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Embedding specialist geriatricians directly into the emergency department can help identify older adults who can be managed safely outside of an acute hospital stay.
Australia’s population is ageing and health services are feeling the pressure. Older adults now represent a growing proportion of emergency department (ED) presentations. These patients often arrive with multiple conditions, frailty and complex needs that do not always fit within traditional acute care models.
This matters because hospitalisation itself can cause harm. Older adults admitted to hospital face higher risks of hospital acquired complications, deconditioning and functional decline. This can lead to poorer outcomes and higher costs of care.
Geriatric emergency care models
Across Victoria, many health services are trialing new approaches to better support older adults in the ED. One such model is the Geriatrician in the Emergency Department Initiative (GEDI). This service embeds specialist geriatricians directly into the emergency department. Unlike traditional consultation only models, the services prioritises early comprehensive assessment and the diversion of patients away from unnecessary hospital admissions. The aim is to provide person-centred care and identify older adults who can be managed safely outside of an acute hospital stay.
Evidence for Impact
International evidence backs this approach. Studies show that geriatricians working in emergency departments can prevent up to 64% of hospital admissions among frail older adults, while also reducing complications and improving functional outcomes.
Locally, health services have implemented variations of this model with promising results. At Eastern Health in Victoria for example (where the authors work), around 70% of older people who were initially planned for hospital admission have instead been safely managed through alternative pathways within the first nine months of the program. This equates to an average of three patients each day, with roughly half transferred directly to subacute care and the remainder discharged home or to their place of residence with a tailored plan. These plans often include support from hospital outreach programs such as Hospital in the Home, Geriatric Evaluation and Management (GEM) at home or residential inreach services.
These models also reduced bed pressures and costs, freeing up hospital capacity for those who truly need it while reducing healthcare expenditure. The results translate directly into better patient experiences and a more sustainable health service.
Why it works
Traditional models prioritise rapid triage and acute interventions, which do not always align with the needs of frail older adults who often present with multimorbidity and atypical symptoms. By embedding geriatricians in the emergency department, these services ensure that patients receive early specialist input. Geriatricians undertake a comprehensive assessment that considers mobility, function, cognition and social factors to devise a care plan that links them directly to community or subacute services.
Supporting the workforce
These models support the clinical workforce. Emergency Department clinicians report increased confidence in managing older patients, knowing that they can access specialist geriatric expertise at the point of care. Allied health staff are central to assessments and discharge planning, which has helped build stronger interdisciplinary collaboration.
These services also develop future workforce capability. Junior doctors and emergency department staff gain hands on training and experience in geriatric emergency care, equipping them with the skills needed to deliver care in fast paced and high-pressure environments.
It is not just about the illness
Older adults do not just present with a single clinical issue. They bring a combination of health, social and family considerations that must be respected in their decision making.
Patient stories further illustrate the initiative’s impact. One example involving a 76-year-old woman who presented to the emergency department with delirium and mobility issues after recently moving house. Rather than admit her to hospital, she was able to be managed at home with oral antibiotics, withdrawal of inappropriate medications and rapid deployment of GEM at Home services. This stabilised her condition, provided practical support in her new home and avoided the risks of hospitalisation such as worsening delirium. Importantly, her care plan also addressed mobility and functional needs in her new living environment, which had not yet been properly set up for her.
A model of value based healthcare
Geriatric emergency initiatives exemplify value based care. They achieve outcomes that matter to patients while making better use of health system resources. Importantly, these models show that true innovation does not always require new infrastructure or expensive technology. Sometimes it comes from reimagining how and where care is delivered. Ensuring that the right expertise is available in the right place and at the right time.
Next steps
As demand continues to rise, health services across Australia will need to rethink how they care for older adults in emergency settings. Geriatric emergency models (whether GEDI or similar programs), offer a compelling way forward.
They’re not just another service. They’re a new way of thinking about care.
Dr Simon Grof is a geriatrician and clinical director with Eastern Health.
Dr Jonathan Beavers is a geriatrician and clinical service director with Eastern Health.
Dr Katrina Sands is a geriatrician and acting clinical director with Eastern Health.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Of particular interest to myself as an emergency physician, and not entirely clear to me in the International Evidence article, is the effect that having Geriatricians in ED has on the ED length of stay. (LOS). Where are these patients physically located whilst undergoing this comprehensive assessment, and how long are they staying in ED or a short-stay/observation unit (ESSU) whilst it occurs? If the intervention leads to either increased ED LOS or ESSU admissions, then this adversely affects our ability to maintain timely patient throughput.
