Discharging Elderly Patients Presents Challenges in the Age of COVID-19
By Jeanie Davis
COVID-19 has brought new challenges to discharge planning for elderly and seriously ill patients, says Liz Barlowe, MA, CMC, president of the Aging Life Care Association (ALCA) board of directors.
“These patients are the most vulnerable, at greater risk of dying if they get the virus,” Barlowe says. “If one of them is ready to be discharged to their home or a facility, they need a plan in place to keep them safe.”
ALCA connects consumers with paid care managers/health advocates in every region of the country. The care manager/health advocate often is a nurse, social worker, gerontologist, physical therapist, occupational therapist, or other health-related professional.
Public health officials have advised that patients with lung disease, diabetes, and compromised immune conditions are at greatest risk of critical illness from COVID-19. Geriatric patients might have a lower fever than younger adults and children; however, elderly patients will need the greatest care.
The most vulnerable patients also include those with ongoing pulmonary disease, emphysema, asthma, hepatitis, lupus, and those taking medication that suppresses the immune system.
Barlowe believes hospital case managers, patients, and families can benefit when a private case manager helps facilitate discharge planning.
“Right now, more than any time, people need extra support,” she says. “I encourage case managers to refer people to the Aging Life Care Association. We can help them prepare patients for transition. We can help strategize. We realize a case manager’s time is of the essence.”
Start the conversation as soon as the patient is admitted, Barlowe advises. “We can help get things off to a good start wherever they are being transferred, whether home or a facility.”
Reduce Unnecessary ED Visits
She advises hospital case managers to talk to families regarding a “do not hospitalize unless life-threatening” order. This prevents unnecessary trips to hospital emergency departments (EDs), which are now overwhelmed with COVID-19 patients.
“Typically, if a patient falls in a facility, the staff are quick to call 911 to get the person medically assessed quickly, as there could be a liability issue,” Barlowe explains. “In the COVID-19 climate, we have to help preserve the hospital resources.”
A skilled nursing facility will have a nurse on staff to assess the patient’s medical condition. But that is not true of assisted living facilities, she says. “If family has a private care manager overseeing the patient’s care, that can prevent an unnecessary trip to the ED.”
Long-term care facilities still are accepting patients, but they will be in quarantine the first 14 days, says Barlowe. “It’s important for families to know that.”
The case manager should consider the patient’s needs before transfer to the facility. Does he or she need a private duty caregiver to help with the transfer or with adjustment? “Some facilities are allowing private duty caregivers; others are not, as they want to limit the people entering the building,” she explains. “Some are hiring extra facility caregivers during this time.”
When the pandemic first started, facilities were reluctant to let family members come inside, Barlowe explains. “Instead, they would bring the patient to the front porch to visit, staying within appropriate physical distance. Now that the facilities are on lockdown, that has progressed to ‘window visits’ and videoconferencing.”
Facilities are doing their best to implement social media or videoconferencing so patients can communicate with family members, she says. “It’s been difficult, as none of the facilities ever anticipated a lockdown.”
If the patient is discharged home, “it’s important that the home be set up for quarantine, including equipment and caregivers,” Barlowe says.
A case manager can help with the patient’s transfer from hospital to home, she explains. The case manager can help the family develop a plan for home quarantine, and be on the receiving end when the patient comes home. The private case manager will set up meal delivery, medical equipment, and ongoing nursing care, with safety as the priority.
If the patient needs a caregiver at home 24/7, arrange for as few caregivers as possible, she advises. Try to arrange three people (or four maximum) to alternate on 24-hour shifts. Some may handle two days in a row during the week.
- Screen every caregiver, every day. Take his or her temperature on arrival.
- If possible, provide fresh scrubs for each caregiver. Wash them in your own home so you know they are clean.
- The caregiver should put dirty scrubs in the washer; the next shift caregiver can dry them.
- When the caregiver arrives, he or she should change into scrubs in the garage. Street clothes should be left in the garage.
- Caregivers must wear a mask and gloves at all times, if possible.
“Finding a home caregiver is challenging right now, as many aides have kids home from school, or are fearful of working without protective gear,” says Barlowe. “The case manager needs to refer the patient or family to an aging life care professional sooner rather than later. They will need some help making sure the plan is in place, and that it’s a viable plan.”
Hiring a Private Caregiver
Barlowe’s advice for managing hired caregivers (both private or via an agency): Always hire a certified nursing assistant from an agency licensed in your state. This ensures a thorough check of background, certification, and overall safety training.
This especially is critical for a patient who lives alone and is being discharged home, she adds. “They are very vulnerable, so it’s important to have a trusted advisor get them set up with the necessary services, whether they need delivery of meals or medications. An elderly patient should not be in a grocery store right now.”
As the situation is evolving, she is spending time on Zoom calls with care managers around the country, talking about best practices, says Barlowe. “We are ready to help in these situations and will assist families to ensure a safe and comfortable transition home.”
COVID-19 has brought new challenges to discharge planning for elderly and seriously ill patients. Long-term care facilities still are accepting patients, but they will be in quarantine the first 14 days. The case manager should consider the patient’s needs before transfer to the facility.
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