The number of adults age 65 or older will reach about 95 million in the United States by the year 2060. Hospital emergency departments will need to showcase their flexibility by adapting models of care to address the unique care needs of older adults. In this conversation, Julie Dye, clinical nurse specialist in geriatrics at Sharp Grossmont Hospital, discusses the benefits of participating in the Geriatric Emergency Department Accreditation program and the Age-Friendly Health Systems initiative. She describes how Sharp Grossmont blends case worker skills and clinical expertise to identify gaps in care for older adult patients. For more information on Age-Friendly Health Systems, visit www.aha.org/agefriendly.

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Tom Haederle

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Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Age Friendly Health Systems, an initiative of the John Hartford Foundation and Institute for Health Care Improvement, in partnership with the Age and the Catholic Health Association of the United States, is a movement that aims to enhance care for all older adults by implementing the 4Ms framework that's focused on what matters to the patient, their medications, mentation and mobility.

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Tom Haederle

Julie Dye clinical nurse specialist in geriatrics at Sharp Grossmont Hospital, shares the benefits of participating in the age friendly health systems and geriatric emergency department accreditation programs to identify gaps in care that improve the experience for patients 65 and older and their caregivers. Sharp Grossmont’s supportive leadership team provided the emergency department with the staff and resources to treat the whole person, by blending case worker skills and clinical expertise.

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Tom Haederle

In this conversation with Marie Cleary-Fishman, vice president of Clinical Quality at AHA, Julie discusses staff buy-in asking "what matters" to patients and leveraging trusted community partnerships to better serve the population of older adults in the San Diego area.

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Marie Cleary-Fishman

Well Julie, thank you for joining us today. This is really exciting. As so many people know, age friendly is near and dear to my heart and I'm hopeful that by the time I need to show up in someone's emergency department that all the emergency departments are geriatric emergency departments and our hospitals are age-friendly. So that's a great goal for everyone.

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Marie Cleary-Fishman

So maybe could you start a little bit by giving us an overview of how your journey started with age-friendly and where you sort of picked the geriatric emergency department to start with and just give a little overview and then we can dive into some of the more specific areas for our audience.

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Julie Dye

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Julie Dye

But then once we did a deeper dive and getting our clinical informatics team on board right away, we were like, this is definitely not happening the way I think people thought it was happening or the way it was envisioned. We started realizing there were large gaps in care and that was right before COVID. So we had actually started toward our geriatric accreditation and then of course, COVID hit.

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Julie Dye

So again, I think we're I just am so appreciative to our leadership. Most places, understandably stop projects because of COVID. You know, everybody was really short on resources, so you know, we really had a difficult time during COVID, but our administration said, no, we need to keep pushing forward and actually go for gold because this is the heaviest hit population and the caregivers are often also older adults and really need, you know, a ton of support.

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Julie Dye

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Julie Dye

And then it became what we need these guys and therapies and we need these nurse navigators. And it's now grown to this just enormous team of people to make this go. So it's really been a fantastic journey. And then we had discovered the age friendly initiative through the American College for Emergency Physicians and thought, gosh, that adds another layer.

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Julie Dye

We're already doing the medications, the mentation and mobility. But we were interested in the "what matters" piece. It's such an important thing that doesn't tend to get addressed in the emergency department. You know, we're pretty pragmatic that way. You come in, you're here for your broken toe or you're here for your heart attack, and we're here to fix those things and really trying to marry that that social and psychologic and that whole person with that medical complaint make sure that we're doing all those things.

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Julie Dye

And so we really discovered some interesting things through going through the age friendly journey and adding that extra layer that ended up being really important and again allowed us many actionable items and allowed us to involve other teams. And so it's really been a wonderful marriage of all these different interdisciplinary teams, and it's been fun to see how it's grown out now into the community as well.

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Marie Cleary-Fishman

Well, you have just touched on so many key, important things. I feel like we could be here for a long time going through them all.

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Julie Dye

Legitimately.

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Marie Cleary-Fishman

And and one of them, I just want to pause and say, because I know as time goes on, maybe we don't hear this as often, but thank you so much to your team and everyone at Sharpe Grossman who worked so diligently for all of our patients during COVID, and especially for those geriatric patients, because it was particularly difficult for them.

