Generations_PowerofData

GENERATIONS – Journal of the American Society on Aging

The Power of Data Can Support Effective Response to Elder Mistreatment in Hospital Emergency Departments By Kim Dash,

The Elder Mistreatment Emergency Department Assessment Profile and the Geriatric Emergency Care Applied Research Network are effective approaches to mitigating elder mistreatment.

Tony Rosen, Kevin Biese, Timothy F. Platts-Mills, and Ula Hwang

E lder mistreatment is common, with as many as 10 percent of community-dwelling adults ages 60 and older (Connolly, Brandl, and Breckman, 2014; Lachs and Pillemer, 2015), and more than 20 percent of long-term-care residents (Lachs et al., 2016) being victimized each year. This mis- treatment includes physical abuse; sexual abuse; neglect; verbal, emotional, and psychological abuse; and fnancial exploitation. Elder mistreatment leads to dramatically increased mortality, as well as to the develop- ment of depression, dementia, and worsened chronic conditions (Dyer et al., 2000; Lachs et al., 1998). Annual medical and other costs asso- ciated with elder mistreatment are estimated in the many billions of dollars (Connolly, Brandl, and Breckman, 2014). The burden and cost of elder mistreatment is likely to grow substan-

tially with the anticipated growth of the older adult population. Identifcation of and intervention in elder mistreatment should be a major public health priority. Yet, elder mistreatment is infrequently detected. Research suggests that only one in twenty-four cases of mistreatment is identi- fed and reported to the authorities (Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center, and New York City Department for the Aging, 2011). Inadequate detection increases the likelihood of poor outcomes. Hospital emergency department (ED) vis- its provide an important opportunity to identify older adults who are at risk of or are experienc- ing mistreatment, as well as to report and inter- vene when appropriate (Fulmer et al., 2005; Rosen et al., 2016; Rosen et al., 2018). Assess-

abstract Hospital emergency departments (ED) are in a unique position to advance best practices for identifying and responding to suspected cases of elder mistreatment. But implementing programs to improve ED clinical practice is challenging given competing priorities, systems barriers, and ED resource variation. Leaders in elder mistreatment prevention/identification/management, emergency medicine, and implementation science have developed approaches for using data to help EDs adopt such best practices. This article describes the Elder Mistreatment Emergency Department Assessment Profile and the Geriatric Emergency Care Applied Research Network. | key words : elder mistreatment, emergency department, implementation, data-driven decision-making, organizational assessment, patient outcomes

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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ment by a medical provider may be the only time a socially isolated older adult leaves their home or the institution in which they live, and elder mistreatment victims more commonly receive emergency care than outpatient care (Rosen et al., 2016; Rosen et al., 2018). But currently, pro- viders infrequently identify elder mistreatment during ED visits (Evans et al., 2017; Rosen et al., 2018); reasons for this include inadequate medi- cal provider education, and the absence in most EDs of tools and protocols to facilitate detection and response. To address this problem, the National Colla- boratory to Address Elder Mistreatment (The Collaboratory) was formed in 2016 with sup- port from The John A. Hartford Foundation and the Gordon and Betty Moore Foundation. ‘EDs are challenging environments with competing priorities; and implementing new programs is often difficult.’ The Collaboratory and Other Cooperative Initiatives Converge A multidisciplinary group of leaders in the feld of geriatrics and gerontology that had previ- ously been conducting independent research and program development to prevent and address elder mistreatment, The Collaboratory has pooled expertise to develop a preliminary ver- sion of a comprehensive care model that EDs can use to respond to elder mistreatment. This model includes tools and training designed to assess gaps in current processes and readiness for change, as well as protocols for screening, response, and links to coordinated care and sup- port services for at-risk older adults. Converging with The Collaboratory’s work have been efforts to strengthen hospital EDs so that ED clinicians are better able to provide opti- mal emergency care for older adults. To facilitate

improvements in ED geriatric care, Carpenter and colleagues (2014) developed an interorga- nizational, cross-specialty task force that pub- lished the Geriatric Emergency Department Guidelines, highlighting the importance of edu- cation and protocols around elder mistreatment identifcation as quality improvement initiatives. Based on these guidelines, the American Col- lege of Emergency Physicians (ACEP) in 2018 launched the Geriatric Emergency Department Accreditation (GEDA) program. The GEDA program accredits EDs for geri- atric expertise at different levels (Gold, Silver, and Bronze), based on steps an ED takes to opti- mize care for frail older adults (ACEP, 2019a). One option hospitals can choose to fulfll these accreditation criteria is to implement a protocol to identify elder mistreatment and provide appro- priate follow-up in such cases (ACEP, 2019b). A separate Geriatric Emergency Department Collaborative (GEDC), in which thirty-one EDs are participating, and which is supported by The John A. Hartford Foundation and the West Health Institute, works to defne, disseminate, and measure the impact of best practices in geri- atric emergency care, including elder mistreat- ment identifcation and response. Cooperative efforts such as The Collabo- ratory, GEDA, and GEDC can drive important change in EDs to improve the identifcation of and response to suspected cases of elder mistreatment. However, EDs are challeng- ing environments with competing priorities; and implementing new programs is often dif- fcult and resource-intensive, and can affect other operations. Therefore, The Collaboratory, GEDA, and GEDC use data to demonstrate the value of the changes in clinical practice needed to improve elder mistreatment identifcation and response, and how data can support and inform such changes. Additionally, data may motivate change. Two emergent efforts aim to harness data to promote practice change: The Collaboratory’s Elder Mis- treatment–Emergency Department Assessment

