Emergency Department-to-Community Transitions of Care

INTRODUCTION

Older adults, defined as those aged 65 years or older, are an increasing population in emergency departments (EDs) worldwide, with visit volumes increasing at a rate beyond that expected from demographic change alone.¹ Within the United States, older adults account for over 27 million ED visits annually, representing over 18% of all ED visits.² ED care-seeking among older adults has increased because of the aging population, an increased prevalence of loneliness and lack of social support, changes in the organization of primary care, and expectations for convenient medical care by emergency medicine “availablists” within a 24-hour one-stop shop environment.^3,4

Older adults requiring ED care are more likely to suffer from chronic illnesses, multiple chronic conditions, and cognitive and functional impairments potentially limiting their ability to communicate symptoms and preexisting social problems.^5,6

ED visits often reflect a critical inflection point in older person’s health trajectory, with many factors contributing to care-seeking and several outcomes commonly deemed important to older adults (Fig. 1).⁷ Approximately 65% of older adult ED patients are discharged home,⁸ and prior studies show the ED-to-community care transition is fraught with inadequate communication and poor patient comprehension of their medical condition.^9,10 Consequences include a higher likelihood of adverse health outcomes such as decline in mobility and function, ED revisits, hospital admission, and mortality.^11–13 Highlighting the importance of the problem, repeat ED visit rates for older adults after ED discharge are 7.8% at 3 days,¹⁴ 10%–16% at 1 month, 24% at 3 months, and up to 44% at 6 months.¹⁵ The 2014 consensus geriatric ED guidelines and the 2018 launch of the geriatric ED accreditation process have attempted to improve these outcomes in older adults by prioritizing high-quality ED-to-community care transitions.^16–18 This article describes ED-to-community care transitions for older adults and associated challenges, measurement, efficacious and effective interventions, and policy considerations.

Fig. 1.

Conceptual model and framework for ED-to-community care transitions among older adults (From Gettel CJ, Serina PT, Uzamere I, et al. Emergency department-to-community care transition barriers: A qualitative study of older adults. J Am Geriatr Soc. Published online July 2, 2022. https://onlinelibrary.wiley.com/doi/10.1111/jgs.17950. With permission.)

What Do the Guidelines Say?

Published in 2014, the geriatric ED guidelines provide a standardized set of best practices aimed at improving the care of the geriatric population within the ED.¹⁸ Pertaining to care transitions, the published guidelines recommend ensuring adequate communication of clinically relevant information (eg, working discharge diagnosis, new prescription, physician note, follow-up plan) to the patient/family and outpatient care providers, including nursing homes. They also suggest large-font discharge instructions, ensuring a process in place to obtain follow-up clinical evaluation (with consideration for telemedicine), and maintaining relationships with community organizations to facilitate necessary future care.

How to Identify Who Is at Risk

The emphasis EDs must put on efficient care has been strained in recent years because of the higher prevalence of older adults, more complex diagnostic evaluations, and greater boarding of inpatients within the ED.¹⁹ When admitted patients board in the ED, personnel trained and hired to expedite the evaluation and treatment of ED patients are instead used to provide inpatient level of care. These stressors leave clinicians with little time and departments with limited personnel and finances to adequately uncover and address all barriers that hinder ED-to-community care transition success.

Given limited resources, screening instruments have the potential to identify older adults at increased risk of adverse outcomes during the time frame immediately after ED discharge. Screening instruments used in the ED for older patients typically assess activities of daily living and include the Identification of Seniors At Risk (ISAR) tool, the Triage Risk Screening Tool, the Variables Indicative of Placement Risk, and the Inter-RAI ED Screener.²⁰ Validation studies have shown that no current screening test has optimal test characteristics.²¹ The ISAR has been the most frequently assessed tool and has shown only modest predictive accuracy in identifying older adults at high risk of adverse outcomes.²¹

Aside from activities of daily living, emergency clinicians may also consider other tools to screen for factors that impact ED-to-community care transitions including risky medications (AGS Beers Criteria),²² poor mobility (sit to stand test), and impaired cognition (Brief Alzheimer’s Screen or Quick Dementia Rating System).^23,24 Further research is needed to develop screening instruments designed for and validated among ED patients with improved test characteristics that reliably identify older adults in a timely fashion as being at risk during ED-to-community care transitions. In the meantime, emergency clinicians should consider using validated screening tools and engaging a multidisciplinary care team with expertise in geriatric patient care, including case managers, transitional care nurses (TCNs), physical therapists, social workers, and other professionals available locally. Screening questions for emergency clinicians to consider before discharge are shown in Box 1.²⁵

Box 1. Questions to consider before discharging an older adult from the ED.

