Expanding the Role of Interdisciplinary Teams in the Emergency Department: Using a Consultative Model to Serve Older Adults Who Are Abused

Emergency departments (EDs) play an important role in the care of older adults, and this is especially true for those who may have been abused or neglected. Elder mistreatment affects about 1 in 10 older adults who live in the community, 1 in 5 who live in a long-term care situation, and 1 in 2 who have a dementing illness.^1,2,3 Consequences range from emotional to physical to financial for the older adult as well as for those who love them.⁴ Despite the high prevalence and devastating impact, it is under recognized and under reported by physicians for a variety of reasons.⁵

While many of us who provide medical care for older adults do our best to help them avoid emergency rooms, these emergency rooms are always open, staffed with skilled clinicians, and provide safe haven for patients in distress such as those who have been mistreated. There is a growing realization of the roles that the ED can play in caring, connecting, and coordinating follow up for older adults. With the emergence of Geriatric Emergency Departments, the Age Friendly Health System movement, and the significant growth of interdisciplinary teams that assess and address elder mistreatment in local communities, the article by Rosen et al (Vulnerable Elder Protection Team: Initial Experience of an Emergency Department-Based) describes a novel approach based on that used in the child abuse arena and adapted to address the special needs of older adults and emergency room providers. This adds to a growing number of EDs that present creative, comprehensive, and person-centered responses to common problems that cross medical, psychosocial, and traditional health system boundaries.^6,7,8

The authors of this study recognized the difficulty in diagnosing elder mistreatment and the challenge of devoting the necessary time for assessment and care planning in an emergency room setting. They realized that barriers exist in several areas. Chief among them are lack of training, expertise, and time. After laying the groundwork for several years^9,10 they developed an ED-based interdisciplinary consultation service called the Vulnerable Elder Protection Team (VEPT) that launched in 2017.

VEPT is available 24/7 to be activated when an emergency room clinician has a suspicion of elder abuse. The on-call provider discusses the case and provides over the phone and/or in person consultation. The consultation involves interviewing and examination as well as documentation and photographs, all of which are important elements in a criminal proceeding, by a specially trained health care provider (MD, PA, NP). This is accompanied by involvement with a social worker on the VEPT who provides counseling, collateral information/interviews, links to appropriate authorities (e.g., Adult Protective Services, law enforcement), and coordination with the hospital and community-based organizations.

Implementation involved training more than 400 providers in their healthcare system through in person presentations and online modules. Their ED is described as “a large, urban, academic medical center”.⁶ The authors categorized reasons for requesting VEPT consults, the results of the VEPT assessment (including likelihood of abuse), and recommendations made by the team. Using a carefully designed combination of quantitative and qualitative strategies for evaluation they examined if this intervention resulted in greater identification of potential victims and decreased burden on ED providers as well as improved identification of moderate and high-risk situations. Data were gathered through examination of Electronic Health Records, ICD-9/10 codes, surveys, focus groups, and discharge status for those evaluated by VEPT.

Before the intervention elder abuse was reported a mean of 10 times per year over the prior five years. Over the two years of this study there were 200 requests for VEPT consultation and 122 of those were found to be of moderate/high suspicion for elder abuse.

In examining the characteristics of people referred for evaluation, 76% arrived via emergency medical services, more than half had at least 3 chronic conditions, two-thirds had a dementing illness, three-fourths needed help with ADLs, and 79% were women.

Of those identified of having a moderate or high suspicion of abuse, 84% were admitted to the hospital, 45% for a medical issue and 38% primarily for safety reasons. Over two years 46 patients were admitted primarily for safety reasons and had long lengths of stay (median=10.5 days). Three-fourths of the patients evaluated by the VEPT received a safety intervention such as discharge to a different home or shelter and the addition of home-based services. These older adults returned to the ED for an abuse-related issue at half the rate of those pre-intervention (4% vs 8%).

As is often true, it took a while to gather and analyze the data, so the article describes 200 cases that occurred between April 2017 and April 2019. Based on personal communication with the primary author, the COVID-19 epidemic did not slow the program; in fact, the program has expanded since the end of data collection.

Concerns will certainly arise over the cost such as the cost of the team and of admissions to the hospital for safety reasons which may make this exact model quite expensive. But this should not dissuade us from appreciating its value which may be difficult to measure: saved lives, diminished suffering, less provider burnout, better patient satisfaction, and more.

There are several take home messages from this important study. One is that EDs can play an important role not only as a safety net but also as a springboard to services that empower older adults to live their lives as they deserve and wish to live them. Perhaps as more EDs emerge with novel strategies such as this we will see a transformation to a new model that will routinely incorporate teams both inside and outside of the healthcare system and will routinely engage with organizations/resources in the community.

Another message is that elder abuse can be diagnosed and treated appropriately as we do for other illnesses and syndromes such as heart failure and falls. The characteristics of those who were at moderate to high risk of abuse were consistent with prior reports^1,11 and are a good reminder for clinicians to be vigilant on behalf of those who are more susceptible to mistreatment. Because elder abuse is usually related to a complex set of characteristics and dynamics expert teams are needed to unravel the situation using a logical framework¹² and provide practical assistance as well as recommendations for next steps. Of course, this also means that the recommended next steps must be available to the older adult. There are more than 300 Elder Abuse Multi-Disciplinary Teams (MDTs) across the country¹³ and more are needed. APS is finally receiving more funding, but we don’t know if this will be sustained. Electronic Health Records are not available to all members of the health care team across settings, frustrating the communication and collaboration that are necessary to high quality person-centered care.

At the policy level we should encourage funding streams to support efforts such as this. As happens for hospital-based sexual assault teams and child protection teams, funds may come from a variety of sources: health insurance, Victims of Crime Act Funds, government grants/funds, and community groups.

For those who contemplate using the VEPT as a model in their own systems it is important to realize it can be adapted in a variety of ways that fit your needs and realities. As we have seen with other programs such as transitions of care, each health system has a unique set of constraints, goals, and opportunities, and there are many ways to accomplish an objective. We don’t have to reproduce this in whole in order to make progress on behalf of older adults who are abused. Start with what is available in your locale, form new collaborations and teams, and relentlessly advocate for those we serve.