Care transition for elderly patients is fraught with hidden obstacles and risks. Experienced case managers can identify and prevent problems.

  • Visiting patients’ homes can yield answers to questions about multiple medications and home environment.
  • Ask questions about what they mean when they say their loved one can take care of them.
  • Sometimes the best help can be from social and emotional services.

“Transitional care” increasingly are buzzwords used to describe the kind of work case managers do, but too often there’s a tendency to treat all patients in the care continuum in similar ways despite their different demographics and circumstances.

“There’s not one solution out there; it takes a village, and everyone is part of that solution,” says Rani Khetarpal, CEO of Global Transitional Care in Newport Beach, CA.

“Everyone at the table is trying to solve the problem on their own, and then they realize they can’t solve it on their own,” she adds. “They have to work collaboratively to keep the patient at the center.”

With elderly patients, the care continuum can have hidden obstacles and risks. It takes an experienced case manager to identify and prevent problems. This strategy can include having case managers visit high-risk patients’ homes to find answers to personal and environmental barriers to improving their health. Based on more than a year of data and 250 patients seen by Global Transitional Care, this approach works, Khetarpal notes.

“We have had zero preventable readmissions and five unpreventable readmissions on very high acuity-type of patients,” she says.

An example of a barrier that might only be discovered with a home visit is this: A patient who has been discharged home from the hospital told providers that she has a wonderful support system of family and friends who will help her get groceries and assist with medications, Khetarpal says.

“But when the patient gets home, something is lost in translation,” she says. “The person goes home and the nurse finds out that, yes, the daughter does live in town, but she won’t be there to help the patient with medication or to drive the patient to doctors’ appointments.”

The daughter might be giving the patient some support, but just not the kind the patient needs to keep from going back into the hospital, Khetarpal adds. “We look at all the notes and discharge planning and 100% of the time, we find the reality is very different.”

Handling medications is a problem that can be amplified for older patients who have many different prescriptions.

“What patients might not tell the case manager is they have a fishbowl of medications, and they just throw all of them in there,” Khetarpal says. “They don’t know how to ask what they should do with their old medications at home.”

This is where a case manager’s or advanced practice nurse’s home visit can be very important: “When we go into the home, we say, ‘Please bring out all your medications,’” Khetarpal explains. “They will bring out the fishbowl, and our nurse will go through the medications and find duplicates and things that are not valid.”

Deciphering the daily life of elderly patients during care transitions periods can be challenging, and it requires asking the right kind of questions, she says.

“You need to know what kinds of questions to ask that will evoke deeper answers,” Khetarpal says. “So when patients tell you their daughter will support them, ask, ‘What does that mean to you, and tell me about that support.’”

Not asking the right questions or having a home visit can lead to major problems. For instance, Khetarpal recalls a case where an older patient left the hospital with a walker. “We were in contact with the case manager and the discharge manager,” she says. “When we called the patient, he said, ‘We have home health, and my wife is here; I have my meds, and all is fine.’”

But it wasn’t fine, or anywhere close. It turned out that the man’s house was under construction, and his wife worked. So the man was trying to get around with a walker in a house’s construction zone, and there was no one around to help him, Khetarpal recalls.

“He couldn’t get into the bathroom when he needed it, and there was no home health,” she says. “So he needed home health for medication administration at the very least.”

There was an almost certain probability that the man would be readmitted. “You can imagine the mess we saw when we walked in there,” Khetarpal says. “It was a high-risk fall situation, and the man was a diabetic; it’s so clear when you go into patients’ homes why they end up back in the hospital.”

In another case, a patient who was an orchestra violinist had a broken arm. The woman, in her 70s, returned home in a state of emotional exhaustion since the injury affected her work and passion. On top of that, she was the chief caretaker of a husband who had Parkinson’s disease, Khetarpal recalls.

“The woman expected her daughter to take care of her, but the daughter was very busy with a severely autistic son,” she says.

The patient had comorbid conditions that qualified her for in-home services, but what she mostly needed were social services, Khetarpal says. “We got her Meals on Wheels because she couldn’t cut food, and we found her transportation services because she couldn’t drive.”

The woman also benefited from home health therapy for her arm and clergy services to help with her emotional distress. Without this help, she likely would have ended up back in the ED within a day or two of discharge, Khetarpal says.

Telephonic case management intervention is very important, but often it takes a home visit to discover the issues that might result in patients being readmitted, she says. “When you walk in the front door, you can see the reality of it.”