Ula Hwang

The Centers for Medicare & Medicaid Services recently introduced 2 clinical quality measures that intend, in part, to disincentivize hospital boarding: a patient safety concern that involves holding admitted patients in the emergency department while an inpatient bed is unavailable. The Age-Friendly Hospital Measure (AFHM), a structural measure, asks hospitals to attest to having protocols in place to reduce boarding for older patients. The Emergency Care Access and Timeliness (ECAT) measure, an intermediate outcome measure, will require hospitals to report on the proportion of boarded patients. Each measure was developed under a different parent quality reporting program—1 inpatient and 1 outpatient—which has the unintended consequence of producing meaningful variation between the measures. We describe opportunities to standardize and synergize the AFHM and ECAT to capture the prevalence of boarding uniformly, prevent gamesmanship, and enhance their impact on hospital performance. In particular, we highlight the importance of stratifying ECAT by the older-adult patient population to complement AFHM and since older adults are uniquely vulnerable to boarding and its associated safety risks.

Background: Three San Francisco health system emergency departments have developed Geriatric Emergency Department (GED) models of care programs supporting and providing care for emergency department (ED) patients at risk for or living with dementia. Each system recognized: 1) the high proportion of older adult ED patients and those at risk for dementia, 2) the need to identify cognitive impairment in older adult ED patients, 3) the importance of developing approaches to connect older adult ED patients and their care partners with resources and diagnostic specialty services. Methods: We describe how each hospital adopted and implemented pragmatic GED models of care to support and improve care for ED patients at risk or living with dementia. We also report the proportion of ED encounters made by patients with dementia histories and the number of these reached by GED programs. Results: Three San Francisco hospitals (a tertiary care, critical access, and large integrated health system-community ED) independently implemented GED programs to support and enhance emergency care for patients living with dementia. Each uses screening and assessment tools to identify patients at risk for cognitive impairment. Each captures screening and assessment data to facilitate care and resources for post-discharge care, ensuring coordinated transitions and support for older adults. Programs varied by target patient population age and staff and resource allocation to support program goals. Site-specific pathways differed by location, patient populations, and support from geriatrics, emergency medicine, palliative medicine, neurology, psychiatry, pharmacy, referral processes, and/or pastoral care. Conclusions: Developing GED care interventions that facilitate care for patients at risk of or living with dementia is possible and sustainable when the pathway aligns with health system leadership goals through persistent value demonstration, communication, and promotion. Ultimately, developing and disseminating models of GED care is designed to address geriatric syndromes inclusive of dementia care through continuous quality improvement. KEY POINTS: This paper demonstrates the feasibility of implementing Geriatric ED programs with targeted support for people living with or at risk for dementia across three distinct health systems in San Francisco. We describe the reach and implementation processes of each program including commonalities, differences, challenges faced, and opportunities for future improvement. Creating unique care pathways for older adults and those with cognitive impairment in the emergency department (ED) is often guided by health system resources. Assessing cognition and identifying potential dementia is feasible during an ED visit. An interprofessional approach to geriatric ED care is essential to sustainability and success.

Introduction: More than half of older adults with Alzheimer's Disease and Related Dementias (ADRD) are undiagnosed, limiting timely access to person‐centered care. Therefore, clinicians, researchers, and population health managers need scalable, reproducible approaches to monitor both prevalence and diagnostic gaps. We evaluated whether a decision‐analytic modeling framework can translate a limited number of clinician‐adjudicated cases of ADRD into a probabilistic computational phenotype for accurate, population‐level assignments of probable ADRD in the emergency department (ED) setting using routinely collected electronic health record (EHR) data. Methods: Retrospective cohort study of 5000 adults aged ≥ 65 years from nine EDs within a large integrated health system (2014–2022). We randomly selected 500 individuals for clinician adjudication of dementia status (reference cohort), reserving the remaining 4500 as a phenotyping cohort. We developed the phenotype as a logistic regression model trained on adjudicated cases, embedding pattern‐mixture multiple imputation to address information bias. We applied decision‐curve analysis to evaluate clinical utility across probabilistic thresholds. We applied the phenotype to assign dementia status to 4500 unadjudicated patients and compared clinical characteristics to adjudicated cases. Results: The mean (SD) age was 77.4 (9.0) years; 55.4% were women; 102 individuals (20.4%) had clinician‐adjudicated ADRD. The model demonstrated good discrimination (AUROC 0.87; 95% CI 0.82–0.91). Decision‐curve analysis revealed net clinical benefit across examined thresholds (predicted probabilities 12%–32%), identifying an additional 16–18 probable ADRD cases per 100 older adults. Among those without ADRD‐related diagnosis codes, net benefit ranged from 8 to 13 additional correct identifications per 100. Phenotype‐assigned cases closely resembled clinician‐adjudicated cases (standardized mean differences ≤ 0.20). Conclusions: A probabilistic computational phenotype derived from routinely collected EHR data accurately reproduced clinician‐adjudicated ADRD status and demonstrated net clinical benefit, including among ED patients whose ADRD was not captured by diagnosis codes. Adoption of this replicable framework may enable healthcare organizations to strengthen ADRD surveillance and reduce underdiagnosis.