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Marie Cleary-Fishman

And I love the fact that you hit on the "what matters," because so many people were separated from their caregivers or separated from their families, and it made it really difficult. Could we pause on the "what matters" for just a few minutes and maybe for our audience? You could just just describe "what matters" a little bit more a little bit more depth for the audience.

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Marie Cleary-Fishman

And then I just want to talk a little bit more about it. But if you could start with a description, that would be great.

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Julie Dye

Absolutely. So we ended up choosing "what matters" in life and what matters. This visit, we always have to marry it a little bit with what are we going to do with the information and how can we make it comfortable for the patient. That was a big lesson we learned is sure, they're a little off put sometimes by the questioning, and so we had to learn how to script it such that we're earning trust, that we're, you know, explaining what are we going to do with this information, you know, once we get those things asked.

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Julie Dye

So we chose those two questions to give us a really good idea of, you know, where are you at in life? When was a good day for you? What does that look like? What are your goals? Those really big questions. And then what really matters to you this visit and how can we marry those two questions? And so oddly, that ended up being a big part of our program because it forced us to start at the beginning of the visit with "are we even having the right conversations as far as what care looks like?"

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Julie Dye

And in some cases we discovered, you know, we've had patients who've said, I just want to be done. Yeah, I'm not eating because I don't want to go to the doctor anymore. I'm tired of suffering with these symptoms and things. We were able to loop in teams more toward that end versus, you know, let's go to cath lab or let's go to surgery or let's go here.

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Julie Dye

Being able to do a better assessment of what their goals are and marry those things. And in some cases that looks more like, you know, depression from needing social support. I'm losing my house, I can't pay my bills, things like that. So then we're able to say, okay, well, yeah, let's fix your medical issue today, but let's also get these other things in to make life easier, help you be independent longer.

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Julie Dye

So asking those questions has been a huge part of the program that we really weren't anticipating would be as important as it is. It's also given us actionable information where we've been able to create community partnerships. So for instance, what matters in life is often people's animals. And for these people, sometimes those animals are legitimately children for them.

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Julie Dye

So we were finding that patients with AMA from the emergency department and from the hospital because they were worried no one would be there to take care of their pets. And so we were able to partner with the Humane Society and say, you know, if you can provide us emergency animal services, we can encourage these people to stay and get appropriate treatment.

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Julie Dye

So it really did have actionable outcomes for us and really helped us understand the right teams and the right resources to involve, you know, early on in the visit, help get the provider on board. This is what the patient really wants. These are the conversations we need to be having versus, jumping immediately to how do we fix the medical problem if that makes sense?

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Marie Cleary-Fishman

it makes so much sense. And I think the the fact that you worked with out in the community to find a partner that would help, I mean, you know, as an animal lover and someone who's getting older and I think, boy, I better make plans for those animals. But making that connection for people is so important.

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Marie Cleary-Fishman

There's a whole other case study there Julie for us to look at.

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Julie Dye

Well, and honestly, I'm so lucky. We have the Senior Community Resource Center run by Dan and Natalie and Loraine and they are an amazing community resource because it isn't just a list of, oh, here's a list of numbers where you can get meals. These are all vetted resources. They have personal relationships with people. They can really tell you, you should use Right At Home.

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Julie Dye

You should use these following services because we have good relationships with them and we know you're likely to have a good outcome versus, we went to Google and we found that these following people, you know, are helpful with home health and, you know, or helpful with yard work or things like that. We can really tell them, Hey, we feel really good about these resources.

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Julie Dye

We can help you, we can call you back and see how you're doing. We're incredibly lucky to have that community resource center here at Sharp.

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Marie Cleary-Fishman

That's great. That's so, so amazing. Now, let me ask you a little bit more about that, but I want to take it in another direction, and that is toward the workforce. So as you're talking and you know, my nursing background and I think about being back at the bedside or back in my role in quality and tell me a little bit about how the "what matters" helps with the workforce or if it does, you know, we hear reports and you made the comment about this started before COVID and it kept going.

