IMPORTANCE There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. OBJECTIVE To evaluate the association of GED programs with Medicare costs per beneficiary.

In the era of Medicaid Redesign and the Affordable Care Act, the emergency department (ED) presents major opportunities for social workers to assume a leading role in the delivery of care. Through GEDI WISE-Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements,-a unique multidisciplinary partnership made possible by an award from the Center for Medicare and Medicaid Innovation, social workers in The Mount Sinai ED have successfully contributed to improvements in health outcomes and transitions for older adults receiving emergency care. This article will describe the pivotal and highly valued role of the ED social worker in contributing to the multidisciplinary accomplishments of GEDI WISE objectives in this new model of care.

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In 2009 we described a geriatric service line or "portfolio" model of acute care-based models to improve care and reduce costs for high-cost Medicare beneficiaries with multiple chronic conditions. In this article we report the early results of the Medicare Innovations Collaborative, a collaborative program of technical assistance and peer-to-peer exchange to promote the simultaneous adoption of multiple complex care models by hospitals and health systems. We found that organizations did in fact adopt and implement multiple complex care models simultaneously; that these care models were appropriately integrated and adapted so as to enhance their adoptability within the hospital or health care system; and that these processes occurred rapidly, in less than one year. Members indicated that the perceived prestige of participation in the collaborative helped create incentives for change among their systems' leaders and was one of the top two reasons for success. The Medicare Innovations Collaborative approach can serve as a model for health service delivery change, ultimately expanding beyond the acute care setting and into the community and often neglected postacute and long-term care arenas to redesign care for high-cost Medicare beneficiaries.

Background Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from “voltage drop” (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or “program drift.” (decreased benefit arising from deviations from study protocols). Methods Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. Results Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11–44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (− 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). Conclusions We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential ‘program drift’ or ‘voltage drop.’ Trial registration Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study “in which the assignment of the medical intervention is not at the discretion of the investigator.” Electronic supplementary material The online version of this article (10.1186/s12913-019-4063-8) contains supplementary material, which is available to aut...