The Champlain Geriatric Emergency Management Plus (GEM+) Program Improves Outcomes & Reduces Hospital Utilization

Rationale / Objectives

Many people enter and access the healthcare system through the emergency department (ED). This can lead to overcrowding combined with a high stress environment. In some cases, there is the potential assessment and discharge of patients whereby only the patient’s presenting complaint is evaluated without addressing other underlying issues. This can be particularly problematic for the vulnerable population of older adults who are at a higher likelihood of having multiple underlying comorbidities. Due to the increased burden of disease, these patients tend to have higher rates of visits to the ED and subsequent admission to hospital, in many cases resulting in poor outcomes. Due to these concerns, the Regional Geriatric Program of Eastern Ontario (RGPEO) administers the Champlain Geriatric Emergency Management Plus (GEM+) program across Eastern Ontario as part of the Champlain Local Health Integration Network (LHIN). The goal of the program is to promote safe and sustainable discharge of high-risk seniors from the ED. Other organizations are also focused on addressing the needs of the older adult population (see a relevant case study from Mount Sinai Hospital here) and developing senior-friendly emergency rooms and associated guidelines.

Project/Program Description & Major Achievements

The GEM+ program was started in 2008 as part of Ontario's Aging at Home Strategy by the Champlain LHIN. A two-stage approach is utilized to identify geriatric syndromes and provide resources upon discharge to the community to Specialized Geriatric Services (SGS) and Community Support Services (CSS). The collaboration of these two organizations results in consistency of care throughout the Champlain region. This supports many older adults to remain healthy and independent at home, while preventing return ED visits and reducing hospital admissions. The Plus (+) component deals with the collaborative nature of the design whereby it brings together multiple organizations to aid in the safe discharge of patients back into the community. GEM+ ED nurses, with special training in Geriatric Medicine, provide a targeted geriatric assessment, to support early identification and intervention of reversible and preventable medical issues. On average, admitted GEM+ patients had a shorter average length of stay (ALOS) and a lower total cost when compared to a non-GEM+ comparator group. Cost avoidance of the GEM+ Program has been calculated at The Ottawa Hospital as $1.9 million and a savings of 1,310 bed days for fiscal year 2012/13. 

Lessons Learned

There are various critical elements contributing to the success of the GEM+ program. The regional governance structure of the project includes a project leadership team that oversees the 20 program partners and the growth of the GEM+ program. Also, there are accountability agreements which are signed by all parties to agree to mandatory statistical and financial reporting used to monitor and shift resources according to demand. Purchasing of urgent access to services means that 72% of GEM+ funding goes to support priority access to SGS and CSS, which is unique to the Champlain GEM+ model. 

Further Description

The GEM+ program utilizes a two-stage approach to screening older adults to determine those at higher risk of poor outcomes upon returning home after discharge. The first screening test involves meeting all of the following criteria including that the patient is aged 75 years or older, has had two or more ED visits in the previous six months, is not currently living in long term care, presents with a Canadian Triage and Acuity Scale or CTAS score of greater than 2, and lives in the Ottawa-Carleton region in Ontario, Canada. If the patient meets the stage 1 criteria, they then undergo another risk assessment using the Identifying Seniors at Risk (ISAR) screening tool. Those patients who are identified as high-risk receive a targeted geriatric assessment by a trained GEM+ nurse. This geriatric assessment determines the risk and identifies priority areas to enhance appropriate ED care and discharge. The GEM+ nurse works with a team in the ED to ensure a plan for a safe discharge for the patient using participating SGS and CSS organizations. 

Major Achievements

The RGPEO works in partnership with The Ottawa Hospital (TOH), and the findings in the table below are reflected in a costing analysis prepared using TOH’s GEM+ program data. The total cost avoidance through the GEM+ program at TOH was $1,941,340.79 for fiscal year 2012/13. Additionally, the program saved 1310 bed days, the equivalent of 4.75 hospital beds saved. 

Metric Result
Total Costs Avoided by the GEM+ Program $2,326,284.79
TOH GEM+ Program Costs (e.g., staffing)  -$384,944.00
Total Cost Avoidance $1,941,340.79

A related case study of successful GEM implementation at Markham Stouffville Hospital can be found here.