EXECUTIVE SUMMARY

Millions of older Americans visit emergency departments each year, often for traumatic injuries, including falls that can lead to death. Case managers and health systems should consider how to improve end-of-life care discussions and advance directive documentation in this population.

  • Transdisciplinary care can help patients’ well-being as well as lower costs.
  • Care should address older patients’ social needs, including housing and food security.
  • Older patients experience more severe injuries, more comorbidities, and worse outcomes and they take more medications. They are especially in need of advance directives.

By the end of this decade, one in five Americans will be older than age 65 years, according to the U.S. Census Bureau.1,2

Data show adults age 65 years and older comprise more than 22 million emergency department (ED) visits annually and represent 16% of all ED visits in the United States. Two-thirds of older adult ED patients are discharged home.3

“As our geriatric population grows, we are seeing people live longer and more functional lives into their 80s and 90s, which is great,” says Maureen Dale, MD, assistant professor and director for education and clinical care of the Geriatric Fellowship Program at the University of North Carolina at Chapel Hill. “But what it means is when our geriatric patients get hospitalized, they’re at higher risk of complications happening in the hospital. This can lead to longer hospital stays and the need for short-term stays in rehab facilities. It also can lead to loss of some degree of independence at discharge from the hospital.”

Timely communication between hospitals and post-acute care providers can improve the discharge process and reduce readmissions, she adds. (See story in this issue on improving care for geriatric patients.)

Case management continues to evolve toward optimal transitions for geriatric patients, particularly those with life-threatening illnesses or injuries that land them in the ED.

One best practice is transdisciplinary care that attends to patients’ well-being, health, and lowers costs, says Cameron Gettel, MD, MHS, assistant professor in the department of emergency medicine and clinical investigator with the Yale Center for Outcomes Research and Evaluation.

“It is such a complicated issue that there isn’t a one-size-fits-all,” Gettel says.

One area to measure is patients’ functional status — their ability to walk up stairs or go on a long walk.

Researchers need to perform more qualitative research, including in-depth interviews with patients, Gettel notes. For instance, investigators could ask patients these questions:

  • How was the discharge process?
  • Why did you go to the ED?
  • What were you told at discharge?
  • How was the follow-up experience?
  • What barriers did you experience during the care transition?
  • How could this process improve?

“Getting the direct patient experience in words is going to be really foundational to identify interventions that will be directly helpful,” Gettel says. “Certain interventions will have to be tailored to older adults, but it has to be designed by the emergency medicine society, the case management society, local communities, and more. It has to be a pairing with local community services.”

Case management and transdisciplinary care of older patients should address their social needs and include a component that recognizes the importance of adequate food and housing. “There has to be a continued focus because so much of our health depends on the social aspect and the resources we have available,” Gettel adds. “So much needs to be transdisciplinary to address the social needs of older adults.”

While there is not yet a blueprint for this approach, a concerted effort is underway to learn more about successful care transition interventions, particularly for geriatric patients in the ED. For example, the Geriatric Emergency care Applied Research (GEAR) Network has engaged interdisciplinary stakeholders and searched electronic databases to identify ED discharge care transition interventions among older adult populations.

A paper on the GEAR Network noted ED care transition intervention studies often address at least one social need of patients. These most commonly are related to access to food, medicine, or healthcare.3

“Some of the research thus far has focused on the social determinants of health, and more needs to happen and be addressed about the individual social needs of adults,” Gettel says. “Other countries address the social needs more than we do as a country. I think there is an opportunity for improved patient outcomes and less cost to the system in general.”

The first step is more research into the needs of geriatric patients. “Many of these interventions that we looked at were bundled with a comprehensive geriatric assessment, a telephone follow-up, and discharge planning,” Gettel explains. “Many of these trials and interventions threw the kitchen sink at these adults to help them. But it’s important to identify which of these components is really helpful and beneficial, and then [use data] in boosting support for that care transition, whether it can be case management, discharge planning, or a telephone call to make sure there is adequate follow-up.”