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GENERATIONS – Journal of the American Society on Aging

Profle (EM-EDAP) and the GEDA and GEDC’s GEAR Network.

increase identifcation of and response to elder mistreatment. Additionally, hospitals may use EM-EDAP results to compare their readiness to implement improvements in the identifcation and management of elder mistreatment with that of other hospitals; and may administer the assess- ment periodically to monitor changes in hospital ED practices over time after implementation. The EM-EDAP includes twenty items, with sub-items that cover the following domains: how often elder mistreatment is encountered in prac- tice and how it is managed; the existence of for- mal policies and training protocols surrounding elder mistreatment; attitudes about the issue’s importance and the quality of current approach­ es to response; relationships to community resources; and the relative importance of bar- riers, previously described in the literature and within the ED, to addressing elder mistreatment Items also take into account issues such as the role of various disciplines within the ED for elder mistreatment identifcation and response. Additionally, given that hospital EDs are open 24/7, items also focus on differences between approaches taken during the weekdays versus those applied on nights and weekends. Com- bined results of the EM-EDAP from providers at an individual hospital ED may provide evidence of need for improvement and important motiva- tion to drive implementation of new protocols. The Geriatric Emergency Care Applied Research Network Both the GEDA and GEDC programs offer vec- tors to rapidly and effectively spread best prac- tices across multiple EDs. By training EDs in best practices for elder mistreatment screening and intervention, and offering toolkits to facili- tate implementation, the GEDC can encourage expedited and comprehensive adaptation of best ED elder mistreatment interventions. GEDA, by encouraging elder mistreatment screening and intervention and thinking of it as a qual- ity improvement program through which to gain accreditation, it can signifcantly enhance

The Elder Mistreatment Emergency Department Assessment Profile

Identification of and intervention in elder mistreatment should be a major public health priority. Careful assessment of current processes, staff attitudes and knowledge, barriers, gaps, and readiness for change is a crucial component for successfully implementing new programs. To help hospital EDs systematically assess issues surrounding elder mistreatment in that environ- ment, The Collaboratory in 2019 developed the Elder Mistreatment–Emergency Department Assessment Profle (EM-EDAP). The EM-EDAP is a short, self-adminis- tered online survey tool for frontline ED provid- ers frommultiple disciplines. It is modeled on the Geriatric Institutional Assessment Protocol (GIAP), a self-report survey designed to evalu- ate a hospital’s readiness to implement a geri- atric program in the hospital setting (Abraham et al., 1999). It also draws upon a 2016 survey of ED provider knowledge, attitudes, and practices around elder mistreatment developed at Weill Cornell Medicine. The Collaboratory developed the EM-EDAP using an iterative process with focus group feed- back, at several stages, from ED clinicians work- ing within diverse hospital settings, including large, urban teaching hospitals as well as small and rural community-based hospitals. Six hos- pitals have completed the EM-EDAP as part of an initial study to test the feasibility of adopting The Collaboratory’s comprehensive care model to address elder mistreatment. The EM-EDAP identifes important issues for hospital EDs that are planning to implement elements of The Collaboratory’s elder mistreat- ment care model, or other approaches that would

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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Taking Action Against Elder Mistreatment

uptake. Together, GEDC and GEDA have the potential to rapidly evolve ED practices around elder mistreatment. Since their launch in 2018, GEDA EDs already have had signifcant impact. As of February 2020, there were 130 accredited EDs in twenty-nine states, withmore than 250 EDs expressing inter- est and-or applying. These EDs have demonstrated decreased admissions (Hwang et al., 2018), and many of them also have reported decreased thirty- day repeat ED visits, reduced total hospital (ED and inpatient) lengths of stay, and total thirty-day patient costs. More than 90 percent of these EDs have been funded by hospitals or healthcare sys- tems without external support, suggesting that healthcare system leadership fnds signifcant value in accrediting their EDs as geriatric-appropriate. Still, despite the existence of Geriatric Emer- gency Department Guidelines and GEDA/GEDC activities, there are limited data and-or evidence describing what constitutes better quality geriat- ric emergency care. Even less is known about the ‘The GEAR Network has identified elder mistreatment screening and intervention as a high-priority research topic.’ impact such care may have on patient outcomes. Recognizing this, GEDC and GEDA leaders have formed the GEAR Network (see Authors’ Note at the end of the article). Funded by the National Institute on Aging, the GEAR Network is taking the following steps: establishing research priorities and standard- ized data approaches and measures for common geriatric emergency care syndromes; building a validated data bank to support opportunities to conduct geriatric emergency care research; and facilitating future multi-center pragmatic tri- als, dissemination, and implementation stud- ies, and other interdisciplinary projects that will further advance best practices in geriatric emer- gency care.

