Older adults (age ≥ 65 years) experience high rates of Emergency Department (ED) visits 1. Guidelines recommend holistic geriatric assessment (GA) by a geriatric specialist during an ED visit 2, 3. GA identifies difficulties with cognition, mobility, activities of daily living, medication management, and caregiver stress. Prior studies of GA in the ED have shown decreased hospital admissions, ED revisits, and overall lower healthcare costs; however, most EDs do not have access to geriatricians 4-9. Those EDs that provide GA usually rely on added staff, as most emergency physicians lack the time and training to provide comprehensive GA. In the Geriatric ED Initiative and the Aged Care Services Emergency Team models, GA is performed by a nurse or nurse assistant with additional training and specialization 5, 10-13. In other models, a geriatrician or geriatric advanced practice nurse (nurse practitioner, NP) completes the assessments 14-17. One advantage of a geriatric NP model is the ability to bill and collect revenue for GA. Our health system implemented an ED geriatric NP model. To encourage dissemination of this model, we report productivity, salary cost and reimbursement for the first year of the program. This was a retrospective cohort study of non-identifiable billing data. Our academic medical center has an ED volume of 1400 older adults per month and is an accredited Level 1 Geriatric ED with protocols for fall risk, delirium, and transition of care needs 18, 19. The NP worked 8 a. m. –4 p. m. , Monday–Friday. The NP prioritized ED and ED Observation unit (ED/OU) consults while also assisting with inpatient geriatric consults. Prior to the creation of this position, all ED and inpatient geriatric consults were completed by the inpatient geriatric consult service. The NP was hired in October 2023, trained, and began practicing independently in January 2024. Patients who were evaluated and subsequently discharged from the ED were billed as an outpatient geriatric consultation; this is in line with Medicare guidelines. If an ED/OU patient was subsequently admitted to the hospital, it was coded as an inpatient visit. These are independent encounters that were reimbursed at 85% of a physician rate. Data was obtained from the hospital's billing system for all visits between January 1, 2024 and December 31, 2024. In 2024, there were 17, 662 ED encounters for adults ≥ 65 years old. Of these, 7. 3% (n = 1285) received a geriatric consultation during their ED stay (n = 199) or hospitalization (n = 1086), an increase from the 2021 to 2023 rate of 5. 9% (chi2 p < 0. 001) 19. Month by month geriatric consults also show a sustained increase after the addition of the ED geriatric NP (Figure 1). Monthly revenue value units (RVUs) billed by the NP ranged 152–248 with a mean of 213 per month in the last 6 months. The ED geriatric NP completed 827 individually billed encounters in 2024. One-fifth (19. 3%, n = 199) of evaluations were in the ED/OU, with the remaining GAs occurring on inpatient units. The majority were new inpatient consult evaluations (87%, n = 717) which were handed off to the inpatient consult team for subsequent inpatient follow-up. Patient complexity was high as 72% (n = 594) required high medical decision-making. Total charges for individual encounters were 352, 225 with total collected payments of 86, 647. Additionally, 56 consultations (6. 8%) were not charged and not collected (NCNC). Excluding the NCNC encounters, the average collection rate was 106. Base annual 2024 salary for an Advanced Practice Provider Level 3 position at our hospital was 100, 000–130, 000, depending on experience. These data represent real world implementation of a geriatric NP in a high volume ED. We show that revenue generated by the NP covered 86% of salary (assuming an annual salary of 100, 000). Total payments collected could have been higher if more charges had been recouped, but there were some billing issues in the first few months of rollout. This revenue analysis also does not consider other benefits to the hospital such as decreased admissions, decreased hospital length of stay from improved delirium management, or improved quality measure adherence 9, 20. Based on increased consult volume and positive downstream benefits, our hospital administration approved continuation of this program. A limitation of our study is that geriatric consultation by the ED NP is only available weekdays, 8 a. m. –4 p. m. Additionally, the setting is an academic medical center with an accredited Level 1 Geriatric ED, which may have different attitudes towards involving geriatricians in ED care than other sites. Data was limited by available billing information; improperly billed or non-billed encounters affected usable data. Hospitals considering an ED-focused geriatric NP program can use this data to benchmark current practice or extrapolate the impact on their patients and revenue streams. L. T. S.: conceptualization, funding, investigation, data collection, writing, formal analysis, writing. S. R. S.: analysis, writing, first draft. N. T. -M.: data collection, writing. T. R. G. and M. B.: conceptualization, writing. E. L. S.: data collection, writing. All members contributed to the review and editing process. L. T. S. is responsible for data integrity. L. T. S. and J. S. were funded by National Institute on Aging (NIA), K23AG061284. The funders had no role in the study design, interpretation of data, and writing of the report. The authors declare no conflicts of interest.
Singh et al. (2026) studied this question.