• Have you accounted for any cognitive deficits or changes in mental status?

• Have you assessed for safe ambulation (if ambulatory)?

• Have you discussed the level of care needed at home and whether carers will be available?

• Do you have any concern for abuse or neglect, even self-neglect?

• Have you double checked any new prescriptions for medication interactions?

• Have you confirmed good understanding of the discharge instructions with the patient and caregiver?

• Does the patient feel comfortable and ready for discharge? Is there anything the patient is worried about?

• Has the plan of care been communicated with the patient’s general practitioner?

From Southerland LT, Pearson S, Hullick C, Carpenter CR, Arendts G. Safe to send home? Discharge risk assessment in the emergency department. Emerg Med Australas. 2019;31(2):266–270. With permission.

Discharge Instructions

Older adults discharged from the ED are at particular risk of adverse outcomes, and adherence to ED discharge instructions may mitigate that risk. Suboptimal rates of adherence are present for adults of all ages, with only 68% to 88% filling prescriptions for new medications,^26,27 51% to 70% following up with primary care providers,^28,29 and 49% having at least a minimal understanding of reasons to return to the ED.³⁰ Focusing on certain populations may be the most effective use of time at ED discharge, as those of advanced age, with depression, or functional limitations are less likely to recall “red flags” (signs of worsening health requiring further medical attention), and those with limited English proficiency are more likely to have unplanned short-term ED revisits.^31,32 Prior work has shown subsequent hospital revisits may be reduced among older adults by using the limited time at ED discharge to focus on medication adherence, follow-up appointments, and knowledge of clinical warning signs.³³ As part of the discharge instructions, older adults could be provided with a scheduled follow-up primary care visit. Some EDs hire care navigators to schedule these follow-up visits before ED discharge or to help patients establish care if they are new to the area or lack primary care.³⁴ In broader adult populations, several studies have shown an absolute improvement of approximately 20% in obtaining follow-up care when employing this practice, suggesting the possibility of adapting this practice to the more vulnerable older adult population.³⁵

Several health systems have also adopted the “4 Ms” model to enhance geriatric care, including the ED discharge process. Developed by the John A. Hartford Foundation and the Institute for Healthcare Improvement, the Age-Friendly Health Systems’ initiative ensures a patient-centered and evidence-based approach is used for older adults through the “4 Ms” model—What Matters, Medication, Mentation, and Mobility.³⁶ Addressing “What Matters” has proven feasible (3 minutes on average) within the ED setting to gain valuable information from older adults regarding their fears/concerns as well as their desired outcomes (Box 2).³⁷ This structured framework has the potential to facilitate ED clinicians in obtaining valuable information regarding initial and possible future care-seeking behaviors among older adults that may be incorporated within discharge instructions. Components of the Age-Friendly Health Systems initiative and “4 Ms” model have been implemented in several EDs with evidence of success.³⁸

Box 2. “What Matters” semi-structured interview guide for older adult patients and their treating clinicians.

Questions for older adult patients

1. One question to ascertain fears or concerns about health care in ED.

   1. What concerns you most when you think about your health and about being in the ED today/tonight? or

   2. What fears and worries do you have about your health as you think about what brought you to the ED today/tonight?

2. One question about outcome patients most want from their ED visit

   1. What outcome are you most hoping for from this ED visit? or

   2. What are you most hoping for or looking for from your ED visit?

From Gettel C, Venkatesh A, Dowd H, et al. A qualitative study of “What Matters” to older adults in the emergency department. West J Emerg Med. 2022;23(4):579–588. With permission.

Existing Interventions to Enhance Care Transitions

Qualitative studies have identified patient and caregiver concerns surrounding the ED-to-community care transition that should be considered when developing care transition interventions.^7,39,40 Themes have been identified regarding barriers experienced during ED-to-community care transitions and root causes for seeking emergency care again in the immediate time period after ED discharge. Motivations to seek emergency are included that older adults felt confident that they would get needed care within the ED if acutely ill and that their primary care provider (PCP) suggested seeking emergency care. However, many stated that they could not obtain reliable follow-up with their PCP in a timely fashion and that the index ED visit discharge instructions were not clear. These themes showcase perceived needs by older adults that interventions discussed here have addressed.