The authors of a new study suggested a benefit to geriatric care when advance care planning is integrated.2

There is a need for advance directives and care transition tactics to help a population that experiences more severe injuries, more comorbidities, and worse outcomes and they take more medications. says Janet S. Lee, MD, resident physician in the department of trauma and acute care surgery at the University of Colorado Health Memorial Hospital. Lee also is resident physician at Anschutz Medical Campus, Aurora.

“Thirty percent of trauma patients are over age 55; they take a huge proportion of the trauma population. This number is expected to rise as the population gets older,” Lee says. “The most common cause in the geriatric population is falls.”

Fall deaths among older adults in the United States increased by 30% from 2007 to 2016, according to the CDC.4

When geriatric patients visit the ED after a fall, the emergency doctors and trauma team evaluate the patient for an injury that requires admission, Lee says. Someone also could determine whether the patient has an advance directive.

“Our service, led by geriatricians, does a good job of talking with patients about their care goals and what their wishes are,” Dale says.

This is particularly important for patients who visit the hospital frequently because their chronic conditions are exacerbated. “One of the things we have always known is we need to do a better job of talking about advance care planning with patients, both in the clinic setting and in the hospital,” Dale says. “We have found, over the course of the last 18 months of the pandemic, that this is more critical work than ever, but it’s work that still is often overlooked and unrecognized.”

The ideal place to start advance care planning discussions and documentation is in the outpatient setting, where there is more time for patients to discuss their own values and goals for end-of-life care.

People need time to identify a decision-maker and decide what they want to happen when they cannot decide on their own, Lee notes. But this does not always happen. If the patient is in the ED or admitted to the hospital for a serious trauma, there is no documentation of the patient’s wishes.

“When they come after a severe injury, sometimes they’re not able to participate in that discussion. That’s when advance directives really matter,” Lee says. “It’s a lot of emotional burden for them.”

Case managers and social workers can help fill in the gap when hospitalized patients suffer trauma or severe illness and lack an advance directive. (See story on talking with patients about advance directives in this issue.)

Many geriatric patients are readmitted soon after a fall or traumatic injury, and there is a risk of death. This suggests someone could intervene at the time of the first ED visit or hospitalization to begin an advance directive conversation.

“One quality improvement [metric] is identifying whether a patient has an advance directive,” Lee says. “Even if the patient doesn’t have an advance directive when arriving at the trauma center, there’s an opportunity for us to intervene and have that discussion. This could be a nurse, social worker, and case manager.”

For instance, one hospital paired a social worker with the palliative service to obtain advance directive documentation on all admitted patients. “The social worker went first and discussed it with patients,” Lee adds.

If the patient already prepared an advance directive, the social worker would track it down.

Another tactic is to ensure everyone who is admitted to the ICU — regardless of age — has documentation of power of attorney and a decision-maker.

Also, case managers should know advance care planning may not be one and done. It is something that should be discussed at every hospital admission with every geriatric patient, and it should continue each time a patient is admitted or seen, Dale says.

“There are ongoing discussions with patients, loved ones, and caregivers about what they want in care, looking to the future and understanding where care is at that moment,” Dale explains. “It can change from office visit to office visit, from hospitalization to hospitalization.”

REFERENCES

  1. United States Census Bureau. Older people projected to outnumber children for first time in U.S. history. Updated Oct. 8, 2019.
  2. Lee JS, Khan AD, Dorlac WC, et al. The patient’s voice matters: The impact of advance directives on elderly trauma patients. J Trauma Acute Care Surg 2021; Sep 14. doi: 10.1097/TA.0000000000003400. [Online ahead of print].
  3. Gettel CJ, Voils CI, Bristol AA, et al. Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; Jul 30. doi: 10.1111/acem.14360. [Online ahead of print].
  4. Centers for Disease Control and Prevention. Facts about falls. Reviewed Aug. 6, 2021.