A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults

Abstract

Background: Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care.

Methods: Setting: A medium-sized urban ED with 55,000 patient visits a year.

Intervention: Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail.

Results: From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates.

Conclusions: Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

Keywords: Emergency Department; community services; elder abuse and mistreatment; older adults; social services.

FIGURE 1

A new care pathway incorporating a community Office on Aging case manager into the hospital setting overcomes prior care gaps. The hospital social worker or case manager identifies older adult patients with possible community care needs and gives the information to the Office on Aging case manager who performs and in person assessment during the Emergency Department (ED) visit. If a patient cannot communicate their needs, a community case manager can check whether they care currently receiving community services in their system, message their personal community case manager, or set up for a home intake assessment after the ED visit.

FIGURE 2

Community‐dwelling adults ages 60+ in the Emergency Department were assessed for community services needs by county Office on Aging case managers. The Office on Aging case managers confirmed sufficient services in 8% who had existing enrollments and immediately enrolled or referred to other county Offices on Aging 55% of the patients.