Adaptations to the Care Transitions Intervention

One example intervention that has shown promise in improving ED-to-community care transitions has been the Coleman Care Transitions Intervention (CTI).^41,42 Originally developed as a hospital-to-home CTI, the modified CTI model uses community paramedics from ambulance-based emergency medical services (EMS) system to follow up with older adults after ED discharge. Community paramedics can be particularly beneficial for older adults with multiple chronic conditions given training on guiding older adults on self-management strategies and coordinating follow-up care with PCPs. In a population of patients aged ≥60 years, the modified CTI did not show a reduction in 30-day ED revisits but did result in a significant increase in key care transition behaviors such as outpatient follow-up and red flag knowledge.⁴³ Within a pre-planned subgroup analysis of community-dwelling older adults with cognitive impairment, the modified CTI did result in a significant reduction in the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval 0.07–0.90).⁴⁴ If considered for use locally, the ED-modified CTI model requires collaboration with EMS agencies but offers considerable opportunity to improve patient outcomes as shown by reduced risk of hospital readmission. Aside from the modified CTI model using community paramedics, researchers have also tested the effect of an adapted CTI using home visits and follow-up telephone calls by Area on Aging care coaches to address the four “pillars” of timely follow-up clinician visits, understanding of disease warning signs, medication reconciliation issues, and lack of a personal health record. Compared to usual care, the adapted CTI did not reduce return ED visits or hospitalizations at 60 days (primary outcome); however, a shorter timeline may be more relevant and is more commonly used in ED-based studies.³⁹

Emergency Department Navigators

ED-based TCNs have also proven beneficial with regard to certain patient-centered outcomes and lower Medicare expenditures among fee-for-service beneficiaries.^45,46 By identifying patients with geriatric-specific health-related needs and coordinating their transition from ED to community, TCNs aim to avoid inpatient admissions that may predispose older adults to deconditioning, delirium, and infections. In a 2018 study, individuals exposed to a TCN had a significantly lower risk of inpatient admission during the index ED visit at 3 included hospitals, and for 2 of the 3 hospitals, this decreased risk persisted over the subsequent 30 days.⁴⁷

Similar to the TCN model, assessments by other ED “navigators” have also shown promise, particularly when risk-prediction tools have been used to identify those at the highest risk.⁴⁸ In separate studies, referrals to community services placed by these professionals (eg, social worker, nurse, care coordinator, case manager) for the highest risk older adults resulted in fewer return visits to the ED and fewer admissions to nursing homes.^49,50 Without risk stratification, interventions reliant on referrals among a broader older adult population failed to reduce ED revisits, nursing home admissions, or mortality.^51,52 Aside from one-time in-ED engagement strategies, interventions with multiple touchpoints with health care team members offer a potentially more robust approach to ED-to-community care transitions. Inconsistency across outcomes has been noted,⁴⁸ yet reductions in hospitalizations at 30 days and ED revisits at 3 months have been reported for coordinated teams that extend beyond the ED.^53,54

Telephone Follow-up

Aside from incorporating “positive” findings from existing studies on care transition interventions, it is also critical to consider studies with “null” results as this work may inform clinicians, researchers, and administrators where to invest time and resources and also provide information about study strengths, weakness, and modifications to consider for future investigations. Biese and colleagues reported “null” findings for a scripted telephone intervention for older adults discharged from the ED to home.⁵⁵ Although Biese and colleagues did not identify a significant difference in risk of the primary composite outcome of ED revisit, subsequent hospitalization, or death within 30 days, a more recent study of adults of all ages by Fruhan and Bills did identify a reduction in 3-day and 7-day ED return visits after an automated follow-up telephone call about remaining questions about discharge instructions 2 days after ED discharge.⁵⁶ These varied results suggest that telephone or telehealth (allowing visualization of the patient) follow-up remains a viable possible ED care transition intervention that could prove efficacious in future studies within specific ED populations, including those with functional or cognitive impairments.⁵⁷

