The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform

The Importance of Addressing Social Drivers of Health and Unmet Social Needs in Optimizing Geriatric Emergency Care

Social factors and determinants have an immense impact on health. These "social drivers of health" have been broadly defined as economic and social conditions that influence the health of people and communities. Unmet social needs contribute to poor health outcomes, particularly for patients with poor access to outpatient care. Emergency departments (EDs) play a critical role in providing health care to vulnerable populations with these needs, and delivering this care is a central component of emergency medicine's public health mission. Here, the authors describe the major unmet social needs that may impact geriatric patients' care in the ED and provide some ways to address them.

The critical role of the specialized social worker as part of ED/hospital-based elder mistreatment response teams

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Elder Mistreatment: Emergency Department Recognition and Management

Elder mistreatment is experienced by 5% to 15% of community-dwelling older adults each year. An emergency department (ED) encounter offers an important opportunity to identify elder mistreatment and initiate intervention. Strategies to improve detection of elder mistreatment include identifying high-risk patients; recognizing suggestive findings from the history, physical examination, imaging, and laboratory tests; and/or using screening tools. ED management of elder mistreatment includes addressing acute issues, maximizing the patient's safety, and reporting to the authorities when appropriate.

Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study

The Care Transitions Intervention (CTI) is an evidence-based intervention aimed at supporting the transition from hospital back to the community for patients to ultimately reduce preventable re-hospitalization. In a pilot randomized controlled trial, we examined the preliminary effectiveness of an Enhanced Care Transitions Intervention (ECTI), CTI with the addition of peer support, for a racially/ethnically diverse sample of older adults (age 60+) with co-morbid major depression. We observed a significant decline in health-related quality of life (HRQOL) after being discharged from the hospital among those who received CTI. Additionally, those who received ECTI either maintained HRQOL scores, or, saw improvement in HRQOL scores. Findings suggest the Enhanced Care Transitions Intervention can maintain or improve HRQOL and reduce disparities for older participants from diverse racial/ethnic backgrounds with clinical depression.

Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps

Emergency Department (ED) visits provide an important but seldom realized opportunity to identify elder mistreatment. Many screening tools exist, including several that are brief and may be effective, but few have been specifically designed for or tested in EDs. In addition to the absence of validated tools, other challenges with implementing ED elder mistreatment screening include difficulty integrating anything longer than a few questions into a busy clinical encounter and resources required to respond to positive screens. The Electronic Health Record (EHR) offers a critical tool to facilitate elder mistreatment screening through required data entry and real-time monitoring of compliance and results. We describe current work in the field and recommend next steps including design and testing of a two-step screening process, implementation research to accelerate adoption, development of ED-based interventions and referral protocols for positive cases, and consideration of the important role of pre-hospital providers in case identification.

Developing the Emergency Department Elder Mistreatment Assessment Tool for Social Workers Using a Modified Delphi Technique

Elder mistreatment is common and has serious consequences. The emergency department (ED) may provide a unique opportunity to detect this mistreatment, with social workers often asked to take the lead in assessment and intervention. Despite this, social workers may feel ill-equipped to conduct assessments for potential mistreatment, due in part to a lack of education and training. As a result, the authors created the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS) using a multiphase, modified Delphi technique with a national group of experts. This tool consists of both an initial and comprehensive component, with 11 and 17 items, respectively. To our knowledge, this represents the first elder abuse assessment tool for social workers designed specifically for use in the ED. The hope is that the ED-EMATS will increase the confidence of ED social workers in assessing for elder mistreatment and help ensure standardization between professionals.

Individual and Organizational Factors Associated With Hospital Readmission Rates: Evidence From a U.S. National Sample

Objective: Hospital readmission rate is an important indicator for assessing quality of care in the acute and postacute settings. Identifying factors that increase risk for hospital readmissions can aid in the recognition of potential targets for quality improvement efforts. The main objective of this brief report was to examine the factors that predict increased risk of 30-day readmissions. Method: We analyzed data from the 2013 National Readmission Database (NRD). Results: The main factors that predicted increased risk of 30-day readmission were number of chronic conditions, severity of illness, mortality risk, and hospital ownership. Unexpectedly, discharge from a for-profit hospital was associated with greater risk for hospital readmission in the United States. Discussion and Conclusion: These findings suggest that patients with severe physical illness and multiple chronic conditions should be the primary targets for hospital transitional care interventions to help reduce the rate of unnecessary hospital readmissions.