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Marie Cleary-Fishman

It was one of the things we've heard that over and over from folks. This is one of the initiatives that people felt they could keep going with during COVID. Tell me a little bit about what this does for the workforce.

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Julie Dye

It's interesting that you should say that. I wasn't sure how they would receive it. Most of my nursing career we've been in a nursing role and social work is in a social work role. So we're we're pretty siloed. And so what I'm loving about this and really what the nursing staff has reported back, especially the nurses that work in this capacity, is they really have enjoyed learning about the case management and social work role.

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Julie Dye

What they're starting to realize is if the person can't comply for social reasons, whether those are psychiatric, cognitive, financial, you know, there's so many reasons that people struggle, then they simply can't be compliant with their medical care. And so you'll just continue to see them, you know, come back to the emergency department often in worse shape. And that's been a frustrating thing for nursing, is the patient will come in, we'll do all these great medical things.

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Julie Dye

We send them off into the community, they come right back. And it's a simple question. Did you fill your antibiotics? Did you fill your heart failure medication? Well, no. Gosh, I noticed you were here earlier this week for having high blood sugar. Did you know how to use your pens? Well, no. So realizing while we physically have them here and we can see them, they have difficulty seeing, hearing things like that, realizing we need to bring the care to them.

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Julie Dye

So if we have them in a gurney here in the emergency department, this is the time to assess for all that whole spectrum of things to make sure they can be successful at discharge. You know, do they have all the things that they need? Do they have the education they need? Do they have a scale? Do they have a blood pressure cuff?

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Julie Dye

Do they have the things that they would need to be successful? So I think it took a minute for the nursing staff to start realizing, you know, am I doing a full assessment of this person and then adding that piece in, are we even having the right conversations? Okay, you may have all of this adjuncts, but are you tired of living with heart failure or your symptoms are poorly controlled?

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Julie Dye

What really matters to you? Does it matter that you get to go on that trip to Maui? You know, is that more important than spending a night in the hospital on observation just to make sure everything stays stable for the next 24 or 48 hours? Those kinds of things are really important conversations, especially when it comes down to holidays or things like that.

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Julie Dye

We started discovering, especially during COVID, where people were very, you know, the hospitals were on lockdown. These people were spending what was quite possibly their last holidays here alone. Maybe that wasn't their goal. Many of these patients would rather be at home, even if that meant an impact to their physical outcome that was more important to them. So asking that question helped us really understand what their goals would be and make sure that we're aligning with that.

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Marie Cleary-Fishman

I love that detail in that at the point is so, so important. You know, what do you want to spend your last time doing? And is it sitting in a hospital? Is it sitting right? Where is it? What do you want to do? I mean, if we all thought about that on a personal level and then applied it, my dad's 92.

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Marie Cleary-Fishman

We live he lives with us. And I certainly know it's not in a hospital, even though, you know, he loves the fact that I'm a nurse, but it's not where he wants to spend his time. So that's a really important thing and that's important for the workforce. And I love the fact that that message has gotten through. You have a GEM nurse?

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Julie Dye

Correct.

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Marie Cleary-Fishman

Can can you talk a little bit about that role for people so that we have an understanding of what that is and what are some of the things that position does?

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Julie Dye

That role is a game changer, honestly. So it's geriatric emergency medicine and we actually recruited from our staff. So what we wanted was people who were passionate about marrying again, that case management, social work side with the nursing side and really being essentially a hub or a nurse navigator. So we recruited from the staff. We had a whole list of interview questions and things we really wanted to get to the bottom of.

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Julie Dye

What did they hope to accomplish with the role? What did they want to learn from the role? Most of the people who applied had been a caregiver in some form or fashion and realized how impossibly hard it is to be a caregiver and the amount of caregiver strain. Right. And that's often what brings people to the emergency department is they are unpaid, untrained.

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Julie Dye

San Diego is one of the most expensive cities in the union. Everyone is struggling so much, but you don't know what you don't know. And so you just keep struggling at home until you're finally like, I can't do it another second. And then you come to it ED and you're suddenly tapped out. So we really wanted to grab nurses who understood what that's like for caregivers.