Study Objective: Emergency department (ED) visits among older adults represent critical transition points in health care, often resulting in substantial downstream utilization. We aimed to quantify health care contact days in the 30 days following a treat‐and‐release ED visit among older adults and examine associations with demographic and clinical characteristics. Methods: We conducted a pooled cross‐sectional analysis of 2016–2021 Medicare Current Beneficiary Survey data. The sample included treat‐and‐release ED visits among beneficiaries ≥ 65 years. Health care contact days were categorized as institutional (ED, hospital, skilled nursing facility, hospice) and ambulatory (outpatient visits, labs, imaging, procedures, or treatments). We applied zero‐inflated Poisson regression to estimate the likelihood and intensity of health care contact. Results: The analytic sample comprised 10,964 treat‐and‐release ED visits. Within 30 days, 22.5% of visits resulted in institutional contact and 84.4% in ambulatory contact. On average, each ED visit was followed by 4.3 total contact days (3.0 ambulatory, 1.3 institutional) within 30 days. Having ≥ 2 chronic conditions was associated with greater odds of both institutional (OR: 1.46, 95% CI: 1.28–1.66) and ambulatory contact (OR: 1.44, 95% CI: 1.25–1.66). Dementia was associated with reduced odds of ambulatory contact (OR: 0.51, 95% CI: 0.37–0.72). Conclusions: Older adults experience frequent and sustained health care contact following treat‐and‐release ED visits, with particularly high intensity among those with multi‐morbidity. Reduced ambulatory follow‐up among patients with dementia highlights a potential gap in care coordination after ED discharge.

Background: Since 2018, the Geriatric Emergency Department (GED) Accreditation Program has recognized Emergency Departments (EDs) that provide high‐quality care tailored to older adults. GEDs have expanded rapidly across the United States in recent years, but little is known about how GED care is associated with patient outcomes, including hospital admissions and subsequent mortality. Methods: We used the 2018–2021 Health and Retirement Study (HRS)‐Medicare linked data of adults aged ≥ 65 years. We supplemented these data with the American College of Emergency Physicians (ACEP) GED accreditation list and American Hospital Association (AHA) data. Receipt of acute care in a GED was defined as having an ED visit at a GED. Patient‐level analyses were conducted using each individual's most recent ED visit. Multivariable logistic regression models were used to estimate associations between receipt of acute care in a GED and outcomes of hospital admission and 30‐day mortality, adjusting for patient demographics, socioeconomic status, health conditions, ED visit severity, and hospital‐level characteristics. Results: Among 4563 older adults who had an ED visit, 270 (5.9%) received acute care in GEDs and 4293 (94.1%) received non‐GED care. Compared with those treated in non‐GEDs, patients treated in GEDs had significantly lower odds of hospital admission (OR, 0.61; 95% CI, 0.42–0.87; p < 0.01) and 30‐day mortality (OR, 0.62; 95% CI, 0.40–0.96; p < 0.05). Subgroup analyses showed that the association with admission was more pronounced among adults aged 65–80 years (OR, 0.43; 95% CI, 0.24–0.76; p < 0.01) and non‐Hispanic White individuals (OR, 0.51; 95% CI, 0.34–0.78). An association with lower mortality was observed among non‐Hispanic White individuals (OR, 0.51; 95% CI, 0.30–0.87; p < 0.05). Conclusions: GED care was associated with lower odds of hospital admissions and 30‐day mortality among older adults. Broader implementation may expand the reach of GED programs across diverse populations.

Introduction: The rapidly ageing population and multimorbidity are associated with increased emergency department (ED) visits by older adults. In the ED, older adults have higher risk of hospitalization, functional and cognitive decline, and mortality. Boarding, holding admitted patients in the ED awaiting a hospital bed, exacerbates these negative outcomes, which disproportionately affect older adults. Methods: We conducted a cross-sectional analysis to investigate US boarding trends by age using clinical administrative data from 5 health systems and publicly available NHAMCS data from 2018 to 2024. Results: Boarding ≥3 h in the ED has increased across diverse hospital types, with oldest adults (85+) facing the greatest risk (System 4: IRR [95% CI] = 1.18 [1.15-1.20], System 5: IRR [95% CI] = 1.20 [1.17-1.23], System 3 [Community Hospital]: IRR [95% CI] = 1.25 [1.19-1.33]). These results were recapitulated at the national level in NHAMCS (IRR [95% CI] = 1.30 [1.05-1.61]). Discussion: The trend of increased boarding has serious implications for patients, caregivers, and health systems. The 2025 CMS Age-Friendly Hospital Measure offers opportunities to improve processes and procedures to mitigate the negative effects of hospital boarding on older patients. We highlight opportunities to address this challenge, including ongoing quality improvement initiatives, bed prioritization algorithms, and alternate admission pathways.