ACE Model for Older Adults in ED

The emergency department (ED) is uniquely positioned to improve care for older adults and affect patient outcome trajectories. The Mount Sinai Hospital ED cares for 15,000+ patients >65 years old annually. From 2012 to 2015, emergency care in a dedicated Geriatric Emergency Department (GED) replicated an Acute Care for Elderly (ACE) model, with focused assessments on common geriatric syndromes and daily comprehensive interdisciplinary team (IDT) meetings for high-risk patients. The IDT, comprised of an emergency physician, geriatrician, transitional care nurse (TCN) or geriatric nurse practitioner (NP), ED nurse, social worker (SW), pharmacist (RX), and physical therapist (PT), developed comprehensive care plans for vulnerable older adults at high risk for morbidity, ED revisit, functional decline, or potentially avoidable hospital admission. Patients were identified using the Identification of Seniors at Risk (ISAR) screen, followed by geriatric assessments to assist in the evaluation of elders in the ED. On average, 38 patients per day were evaluated by the IDT with approximately 30% of these patients formally discussed during IDT rounds. Input from the IDT about functional and cognitive, psychosocial, home safety, and pharmacological assessments influenced decisions on hospital admission, care transitions, access to community based resources, and medication management. This paper describes the role of a Geriatric Emergency Medicine interdisciplinary team as an innovative ACE model of care for older adults who present to the ED.

Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team

BACKGROUND

An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims.

METHODS

We qualitatively explored provider perspectives to inform intervention development. We conducted 15 semistructured focus groups with 101 providers, including emergency physicians, social workers, nurses, technologists, security, radiologists and psychiatrists at a large, urban academic medical centre. Focus groups were transcribed, and data were analysed to identify themes.

RESULTS

Providers reported not routinely assessing for elder mistreatment and believed that they commonly missed it. They reported 10 reasons for this, including lack of knowledge or training, no time to conduct an evaluation, concern that identifying elder abuse would lead to additional work, and absence of a standardised response. Providers believed an ED-based consultation service would be frequently used and would increase identification, improve care and help ensure safety. They made 21 recommendations for a multidisciplinary team, including the importance of 24/7 availability, the value of a positive attitude in a consulting service and the importance of feedback to referring ED providers. Participants also highlighted that geriatric nurse practitioners may have ideal clinical and personal care training to contribute to the team.

CONCLUSIONS

An ED-based multidisciplinary consultation service has potential to impact care for elder abuse victims. Insights from providers will inform intervention development.

The Impact of Peer Support on the Risk of Future Hospital Readmissions among Older Adults with a Medical Illness and Co-Occurring Depression

Older adults account for 60% of all preventable hospital readmissions. Although not all readmissions are preventable, evidence indicates that up to 75% of hospital readmissions can be prevented with enhanced patient education, pre-discharge assessment, and effective care upon discharge. Social support, specifically peer support, after discharge from hospital may be a crucial factor in minimizing the risk of preventable hospital readmission. The pilot study reported here evaluated the relationship between peer support and hospital readmissions in a sample of depressed older adults (N = 41) who were recently discharged from hospital due to a medical condition and who simultaneously had an untreated mental health diagnosis of depression. As hypothesized, participants who received the 3-month long peer support intervention were significantly less likely to be readmitted compared to those who did not receive the intervention. Findings from this preliminary information suggest that peer support is a protective factor that can positively affect patient outcomes, reduce the risk of hospital readmission, and reduce depressive symptoms among older adults with health and behavioral health comorbidities.

Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department

Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.

Improving Quality of Care in Hospitals for Victims of Elder Mistreatment: Development of the Vulnerable Elder Protection Team

PROBLEM DEFINITION

Hospitals have an opportunity to improve the quality of care provided to a particularly vulnerable population: victims of elder mistreatment. Despite this, no programs to prevent or stop elder abuse in the acute care hospital have been reported. An innovative, multidisciplinary emergency department (ED)-based intervention for elder abuse victims, the Vulnerable Elder Protection Team (VEPT), was developed at NewYork-Presbyterian / Weill Cornell Medical Center (New York City).

APPROACH

The VEPT is a consultation service available 24 hours a day/7 days a week to improve identification, comprehensive assessment, and treatment for potential victims of elder abuse or neglect. All ED providers have been trained on how to recognize signs of elder mistreatment. Any provider can activate the VEPT via a single page/telephone call, which triggers the VEPT's often time-consuming, complex assessment of the potential mistreatment victim. First, the ED social worker on duty performs the initial bedside assessment and separately interviews the potential perpetrator and/or caregiver. He or she then contacts the on-call VEPT medical provider to discuss next steps and other team members' potential involvement. For patients admitted to the hospital, the VEPT connects with the inpatient social workers and medical team to ensure appropriate follow-up and care planning.

NEXT STEPS/PLANNED EVALUATION

The VEPT program was launched in April 2017 after comprehensive training. Its impact will be measured by tracking the short-term and long-term mistreatment-related outcomes, as well as medical, mental health, functional, psychosocial, and legal outcomes of the vulnerable ED patients for whom the team provides care.

An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines

BACKGROUND

The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit.

METHODS

Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included.

RESULTS

Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%.

CONCLUSIONS

Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.