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Julie Dye

Some people have chronic illnesses themselves and know how much of a strain that is to manage things like diabetes or, you know, where it's just a constant daily battle to stay healthy yourself. So it was really a great thing to have these guys on board who were excited about the work, really wanted to learn how to marry those two things.

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Julie Dye

And again, I can't say enough great things about our leadership. So they gave us a full time equivalent for this role, seven days a week. It's really remarkable.

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Marie Cleary-Fishman

That's amazing.

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Julie Dye

And it's a game changer. Honestly. Initially the providers weren't sure what to make of it. Like, who's this person talking to me about these things? And the nursing staff will get frustrated if there's not a GEM there where they can use them as a resource. So that's been a lovely thing to have, you know, evolved out of this.

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Julie Dye

But they have their own workstation. We do a lot of work through Microsoft teams, which is nice because we can have living documents there that people can update. So we actually have a live link with our community Resource Center. Again, essentially when somebody checks into the emergency department, every nurse here does a quick functional assessment called the Ihsaa or identification of Seniors at Risk assessment.

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Julie Dye

This helps us understand because 65 is pretty young, a lot of 65 year olds are very functional, healthy, working, golfing. We want to make sure that we're targeting resources to people that are really starting to struggle, and sometimes that's just not obvious. So we do that. These guys look for people who've been here within 30 days, chief complaints that are concerning, things like that.

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Julie Dye

So they go out and perform a comprehensive geriatric assessment that has many parts and pieces that you're aware of, and they take the information from those things and then start calling these interdisciplinary teams. So that might be our ED case manager, that might be therapies where it's like, gosh, this was just a simple trip and fall. They look really good, their x rays are negative.

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Julie Dye

Could we send them home with durable medical equipment versus admitting them for OBS? You know, in some cases that's like, gosh, we've noticed you've been here for DKA, you know, twice this month. Let's have the diabetes educator come see you or let's have dietary come see you and see if we can close some of those gaps. Maybe you need home health.

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Julie Dye

We've done some partnerships that way that have been really exciting. So these guys are very much in a hub nurse navigator position of, gosh, this person's been here for heart failure several times. Maybe the heart failure clinic would be the right bridge to cardiology for these guys. And so they'll take that whole assessment, go back to the provider.

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Julie Dye

These are the things we've found. I feel really comfortable with them going home with resources or gosh, this person's just not safe at home. We really do need to admit and figure out what's next. So that navigator position is irreplaceable. That's great. And the last thing they do is they call the patients back after discharge and check on them, which has been a lovely adjunct.

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Julie Dye

It's the patients love getting called and it allows us to identify gaps out in the community before it becomes a crisis where they have to come right back in.

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Marie Cleary-Fishman

Somebody is there to check in on them. That's awesome. That's really love it. I love hearing about that position. So I know we get close on time and I really want us to be able to talk for for a longer time. One thing I want to talk about is dissemination and spread through an organization. So let's let's circle down to that area.

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Marie Cleary-Fishman

And I'd like to hear a little bit about your experience and what you think is key to have in position when an organization wants to look at spreading this, spreading age friendly, doing they're Geriatric ED. Give me a little bit of your sense and experience. And what do you think leads to success in an organization that wants to spread?

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Julie Dye

I think honestly, it really is resource heavy, but it does come back and help you via improved care, patient SAT, things like that. We have so much throughput pressure in the emergency department, so many issues with boarding and certainly that affects geriatrics the heaviest. Boarding is just so bad for them. So it is really nice to have separate resources where this is their only job.

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Julie Dye

They can go in, do a quick assessment, handoff to somebody else to be able to fill those gaps. We did try initially with the geriatric emergency nurse to do everything themselves. So they would do the full med rec, call you know, Sureccripts, call the pharmacy, call the family, do all these different things, try to call the physician.

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Julie Dye

And they were seeing, you know, two patients, the whole shift. They're just very complicated patients. So investing those resources is scary for organizations, understandably, and everybody is hurting. But it really does help provide that total picture. You have the experts working on each of their parts and pieces, so you feel really good about that discharge. You know, if it's something where we're on the fence, we know physical therapy has done the exact same evaluation they would do inpatient.