Objectives: Multicenter research of geriatric emergency department (GED) care remains limited. Our objectives were to: 1. Prospectively collect data prioritized by the Geriatric Emergency care Applied Research (GEAR) network, a transdisciplinary taskforce for GED care, and create a multicenter GED research repository of prospective and electronic health record (EHR) data, 2. Assess concordance between prospective and EHR data. Methods: The GEAR Standardization Study (GEARSS) is a multicenter, prospective study of older emergency department (ED) patients (65+) focusing on the 4Ms of age‐friendly care (mobility, medication safety, mentation, what matters) and elder mistreatment. Demographic and clinical data were collected via interviews by trained research assistants (RA) on Days 0, 4, 30, and 90 and linked to EHR. Prevalence of chronic comorbidities and incident delirium were measured and reported using descriptive statistics. Prospective and EHR data concordance was assessed with Cohen's Kappa. Results: 999 participants were recruited from 5 EDs (3/25/2021–6/30/2022) across 3 institutions: Grady Health System, Northwestern Memorial Hospital, and Yale New Haven Health. The cohort was 57.0% female, 55.2% White, 39.1% Black, and 3.4% Hispanic, and the mean age was 75.1 years. For rheumatologic disease, peptic ulcer disease, diabetes, renal disease, and cancer, prevalence differed between prospective and EHR data by > 10%. About two‐thirds of participants were at risk for falls. Concordance between prospective and EHR data was good for ethnicity ( K = 0.73); excellent for sex ( K = 1.00), age ( K = 1.00), and race ( K = 0.98); fair for disposition ( K = 0.53); slight for ED observation status ( K = 0.33) and dementia diagnosis ( K = 0.24); poor for delirium presence ( K = 0.07). Conclusion: In GEARSS, demographic variables aligned strongly between prospective and EHR data, while diagnosis, disposition, and mentation factors did not. This multicenter data source provides preliminary findings for common geriatric syndromes and conditions. Choice of measures using these data should be driven by GED research questions.

Persons Living with Dementia (PLWD), diagnosed or undiagnosed, have high Emergency Department (ED) use. Identification of such patients poses significant challenges for emergency clinicians with considerable downstream implications on patients, care partners, and healthcare systems. With the advent of Geriatric Emergency Departments (GEDs) there is an opportunity to understand and improve care of PLWDs in EDs with effective allocation of resources and the development of novel techniques to better support detecting those at risk, communicating findings, and coordinating care for such patients. Advances have been made leveraging Electronic Health Record (EHR) data to risk stratify patients for dementia in the hope that those at high‐risk may benefit from further evaluation. The promise of multiple blood‐base biomarkers (BBM) as a future modality to improve detection of those at risk of dementias, will also have the potential to advance the delivery of care of PLWD and their care partners in EDs.Highlights: EDs have an integral role in delivering care for Person Living with Dementia and their care partners. High acuity and fast paced ED environment and other barriers makes it difficult to identify Person Living with Dementia. EHR‐based risk stratification algorithms can identify patients at risk for Dementia in ED and outpatient settings. Use of Blood‐Based Biomarkers in the ED setting is novel and considerations of its use and implications need to be studied. EHR based risk stratification algorithm and Blood Based Biomarkers when used judiciously have the potential to overcome some of the known barriers to identify and improve care for Person Living with Dementia as they transition through EDs.

A core tenant of the Geriatric Emergency care Applied Research Network 2.0—Advancing Dementia Care (GEAR 2.0‐ADC) is the inclusion of community members during all stages of clinical research. As such, we deliberately integrated and supported patient and public involvement in the evaluation and selection of GEAR 2.0‐ADC Pilot Research Grants by developing and adapting traditional grant application review structures, with input from community members, to create the GEAR 2.0‐ADC Community Review Committee approach. Community members, including persons living with dementia, effectively participated in all three rounds of research grant application review and selection, complementing the traditional scientific review process. The structure and flexibility of the GEAR 2.0‐ADC Community Review Committee approach serve as a model for patient and public grant application review involvement with strong potential for applications across grant reviews in other medical specialties.