Information Exchange to the Outpatient Setting

A recent systematic review of randomized controlled trials evaluated the impact of ED-based interventions supporting ED-to-community care transitions of all adult populations.⁵⁸ The authors determined the ED-based care transition interventions did not reduce subsequent ED revisits or hospital admissions but did significantly improve outpatient follow-up rates. Specific to the geriatric population, prompt primary care and subspecialty care follow-up for older adults seen in the ED has been shown to be associated with reduced rates of subsequent, repeat ED visits within 30 days.⁵⁹ Alerting PCPs that older adults sought emergency care has also been proposed and tested as a means to improve ED-to-community care transitions and encourage more older adults to seek close outpatient follow-up. Web-based and electronic health record (EHR) alerts have been most commonly used, with studies across all age categories suggesting higher PCP awareness of the visits but no change in the rate of follow-up.^60,61 Especially if trying to automate this process and pragmatically implement at the point of clinical care, logistical issues associated with this practice include reliable identification of the older adult’s PCP, provision of relevant ED information (eg, chief complaint, laboratory values, treatment plan) to the PCP, and recommendation of follow-up care needs. Health information technologies, remote data transfer, and clinical informatics represent burgeoning fields that may advance data-sharing efforts between clinicians and across settings.⁶²

Considerations for Unique Populations

Social isolation, defined as “a perceived or objective lack of connection to, or support from, social networks,” affects a large proportion of older adults and requires specific attention during ED-to-community care transitions. Findings from a recent national study suggest that approximately 25% of community-dwelling older adults are considered socially isolated.⁶³ Within the older adult population in the ED, estimates have recently found that over 50% actively were experiencing social disconnection, including feelings of being burdensome to others, as if they did not belong, or that people would be better off if they were gone.⁶ In addition to poor psychological, cognitive, and physical outcomes,⁶⁴ social isolation has been shown to be associated with lower rates of in-person follow-up in the week following ED discharge.⁶⁵ Socially isolated older adult populations in the ED may reasonably be the target of future interventions, such as nonemergency medical transportation or coordination with community organizations, given recent calls to build interventions that reduce the health and medical impacts of social isolation in older adults.

Incident functional decline has been noted for older adults discharged from the ED to the community.^11,66 However, older adults seeking emergency care already with functional impairment before the ED visit have been identified as another population that is particularly at risk during ED-to-community care transitions. Lowthian and colleagues discovered that pre-existing functional impairment in activities of daily living (OR 3.21, 95% confidence interval 2.26–4.53) and instrumental activities of daily living (OR 6.69, 95% confidence interval 4.31–10.38) were both strongly associated with new functional decline in the 30 days after an ED visit.¹ Functional assessments, support service incorporation, mobility aids, and instructions on how to use assistive devices correctly have the potential to prevent worsening functional impairments during ED-to-community care transitions among older adults with pre-existing impairments.

Persons living with dementia (PLWD) and their care partners make up a separate population that often requires additional support to ensure successful ED-to-community care transitions. While the majority of PLWD are discharged from the ED,⁶⁷ care partners (eg, family, friends) often provide a significant amount of hands-on care and assistance with navigating follow-up care needs despite frequently being untrained. Thirty-day ED revisit rates are higher for those with a diagnosis of dementia,⁶⁸ which may be a result of unique ED-to-community care transition barriers experienced by care partners including poor communication and care partner engagement by clinicians during the discharge process, taking on additional responsibilities while aiding during the PLWD’s acute illness recovery phase, and difficulty navigating the health-care system for follow-up.⁴⁰

Measuring Success of Emergency Department Care Transitions

ED revisit rates are frequently used as a proxy measure for the quality and success of ED-to-community care transitions. Age, male sex, polypharmacy, and cognitive impairment have been shown to be independent predictors of 30-day ED revisits.^48,69 However, this outcome measure does not account for the condition burden or change in health-related quality of life faced by patients and family caregivers at home after ED discharge and is of limited utility for certain appropriate clinical scenarios that warrant an ED revisit (eg, wound check). The Centers for Medicare & Medicaid Services (CMS) has more recently prioritized the inclusion of the patient experience in the transition away from process measures, such as ED revisit rates, and toward patient-reported outcome measures (PROMs).⁷⁰ Focusing on the outcome of a health care experience, PROMs are questionnaires that report the patient’s perception and may address health-related quality of life, condition-specific symptom burden, functional disability, or other considerations. PROMs addressing ED care transitions to date have been limited by their attempted translation from the inpatient hospital setting or absence of dedicated focus to the geriatric population.⁷¹ The multidisciplinary Geriatric Emergency care Applied Research (GEAR) 1.0 and 2.0 Networks, respectively, focus on emergency care as experienced by older adults and persons living with cognitive impairment and their caregivers and have determined that developing PROMs addressing ED care transitions represents a critical knowledge gap that researchers should prioritize.^72,73

