Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model—what matters (patient goals of care), medication, mentation, and mobility—along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.
Key points
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Transitions of care represent times at which older adults are particularly vulnerable to adverse events, such as medication errors, difficulty recovering from the illness or injury, and miscommunication due to fragmented care.
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Familiarization with the variety of care settings that older adults inhabit can help facilitate a safe disposition by understanding the level of care and adjuncts that are available.
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The Institute for Healthcare Improvement 4-Ms model helps clinicians develop a safe discharge plan. This involves understanding medications, mentation, mobility, and what matters most to the patient as well as safety and social support.
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Goals of care conversations are about what matters most to the patient, which informs the level of care desired.
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Communication is key to safe dispositions, and ED physicians can take steps to ensure that changes to the patient care plans are understood by the patient, caregivers, and other members of the medical team.
Introduction
Transitions of care occur every time an older adult moves from one physical care setting to another or when a new provider assumes care. Transitions of care are frequent for older adults, who often have multiple comorbidities requiring an interdisciplinary team of providers across multiple care settings ( Fig. 1 ). Such transitions often are unplanned and occur when either an exacerbation of an underlying illness or an acute illness or injury results in a visit to the emergency department (ED). This may be due to frailty, where an older person is functioning well but does not have the physical or psychosocial reserve to compensate for an additional injury or illness, or due to the severity of the underlying medical condition. Fragmentation of outpatient care between multiple specialist providers has resulted in the ED becoming an important hub at the center of geriatric care. The ED visit may result in discharge back to the community with a new care plan, discharge to a new care setting, or hospital admission.
Adverse events with transitions to or from the ED are well documented. Adverse events during transitions can be life-threatening or life-altering for older adults and their loved ones, leading to a decline in independence and functional status. Within 3 months of an ED visit, approximately one-third of older adults experience an adverse outcome. Many of these adverse events are medication interactions or side effects. More than a third of patients (38%) prescribed medications from the ED have potential drug-drug interactions on pharmacist review. Prescribing from the ED is complicated by the fact that patient self-report of medications is poor, with older patients taking on average 3.8 more medications than they report. Additionally, emergency providers may feel medication reconciliation is too difficult or not in their scope of practice. Further barriers are created by health systems, because outpatient or clinic electronic health record (EHR) systems often are inaccessible to the ED provider. This is an example of how system-level, provider-level, and patient-level factors all can interact to complicate transitions of care ( Table 1 ). Patient factors contribute to the complexity of decision making and communication at the time of discharge or admission. Systems constraints include limited time in the ED for comprehensive geriatric assessments and the cognitive load of caring for multiple, acutely ill patients. Fragmentation of a patient’s health care team also plays a large role in how information is lost during transitions. Information that is critical to providing optimal care may be miscommunicated or communicated inadequately to other members of their interdisciplinary team and outpatient providers. Insurance issues, social services availability, and stress on family caregivers also play a role in adverse events with transitions of care.
| System Factors | Provider Factors | Patient Factors |
|---|---|---|
| Insurance issues: precertification for medications or home health or nursing facility placement | Patient load | Complex interacting comorbidities |
| Barriers to access to outpatient resources | Implicit biases | Polypharmacy |
| No communication between EHR systems | Lack of training | Cognitive impairment |
| Minimal face-to-face time with the patient and heavy charting requirements | Perception that it takes too much time | Low health literacy or educational level |
| Multiple handoffs and multiple providers | Focus on acute issue only in the ED leads to disregarding chronic issues | Lack of social support |
| Reduced services due to time of day or weekend transitions | Low engagement with community partners | Cultural preferences on communication and family involvement |
| Lack of in person or face-to-face handoffs | Difficulty tailoring instructions to individuals | Communication difficulties (eg, sensory impairment and language barriers) |
| Poor integration of transitions of care services | Minimal planning time for discharge from the ED compared with inpatient time | |
| Lack of inpatient-outpatient continuity of providers | Limited training in transitional care principles | |
| ED crowding and/or inadequate staffing |
How then can emergency clinicians ensure safe transitions of care? One critical issue that is amenable to intervention by the ED team is communication with the patient. Communication with patients and ensuring understanding of diagnosis and care in this population are difficult. Only a fifth of older adults discharged from EDs can state their diagnosis, as opposed to 70% to 80% of younger adult ED patients. , Communication barriers to patients include cognitive impairment, language and sensory barriers, small print instructions, and cultural differences on engagement in health care. In 1 study comparing understanding of return instructions in older adults with varying degrees of cognitive impairment (dementia, delirium, and normal cognition), understanding ranged from 10% to 49%, based on the level of cognitive impairment. This suggests that, at best, only half of older adults discharged understand critical discharge instructions. Emergency clinicians are in a unique position to minimize risk to the patient at care transitions by improving communication and using cognitive screening and strategies, such as teach-back, to assess patient understanding.
