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D-H program to improve geriatric care to expand to other hospitals

Valley News Staff Writer
Published: 1/8/2021 9:42:30 PM
Modified: 1/8/2021 9:42:15 PM

LEBANON — Dartmouth-Hitchcock plans to expand an initiative providing specialized geriatric emergency room services to four smaller hospitals in the Upper Valley.

As it stands now, visitors to Dartmouth-Hitchcock Medical Center’s emergency department who are over age 65 can expect to answer a series of questions to screen for health issues common in older adults.

The questions seek to assess problems such as the risk of falls, cognitive changes and elder abuse or neglect and are part of the hospital’s effort to attain accreditation as a Level 1 geriatric emergency department from the American College of Emergency Physicians through a collaboration with the California-based nonprofit West Health. The hospital first announced the $4.5 million collaboration in the fall of 2019.

Some elements of the project might be less obvious to patients and caregivers because they involve clinicians in the emergency department consulting geriatricians and care managers as to how best to proceed with an individual’s care based on their wishes and goals, Dr. Daniel Stadler, a D-H geriatrician involved with the project, said in a Friday phone interview.

“One thing that COVID has really brought to the fore amongst the elderly population (is a) focus on goals of care,” said Stadler. “What do I want; what don’t I want in the event of an acute illness?”

The project is now set to roll out to Alice Peck Day Memorial Hospital in Lebanon and Mt. Ascutney Hospital and Health Center in Windsor — both D-H health system members — and then to Gifford Medical Center in Randolph and Valley Regional Hospital in Claremont.

Frail elders may end up in the emergency department because they don’t have another place to go, but emergency departments are primarily designed to keep people alive by working quickly, Stadler said. That might not be what an elderly person wants in the face of an acute illness, he said.

The need to answer questions about the care elderly patients want became “so much more palpable” during the COVID-19 pandemic, said Stadler, who as medical director of Hanover Terrace oversaw care of residents there during the largest outbreak in the Upper Valley so far in the pandemic. He said all residents were recovered as of Friday.

Eight residents have died during the outbreak, which has infected 111 people in total.

The pandemic “took some wind out of our sails,” said Dr. Scott Rodi, D-H’s emergency medicine section chief who is also involved in the project.

It has meant the hospital couldn’t convert part of the emergency department to space for evaluating seniors because the area slated for that purpose had to be used as negative pressure rooms to care for those with COVID-19, said Rodi.

The department also has four open positions — two for geriatric emergency medicine nurses, another for a dedicated physical therapist and the fourth for a pharmacist — that it has so far been unable to fill, Rodi said.

“That’s been an unexpected barrier,” Rodi said.

In spite of the challenges, the project continues to make progress. Rodi said he expects that DHMC will receive its accreditation soon.

While the negative pressure rooms may not yet be available for the geriatric ED purpose, he said the hospital plans to install some art with “calming” nature scenes in some other exam rooms, as well as clocks with larger text to make them easier to read.

At DHMC, the initiative has included improving patients’ access to devices to help them better navigate the emergency department such as walkers and canes, as well as sound amplifiers known as “pocket talkers” for the hearing impaired, said Stadler.

While data isn’t yet available on whether the project is improving health outcomes, anecdotally Rodi said he is aware of instances in which a patient’s care plan has been altered to a less aggressive one after emergency department clinicians have consulted with a geriatric case manager.

In a news release on Wednesday, Dartmouth-Hitchcock and West Health said the four small hospitals would serve as “spokes” from DHMC’s “hub” geriatric emergency department, and will enable clinicians at APD, Ascutney and the two other hospitals to consult, using telemedicine technology, with geriatricians at DHMC.

“We think this is going to be a great project,” said Dr. Joseph Perras, CEO of Mt. Ascutney.

Perras noted that the average age of patients in Mt. Ascutney’s emergency department is somewhere in the 70s, and that Vermont and New Hampshire’s populations are among the oldest in the country with the average age expected to increase in coming years.

As at DHMC, Perras said the project will entail some changes to the emergency department’s physical spaces, as well as asking screening questions specific to patients over age 65.

It also will include training of clinicians in the emergency department to increase their knowledge of health concerns of older adults, along with the telehealth support from DHMC specialists.

Both Perras and Dr. Michael Lynch, APD’s chief medical officer, said that the same illness may look different in older adults than it would in younger ones.

Officials hope the project will reduce hospital admissions and readmission, as well as improve the diagnosis and treatment of patients with delirium and dementia, he said.

While different elements of the project will “go live” as they are available, Perras said he thought it would be fully implemented in the next six months or so “as the pandemic is winding down.”

Nora Doyle-Burr can be reached at ndoyleburr@ or 603-727-3213.

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