experience.
After my grandmother’s fall, I experienced the limitations of elder care first hand. As her grandson I knew she and all older adults deserved better. So the doctor in me set to work on a model that better understands and treats the complex needs of older adults patients with compassion.
DEDICATED GERIATRIC EMERGENCY DEPARTMENT
I began to envision the concept of a dedicated geriatric emergency department, and at Mount Sinai Hospital, along with my colleague Dr. Ula Y. Hwang, and others, we created one of the country’s first emergency departments dedicated to those over the age of 60. A geriatric emergency department not only reduces return hospitalizations but by creating the calm, slower pace needed for older patients to express themselves more clearly, it can cut down on medical mistakes, like my grandmother's missed pelvis fracture. Geriatric emergency departments provide better outcomes for patients by combining high tech approaches with more simple ones. Everything from the use of iPads to improve ambiance through lighting and music to increased use of handrails can make a difference.
VOLUNTEERS and SOCIAL WORKERS IMPROVE PATIENT OUTCOME
Even if a hospital system does not have a dedicated geriatric emergency department, elder patient outcomes can be improved with dedicated human interaction from trained professionals and volunteers. At Mount Sinai Hospital, having social workers and nurse care managers as part of our multi-disciplinary approach to the delivery of care in an emergency setting, improved patient satisfaction. Research for which I was co-author and co-investigator showed this type of approach in Geriatric Emergency Departments programs not only improved patient outcomes, but also significantly reduced costs up to $3,200 per Medicare beneficiary. Our findings were recently published in JAMA Network Open™ and were the first to quantify the potential cost savings of Geriatric Emergency Department programs.
We also developed a way for non-professionals to make a difference for seniors through Care and Respect for Elders with Emergencies (CARE), a geriatric‐focused volunteer program designed to reorient high-risk, unaccompanied seniors. CARE volunteers are trained to discuss distinct historical events or milestones in senior’s lives. These memories are easier for older adults with early memory loss to remember and convey, and the discussions calm patients down.
CARE volunteers give patients additional attention in a chaotic environment and potentially prevent complications such as falls, delirium, and the need for interventions like restraints. Though these extraordinary volunteers are not medical professionals or patients’ family members, their care and attention can improve patient outcomes, patient satisfaction and bring much-needed comfort and peace to a vulnerable population. While CARE is temporarily on hold due to COVID-19, more than a dozen hospitals in the United States and health systems in Australia and Canada have utilized the volunteer model first developed at Mount Sinai Hospital. Again, the concept of human connection matters.
HOSPITAL IMPROVEMENTS
As Chair of the Emergency Department of Pennsylvania Hospital, I have created, with colleagues from nursing, facilities, and physician leadership the Committee for Older Adult Care and Health (COACH), a hospital-wide committee focused on changing how we care for older adults. Since the creation of COACH, we have worked hard to receive national accreditation and recognition for many of our programs because we’ve found its often the small things that can make the biggest difference for our older patients. Amenities like floors with smooth transitions, clocks with big, readable numbers, and lights that better mimic daylight to avoid the “sun downing”, the confusion and anxiety so many seniors experience in the evening, all of which greatly enhance patient satisfaction and safety.
WHAT MATTERS?
But I think the most meaningful change has been asking older adult patients one simple question- “What matters to you?”. We continue to ask patients about medical history, mobility and what drugs they are taking, but by asking older adults what matters most to them when initiating a care plan, we are humanizing them and getting to the heart of the care they need. I believe this question can help patients better express what they want and potentially help physicians have better communication with patients and families, leading to better, more nuanced care.
I recently cared for a woman in her 80s whose niece brought her to my emergency department after her most recent fall. She had memory loss and was dependent on others for her care. After a full work up in the emergency department, my options included hospitalization or admission to a skilled nursing facility. But first, I asked her, “What matters to you?” She told me she loved to work in her garden and spend her days there. Her niece agreed that that was where her aunt was happiest. Instead of admission, one of our social workers, Angela D’Ambrosio, set up at-home follow up appointments, home care services and tele-visits with a geriatrician. I recently received a lovely thank you note from the patient’s niece. Her aunt died three weeks after I treated her- at home, and happy, near her garden. That’s what matters.
No one took the time to ask my Grandma Margaret if she could walk prior to her emergency room visit. There was no volunteer to sit at her bedside to try and reorient her after the ambulance ride. There was no social worker to offer resources. No enhanced measures were taken to make the environment more comforting for her. And no one asked my Grandma Margaret what mattered most to her. With just one of these interventions, her outcome may have been different. For older adults, medical interventions matter, but human interactions matter more.
Kevin M. Baumlin, MD, FACEP, is the Chair of Emergency Medicine at Pennsylvania Hospital, and Vice Chair of Emergency Medicine for the Perelman School of Medicine. Dr. Baumlin is Co-Founder of OAK Street Initiative.
Opinions expressed in this article do not represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.