By Jeanie Davis

Social isolation is a life-and-death matter, believed to influence mortality as much as obesity and smoking. Yet amid the growing population of seniors, many are unmarried, widowed, or have no children living nearby.

“They might have a few acquaintances, but not a strong support system, nobody checking on them frequently, no one calling them every day or monitoring their status with a discharge plan,” says Jennifer Axelson, LCSW, CCM, CLCP, a certified life care planner and expert life care manager for Lifecare Innovations.

In her work, Axelson evaluates the patient’s home environment before hospital discharge, and helps smooth the transition to home care. When discharge planning for the lone senior, case managers should know several points about this demographic, she says.

Axelson describes common traits she sees in her patients: “Many come from an era where pride is an underlying theme in their personality. This can make for a dangerous situation when they’re discharged from the hospital because discharge planners may not be fully aware of this isolation.”

The lone senior may not bring anyone to the hospital who can add details to help discharge planning, says Axelson. “The case manager has to take the patient’s word on details about the home environment. The information you get can be pretty limited.”

“This person is predisposed to not doing well post-discharge, which can lead to hospital readmission,” she continues. “Isolated seniors, even with the best of intentions, can be discharged with an insufficient discharge plan because the information given to the discharge planner was incomplete or incorrect. It may be incorrect on purpose or because the patient has a cognitive issue.”

Axelson advocates making an in-person, at-home evaluation of the patient’s living space. Hospitals can contract with community-based care management organizations to provide this on-site evaluation. “It’s often a key component to determining the patient’s capacity and ability to care for oneself.”

How an In-Home Evaluation Works

Evaluating a patient’s living environment starts with a few questions: Is the patient experiencing functional issues? What medical conditions are the patient managing?

Axelson looks for signs of hoarding, fall risks, and bathroom locations. Is the patient still safely driving? Do doors and windows close and lock? Do the air conditioning and heat function? Are there any major repair issues? Are there signs of excess spoiled food? Is the patient taking medications correctly? “Any of these issues can be a red flag,” Axelson says.

The patient may need support that was not obvious, like Meals on Wheels or a medication delivery program, she adds. “Seeing how people live, and talking one-on-one, can give you that information, whether they are making meals or confused about their medications.”

The home assessment can identify other “ticking time bomb” issues that could become a bigger concern, Axelson says. “We curb those issues before they become catastrophic, like malnutrition, dehydration, or hoarding — which leads to falls and bacterial issues that can cause infection.”

One patient was hospitalized for dehydration; a home visit identified 16 medication bottles. The patient had carefully noted the dosage on each bottle cap. But the bottle caps had gotten mixed up, so she was taking cholesterol pills four or five times per day, and pain pills once per day. “We see medication confusion quite often, and it can lead to serious side effects,” says Axelson.

Addressing Deeper Issues

If the patient wishes, Axelson can follow up with a post-discharge visit and provide reminders about follow-up appointments. The level of support she provides depends on how many red flags she finds in her home visit.

The consultation also can go deeper, including legal issues like power of attorney. “The patient may want her daughter in California to be power of attorney. But when we speak with the daughter, we learn she doesn’t want to be involved. We can help make alternative suggestions,” Axelson says.

Another concern: Helping isolated seniors obtain resources on decision-makers, naming a person or organization to make their financial decisions when the time comes. Also, there might be a discussion of putting wishes in writing, like allocation of assets and healthcare decisions at end of life. Those discussions can start at the home evaluation visit.

Often, the patient will lead the conversation, Axelson says. “If they know you will help them, the isolated senior will have their own concerns and will bring them to the forefront. More often than not, people are receptive to our help. Other times, when they are not, we can only provide resources hoping they will eventually take steps.”

Isolated males can be prideful but willing to accept assistance when they get to know you, she explains. “Females are very used to managing things on their own, so not super eager to hand over personal information or to let us start managing things. I get that.”

“Every client we see has their own unique characteristics, life experiences, and their own trail of events that has led them to this point where we meet them,” Axelson adds. “We meet them where they are and understand their situation. Our end goal is to keep them safe. No one likes being in the hospital, so we want to get them out and keep them from going back.”

Agencies providing care management and nonmedical personal care are readily available in most towns and cities, says Axelson. The Case Management Society of America and the Aging Life Care Association can provide names and agencies that can help.

During the COVID-19 crisis, most patient visits have been via phone call, she adds. “We’re assessing status and following up as best we can.”

While insurance does not yet cover the home assessment visit, some hospitals have partnered with community-based organizations. Most care management organizations are willing to work within budgetary guidelines.

“We all have the same goal: to ensure the patient is well cared for, that conditions are managed, and that the discharge plan allows them to live the best possible life with quality,” says Axelson.