The impact of care settings
There are myriad possible care settings that a patient may be coming from or transitioning to as well as additional services that can be of assistance in these different settings. Understanding the capabilities, advantages, and disadvantages of different care settings is essential to determining the appropriate level of care and best transition for patients ( Fig. 2 ). Settings range from aging independently in the community to nursing facilities (skilled nursing facility [SNF]) with 24-hour medical support. The information required at discharge is similar no matter the living situation: medication information, appointments scheduled or needing to be scheduled, any treatments, wound care or therapies needed, and the level of assistance required with ambulation, toileting, and feeding. Many providers assume that home caregivers have been trained to provide services, such as gastric tube care or incontinence care, but home caregivers often are appreciative of further details regarding this care. The ability to discharge a patient to home with home health rather than admission to an SNF often is desired by patients, but this can create a burden on caregivers and has been associated with more ED revisits in the short term. The social support, abilities, and availability of caregivers must be clear and discussing alternative options in the event of caregiver burnout is very helpful.
Another frequent care transition that can lead to need for emergency care is SNF discharge to home. SNFs are pressured to discharge patients to home care, resulting in unexpected challenges for patients who often end up in the ED when family is unable to care for them. System factors, such as insurance payments, may contribute to precipitous care transitions. Patients on Medicare may be unable to afford the $170.50 daily copay (2019 rates) for skilled nursing care after the 20 days of 100% cost coverage elapse, resulting in premature discharges to home. In 1 study, 25% of older adults discharged from a SNF where in the ED within 30 days, compared with 12.6% when a specialized pharmacist/geriatrician discharge intervention was done in the SNF prior to discharge. This illustrates how a lack of attention during transitions still can end up with ED providers caring for these patients and attempting to resolve complicated home care needs and care transition issues.
Another alternative to hospital or SNF admission is Hospital in the Home, a care model for providing acute or subacute care for conditions, such as cellulitis, chronic obstructive pulmonary disease (COPD) exacerbation, a congestive heart failure (CHF) exacerbation, that usually require admission. The Hospital in the Home model has been shown to be feasible and efficacious as well as cost-effective. Patients also are more at ease and may be more active in their own home settings, mitigating the risks of functional decline and delirium seen with normal hospital admissions. Consider, for example, an older adult with COVID-19 stable on 2 L of supplemental oxygen and requiring assistance with activities of daily living (ADLs) due to their illness. This patient may be a candidate for Hospital in the Home and receive in-home nursing care with frequent assessment of vitals and assistance with ADLs while avoiding inpatient admission.
Considering caregiver burden and well-being is crucial to ensuring that older adults under their care receives adequate support. Respite care for older adults at an SNF or at an adult day care is an adjunct utilized to provide respite to caregivers on the order of days to weeks. Caregivers also may benefit from support groups and other community resources. If an older adult with care needs is in the ED for an issue that is subacute or chronic, the underlying reason may be caregiver stress rather than a health issue for the patient. Identifying and addressing this can improve both the patient’s and the caregiver’s health.