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Julie Dye

So we feel really good about, hey, this person could have a modified walk or go home or we can hook them up with home health. We have some great partnerships and we know they'll get seen right away. And so some of those things helps everybody feel better about the plan of care, including the patients, we're respecting what they want.

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Julie Dye

If they're saying, Gosh, this is how I always look when I walk, I have Parkinson's. I'm not going to look like I walked when I was 20. But I feel comfortable going home. We feel comfortable supporting their goals. So that part, I think is really important, is having that administrative support and that willingness to put that resource behind this program.

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Julie Dye

But it really does pay off in spades later on, if that makes sense.

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Marie Cleary-Fishman

That does make sense. It really does. And I'm going to circle back and I think we'll you know, kind of bring things to a close on this topic because you've said it several times and that is the support and the involvement of your leadership. And it just sounds like that's an amazing kind of thing. And can you define leadership for you?

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Marie Cleary-Fishman

When you say your leadership, can you tell me a little bit about what that means to you? Does it does it go all the way up the C-suite? Does it involve the board? Can you give us a little bit of a sense of what leadership means? Because I think it's so different for everybody. And I also think that the model of how leadership gets involved can be so different.

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Marie Cleary-Fishman

So give me a little bit of info about that.

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Julie Dye

Completely agree. So we're really lucky. Our CNO and really our CEO are really the ones who wanted to spearhead this in the first place, based on their knowledge and their past experiences and knowing that this large volume of people was expected to come. They have a lot of forethought to realize this is the growing population and this is where the need is at.

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Julie Dye

So it was really easy to support their vision as well. To your point, though, we have an interesting situation at Grossmont. We're a public-private partnership. So we are partnered with this foundation that is amazing as well. They really want to help support us. We do report outs to them. They support us with funds, in some cases. They they're very supportive of our work too, and they're very invested in what do we bring to the community.

00;22;32;07 - 00;22;59;25

Julie Dye

So they want to see us out there providing free classes, our community Resource Center here at Sharp Grossmont provides free classes for caregivers on how to do caregiver mechanics, how to support them psychologically, because being a caregiver is just so psychologically heavy. All those types of things have been supported by our leadership. They've given us that FTE, they've given us money, they've helped us improve the environment of care.

00;22;59;25 - 00;23;21;29

Julie Dye

They've allowed us to repaint, add dimmer switches, add different equipment, they've allowed us to hold classes, we hold community clinics and get togethers for free. Those things are all supported by our foundation, the board, our C-suite level. I mean, we are on a first name basis with these people. They've always had an open door policy with us if we're concerned about something.

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Julie Dye

And I think that part is irreplaceable as well. They're it's very much they're very close to us, in other words, versus, you know, being somebody who sits in an office across town and I wouldn't be able to pick them out of a lineup. We're really have a close partnership, which I think is irreplaceable, and that helps support our local ED leadership as well.

00;23;42;03 - 00;24;06;17

Julie Dye

Our directors have been amazing. They are very responsive to anything that we need. Our ED manager is amazing. So we really have a ton of support for the program and I just honestly don't think we could do it without that, especially knowing how strongly, how much pressure they have to address throughput and make sure all of their other metrics are being met.

00;24;06;19 - 00;24;12;04

Julie Dye

The fact that they're still have so much support for us is just amazing and irreplaceable, frankly.

00;24;12;06 - 00;24;33;28

Marie Cleary-Fishman

Well, that's a great message, Julie, and I think that's a great place for us to end our conversation today, even though I'd love to keep going. We'll go get have more conversations at another time. But congratulations to your leadership as well as to your Frontline team and everyone in between on achieving the successes in age friendly health care and that you have at Sharp Grossmont.

00;24;33;28 - 00;24;44;01

Marie Cleary-Fishman

And for working with us and for being willing to share this message and this story across the nation, we're very grateful for you. And thank you so much.

00;24;44;04 - 00;24;52;16

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.