Over decades of emergency medicine at specialist level, in which various models of “we need one of our people in your ED” have been trialed, I have now moved into Emergency Telemedicine. I can unequivocally state that specialist input INSTEAD of ED attendance (whether at home or in Residential Aged Care) is much more effective, cheaper and more satisfying for patients than trying to turn around patients who have already arrived in ED.
The article does not describe what hours the Geriatricians work in ED, or what they do when there are no patients requiring their input. As I work exclusively outside “office hours”, I can use my experience to support people when their GPs and specialists are not contactable.
What is even more important, however, is that the skills of specialist emergency physicians are different to Geriatricians, although there is overlap. I now see myself as a “Community Emergency Physician” – I have taken the skills out of the department. EPs excel at episodic care and risk assessment, and – of course – have an intimate understanding of what can and cannot be achieved by a hospital visit.
Perhaps the next article might be from a group of emergency physicians, outlining how emergency medicine skills in risk assessment and problem-solving could be used on the inpatient wards to maximise flow.
Adequate assessment of the whole person as well as the presenting complaint has allways been the ideal method of management in the ED but cost is a problem.To have a Geriatrician embedded in the dept 24/7 woould add upward of a million a year to the payroll costs.
The problem of sendind sick older patients home is care and medical follow up. If they have no full time carer and no GP who can visit regularly they need inpatient care.
While in the Auckland Hospital in1976 as a Medical Student I was surprised to see that all patients over 65 were admitted ìnder a Geriatrician ,if admission was required.
An excellent idea and as one who has been a Geritrician in a former life and now technically geriatric myself at 75 although far from frail I applaud this initiative.
This reorganisation of health resources appears to pass the “pub test” and is apparently backed by evidence. I would suggest further improving the capacity to manage the elderly in environments other than acute community hospitals by restoring the incentives and recognition of GP’s to attend in residential aged care homes. The historic bureaucratic impression of GP’s attending (particularly on multiple patients) appears to have been one of potential “rorting” with the subsequent withdrawal of many GP’s from this highly dependent and vulnerable population. The Geriatricians would then have formal contact point and confidence that any management plan would indeed be attended to.
A quick anecdote is a 93yr old T2 diabetic with long standing hypertension and history of mild CVA and v good functional recovery. Recently admitted to residential facility. Following a tripping fall without LOC nor obvious traumatic injury, protocol demanded ambulance evacuation to local hospital emergency department. Patient spent approximately 6Hrs on trolley in DEM corridor. (a designated holding area so never admitted) before being assessed and returned, appropriately, to her nursing home. However now late at night. This saga could have been circumvented by the availability of competent, willing attendance and assessment by her local GP.
Restoration of GP skilled service in aged locations is long overdue and would significantly reduce the burden of attendance to Acute Care Hospitals and the associated transport services.
There are various attempts in different hospitals across several states in which certain specialities are recruited (or compulsorily made) to provide services to people presenting to emergency departments, wholly bypassing emergency departments services.
Depending on how these services are funded (I doubt the geriatrician model here are any different from others, for example surgical services at emergency departments are ultimately funded by surgical division rather emergency departments funding) which meant this will still result in service provision by silo mentality.
Triaging practitioners will have perverse incentives to channels as much traffic to speciality services (whatever guidelines in place conveniently ignored to try to improve emergency KPI by diverting traffic away from emergency services) whereas speciality services are not sufficiently funded or supported to provide expedited assessments and disposition.
You may think this is a pessimistic view without giving it a go, but let me point out that many Australian ‘initiatives’ are often borrowed from other countries but woefully underfunded compared to host countries, include that 4 hour rule, and also this is nothing new, specialty-led frontline services were a feature in emergency department of certain countries before the turn of millennium, for example in South east Asia. These are responsible for loss of exposure of emergency trainees to various conditions, ultimately these trainees still pass their fellowship without practical working knowledge of these fields.
As the saying goes, there is nothing new under the sun: speciality led emergency services has been done in other countries before, but beware of persevere incentives to achieve ED KPI, which meant patients are not necessarily better off while playing musical chairs. And if the patients does not actually ‘belong’ to emergency department, they may not be able to access fast tracked priority lab or imaging services allocated emergency department patients.
Sounds fabulous. The numbers there seem small with 3 per day being optimized. We have around 20 or more per day of this patient group and the workload seems beyond what this service can provide. Glad it’s working where you are…
GEDI is a great service to assess and manage older patients in ED.
Perhaps us GPs could have access to phone advice from geriatricians for urgent matters to avoid transfer to ED.
We have InReach for RACF residents and Victorian Virtual ED assistance, but geriatrician advice would be an asset.
Hospital in the Home may be available, but urgent nursing assessment, pathology and geriatrician telephone (or video advice to GPs who do home visits) would be a great assistance.