Choosing the appropriate care setting
Multiple risk screening tools have been developed to risk-stratify older adults for adverse health events after an ED visit, but none has shown the necessary levels of sensitivity and specificity. , This likely is due to the fact that there is a plethora of nonmedical and nonquantifiable criteria not included in these scoring systems that influence care decisions. Every patient has a certain level of medical needs that determines the lowest level of care required. For example, a patient who medically needs intensive care needs intensive care regardless of socioeconomic status, home safety, or cognition. On the opposite side of the spectrum, a patient whose medical needs require only outpatient care may require observation or inpatient floor care if they lack social support. Conversely, a patient who medically requires a high level of care may be best discharged to home if what matters most to the patient is not quantity, but rather quality, of life.
One model of geriatric care from the Institute for Healthcare Improvement and John A. Hartford Foundation uses the 4-Ms model: what matters, medications, mentation, and mobility. Although this model was designed for clinics and inpatient settings, the model also is germaine to the ED visit. For the ED, the authors recommend including an S to this model: safety and social support. There also are several validated screening tools that can aid with assessment ( Table 2 ).
- 1.
What matters most? Person-centered and family-centered care is essential for all patients, but especially older adults making difficult decisions about their care. This conversation can start by asking patients and caregivers what they are most concerned about and why. This helps guide the conversation on what the physician can offer. It is important to think creatively. Options, such as hospital at home, overnight observation for further assessment and care coordination, and ED-to-hospice transitions need to be considered in addition to the traditional admit versus discharge decision. This is a type of goals of care conversation that involves the clinician learning about the patient as a person. Exploring the free resources at https://www.vitaltalk.org/ can help in learning how to map out what is most important to the patient, discussing patient goals with a surrogate, and more.
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Medications: a full medication review includes which medications are taken and how and when they are taken, including over-the-counter medications or supplements. Medication review in the ED by a pharmacist identifies errors and medication interactions in 68% of patients, with a mean number of discrepancies of 3 per patient. Common classes of medications known for interactions include proton pump inhibitors, anticoagulants, and selective serotonin reuptake inhibitors. If a trained medication reviewer or pharmacist is not available in the ED, referral for outpatient follow-up with a pharmacist or polypharmacy clinic should be considered. This ED-to-outpatient review strategy led to an absolute 9% reduction in proportion of patients requiring admission to the hospital in the 4 months after an ED visit.
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Mentation: evaluation of mentation requires understanding a patient’s baseline cognitive status as well as screening for delirium and cognitive changes with validated tools during the ED visit. Currently, ED providers rarely formally screen for cognitive changes. , Ignoring cognitive limitations leads to difficulty understanding discharge instructions, which can result in return ED visits, medication misuse, or inability to care for the illness or injury properly at home. Subtle delirium also often is noted only with testing. Mentation is worsened by sensory impairment, such as lack of hearing aids or reading glasses, so, if possible, temporary-use items should be stocked in the ED and hospital to help better assess cognition in the setting of sensory impairment.
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Mobility: safe mobility requires an understanding of what assistive devices patients require, what they have available, and their home living situation. Can they get in and out of the house safely, or are they newly homebound? Will this illness require temporary support? Some EDs have access to physical therapists for gait assessments and equipment training but most do not. ED nurses often can provide insightful information on gait and self-care ability as they are in the room and assisting with toileting and transfers. Mobility can be assessed using the Timed Up and Go (TUG) test, a validated tool accounting for both static and dynamic balance. This is performed by timing the patient when asked to perform the following: stand up from a chair, walk 3 m at their normal pace, turn, and walk back to the chair and sit down ( Fig. 3 ). Patients can use their baseline assistive devices. Individuals with a TUG test greater than 13.5 seconds are in a high-risk category for falls. For EDs that do not have the space for this test or when patients need to remain on telemetry or other monitors, the 4 Stage Balance Test is preferred ( Fig. 4 ). This can be done at the bedside and involves having the patient stand with progressively more difficult stances.
