By Melinda Young
As baby boomers shift into their senior years, hospital EDs are seeing increasing numbers of older patients, a trend noted by a care coordinator at the Cleveland Clinic. These older, at-risk patients need case management services.
“Our aging population is an unprotected population of patients,” says Lauren Delaney, RN, ACM, transitional care coordinator in the ED at Cleveland Clinic. “They don’t have social support, and they have financial issues. Of those that come to the ED, we’re seeing an increase in social issues with geriatric patients.”
Some of these patients experience failure to thrive health issues. They might have problems with alcohol, or are not eating well. They might fall at home and lack family support. Even if they do not need ED services, they can end up there, she adds.
“Some older patients are not able to maintain their physical health in the home,” Delaney says. “Traditionally, at the ED, they’d be a soft admission. But with care transition services, we can help them with a multidisciplinary staff that includes dietary services.”
The ED case manager’s role is to help patients transition to a more appropriate level of care. “We work with other teams and offer alternatives to social admissions,” Delaney says.
For example, an 80-year-old patient lives at home alone. Her family checks on her once a week, but they are busy. Over time, ED staff notice an increase in her falls and ED visits. She appears confused, and is not managing her medications or eating well.
“We bring in that patient and triage her to make sure she’s medically safe,” Delaney says. “If the patient has no fractures, labs and X-rays are OK, and there’s no medical reason to admit that patient, then to admit the patient just for social issues places the patient at increased risk of infections, delirium, and falls,” she explains.
Case managers are brought in to work with patients, families, ED staff, and the geriatric team. They assist with connecting the patient to physical therapy and medication reconciliation. Case managers also help patients transition to skilled nursing facilities (SNFs) for rehabilitation, as needed, she adds.
Physicians, nurses, or the geriatric team will refer patients to case management. Sometimes, case managers will find high-risk patients on their own.
“We’re looking for any high-risk patient — someone who had a 30-day readmission,” Delaney says. “I’d like to know why they’re coming back to the hospital.”
If a case manager identifies an elderly patient who is in the ED because of a fall, he or she will try to find out why the patient fell. Knowing whether it was syncope, a mechanical fall, or Parkinson’s disease can help with a safe transition, she says.
“We had a case where a gentleman came in and had a catheter, and he wanted to be placed in an SNF,” Delaney says. As case management worked with the patient, they found that sending him to a SNF would not be a good fit because he was not strong enough to handle rehabilitation.
“We started talking with him about end-of-life care or hospice, and the transition took a different direction,” she explains.
“A lot of times in geriatrics, it’s sitting down and having those difficult conversations, hashing out what’s best for them and finding out what their goals are,” Delaney adds. “And sometimes we come to the end.”
Case managers can help patients with their transitions more effectively when they listen to his or her own goals of care and transition. They can work as a team to help patients receive in-home oxygen, hospice care, wound care, and other treatments.
ED case managers should be mindful of the hospital’s resources. Case management services need to work within the ED workflow and not tax staff time.
“If I come in, as a case manager, and become burdensome to ED staff, and my interventions are so time-consuming, then I’m not going to be a popular person in the ED,” Delaney says. “You need quick, thorough assessments, and you need to know the appropriate levels of care and be mindful of all the resources, the ED staff, nurses, and physicians.”
Turnarounds should be quick and precise, she adds. “This really is a team approach,” Delaney says. “You can’t take one person out of that loop and be successful.”