Policy and Payment Implications

To improve hospital-to-home care transitions, the Medicare fee-for-service and Medicare Advantage programs currently allow PCPs to be reimbursed for transitional care management (TCM) services to reduce potentially preventable readmissions and errors during the 30 days following discharge from an inpatient hospitalization, an observation status hospitalization, or a skilled nursing facility stay.⁷⁴ Several components are required to bill TCM services, with two relevant components being (1) clinical staff contacting the patient or caregiver via phone, email, or face-face to address the patient’s status beyond simply scheduling follow-up care and (2) conducting a follow-up visit within 7 or 14 days of discharge, depending on the complexity of the medical decision-making involved. What is not included as a triggering event to allow TCM services being performed are emergency outpatient visits, including all older adults experiencing an ED-to-community care transition.

Expanding this practice, CMS has the opportunity to use policy levers in two ways. Designating emergency outpatient visits as a reimbursable event for TCM services would allow and encourage PCPs to more regularly address the new diagnoses, new medications, and new care plans that commonly result from emergency care. Second, CMS and other payors should consider an analogous TCM service to be implemented for emergency clinicians treating and discharging high-risk older adults to the community.⁷⁵ Currently CMS only allows charges by PCPs for this billing code; however, initiatives stemming from ED-based TCM services could proactively set older adults up for success during ED-to-community care transitions. As an example, ED-based TCM services would be similar to Current Procedural Terminology codes 99495 and 99496 in the outpatient setting and could include facilitating referrals, care coordination, and other needed services for older adults that may reduce ED revisits, hospitalizations, and health-care expenditures in the weeks following ED discharge.

However, to truly move the needle regarding ED-to-community care transitions for older adults, meaningful change can come in the way of holding clinicians accountable for a population of patients and their subsequent outcomes through transitioning reimbursement toward value-based care initiatives and away from the United States’ current volume-based fee-for-service model. More widespread uptake of accountable care organizations or capitation models that incentivize high-value care for a population rather than an individual may encourage coordinated clinical care and reduce fragmentation between settings and clinicians. ED-to-community care transition programs, models, and interventions stand to be a central component of needed partnerships with inpatient and outpatient colleagues participating in risk-based contracts.^75–77

SUMMARY

Improving care transitions for older adults across health-care settings and between clinicians is a national priority. Fragmented and suboptimal ED-to-community care transitions can result in repeat ED visits, hospitalizations, and increased health-care costs. Older adults have higher prevalence of risk factors for poor transitions, such as cognitive or functional impairments, social isolation, and reduced comprehension of ED discharge instructions. Efforts to improve patient-centered outcomes in the period immediately after ED visits must be prioritized for older adults through the implementation of effective care transition intervention strategies, the development of clinical practice guidelines, and the expansion of TCM services.

CLINICS CARE POINTS.

• Aside from ED revisit rates, more attention has increasingly been placed on patient-reported outcome measures suggesting that emergency clinicians may benefit by discussing condition-specific symptom burden and functional status and quality of life during the discharge instruction process.

• Emergency clinicians should consider using screening tools (eg, ISAR, Quick Dementia Rating System, and so on) and engaging case managers, transition care nurses, physical therapists, social workers, and other multidisciplinary team members before ED discharge.

• As part of the “4 Ms” model, addressing “What Matters” has been proven feasible within the ED and offers a succinct and structured method to identify the fears/concerns and desired outcomes of older adults.

• Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care.

KEY POINTS.

• Opportunities for improved communication with older adults and their care partners during ED-to-community care transitions may help overcome common adverse events after ED discharge.

• Older adults experiencing social isolation and those with impaired mobility or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care.

• Care transition interventions to date have had variable efficacy and effectiveness in reducing ED revisit rates, yet promising solutions that target at-risk populations exist.

• Investment in transitional care management services in EDs could position ED clinicians, patients, and their care partners to reduce adverse events during this care transition.