The GEAR Network has identifed elder mis- treatment screening and intervention as high- priority research topics and has assembled an interdisciplinary stakeholder task force to focus on them. This task force is reviewing existing lit- erature to identify the most important gaps in cur- rent evidence, to make recommendations about the most critical research questions that should be prioritized, and to identify relevant data elements that should be included in the data bank to sup- port ED-based elder mistreatment research. Preliminary fndings recognize the fol- lowing gaps in the evidence base: studies on the impact of elder mistreatment screening on patient outcomes; ideal outcomes to measure when assessing program effects on patients; ways to facilitate optimal program implemen- tation in the often under-resourced ED setting; and a way to address ethical challenges in elder mistreatment research. The GEAR Network, in its continued work to develop the infrastructure and data collection strategies that can answer these and related questions, is invaluable. GEAR may contribute signifcantly in providing the necessary data and evidence to facilitate the uptake of best practices for and assessments on whether these practices result in improved patient outcomes. Conclusion Increasingly, health leaders such as hospital presidents, health system CEOs, health founda- tions, and medical research scientists see the ED as an important setting for implementing public health interventions to address elder mistreatment, especially with elder mistreat- ment victims being more likely to seek care in the ED than in the outpatient setting (Rosen et al., 2018). Despite the push for interventions to address elder mistreatment in the ED, uptake of such interventions is complicated by competing priorities as well as by cultural, administrative, educational, technological, and systems barriers that vary across institutions (Geerligs et al., 2018; Jabbour et al., 2018; McKay et al., 2009).

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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GENERATIONS – Journal of the American Society on Aging

Because context and culture vary within the ED, the best methods for overcoming these bar- riers also will vary across institutions (McKay et al., 2009). Compelling data show gaps in current practice, opportunities for change, and evidence of the positive impacts of ED-based elder mis- treatment identifcation and response are critical to increase uptake of programs such as the The Collaboratory care model. The EM-EDAP is an efficient survey instru- ment that helps hospital EDs gather institu- tional data, based on staff input, to identify gaps in elder mistreatment care; motivate staff to change, based on assessment feedback; set pri- orities and goals for improving care; and provide a mechanism for benchmarking change with repeated administrations. The GEAR Network, on the other hand, is defning priorities and approaches to help hos- pital EDs collect pertinent data that measures the impact on patient outcomes of GEDA- and GEDC-informed interventions to address elder mistreatment; and also to foster data collec- tion on factors that likely help or hinder uptake of best practices to address elder mistreatment. Together, these complementary approaches can inform practice change to improve the ability of EDs to identify and better care for older adults affected by elder mistreatment. Kim Dash, Ph.D., M.P.H., is senior research scientist at the Education Development Center in Waltham, Massachusetts. She can be contacted at kdash@edc. org . Tony Rosen, M.D., M.P.H., is assistant professor of Emergency Medicine in the Department of Emergency

Medicine, Division of Geriatric Emergency Medicine, at Weill Cornell Medicine/New York–Presbyterian Hospital in New York City. He can be contacted at aer2006@med.cornell.edu . Kevin Biese, M.D., M.A.T, is associate professor of Emergency Medicine, vice-chair of Academic Affairs, associate professor in the Division of Geriatric Medicine, and co-director of the Division of Geriatric Emergency Medicine at the University of North Carolina School of Medicine in Chapel Hill. Timothy F. Platts-Mills, M.D., M.Sc., is as­ sociate professor of Emergency Medicine, vice-chair of Research, associate professor in the Division of Geriatric Medicine, and co-director of the Division of Geriatric Emergency Medicine at the University of North Carolina School of Medicine. He can be contacted at tim_platts- mills@med.unc.edu . Ula Hwang, M.D., M.P.H., is a professor of Emergency Medicine in the Department of Emergency Medicine and at the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, in New York City. She can be contacted at ula.hwang@mountsinai.org . Authors’ Note Tony Rosen’s participation is supported by a Paul B. Beeson Emerging Leaders Career Develop- ment Award in Aging from the National Institute on Aging (K76 AG054866). The GEDC also is concurrently supported by the National Institute on Aging to develop an early research infrastruc­ ture (the Geriatric Emergency care Applied Re­ search [GEAR] network; R21 AG058926-01A1 Hwang) to build and evaluate evidence of geriat- ric emergency care in the domains of elder abuse, cognitive impairment, medication safety, care transitions, and falls.

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Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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