Care Transition Decisions After a Fall‐related Emergency Department Visit: A Qualitative Study of Patients’ and Caregivers’ Experiences

Abstract

Objective Falls are a leading cause of injury‐related emergency department (ED) visits and may serve as a sentinel event for older adults, leading to physical and psychological injury. Our primary objective was to characterize patient‐ and caregiver‐specific perspectives about care transitions after a fall. Methods Using a semistructured interview guide, we conducted in‐depth, qualitative interviews using grounded theory methodology. We included patients enrolled in the Geriatric Acute and Post‐acute Fall Prevention Intervention (GAPcare) trial aged 65 years and older who had an ED visit for a fall and their caregivers. Patients with cognitive impairment (CI) were interviewed in patient–caregiver dyads. Domains assessed included the postfall recovery period, the skilled nursing facility (SNF) placement decision‐making process, and the ease of obtaining outpatient follow‐up. Interviews were audio‐recorded, transcribed verbatim, and coded and analyzed for a priori and emergent themes. Results A total of 22 interviews were completed with 10 patients, eight caregivers, and four patient–caregiver dyads within the 6‐month period after initial ED visits. Patients were on average 83 years old, nine of 14 were female, and two of 14 had CI. Six of 12 caregivers were interviewed in reference to a patient with CI. We identified four overarching themes: 1) the fall as a trigger for psychological and physiological change, 2) SNF placement decision‐making process, 3) direct effect of fall on caregivers, and 4) barriers to receipt of recommended follow‐up. Conclusions Older adults presenting to the ED after a fall report physical limitations and a prominent fear of falling after their injury. Caregivers play a vital role in securing the home environment; the SNF placement decision‐making process; and navigating the transition of care between the ED, SNF, and outpatient visits after a fall. Clinicians should anticipate and address feelings of isolation, changes in mobility, and fear of falling in older adults seeking ED care after a fall.

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement

“…However, two newly published studies indicate that caregivers are facilitators in ED patients agreeing to fall prevention measures and adherence to recommendations made by fall prevention teams. 79,80 Additionally, we detected general consensus regarding the need for a multifactorial intervention. Interventions that focused on providing education alone have limited effect on fall prevention.…”

“…78 Two large studies focused on discontinuing FRIDs as the sole intervention were also not effective in preventing falls. 79,80 In STRIDE, a nurse-administered multifactorial intervention recruited 86 PCP practices with 5,461 participants who were followed for 36 months. There was no reduction in rate of first serious falls injury (hazard ratio = 0.92, 95% CI = 0.80 to 1.06; p = 0.25).…”

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

“…41 Patients and care partners also reported feeling overwhelmed with the burden of information and self-care required during ED-to-community care transitions, potentially contributing to poor rates of follow-up with other healthcare providers. 41,42 Loss of independence, home safety, costs of long-term care, and fear of falling were also reported as concerns from patients with cognitive impairment and their care partners. 42 Patients with cognitive impairment and their care partners identified several outcomes to be important during ED-to-community care transitions.…”

“…41,42 Loss of independence, home safety, costs of long-term care, and fear of falling were also reported as concerns from patients with cognitive impairment and their care partners. 42 Patients with cognitive impairment and their care partners identified several outcomes to be important during ED-to-community care transitions. Specifically, both groups recommended that education be provided regarding newly prescribed medications, including common adverse reactions.…”

Can an Emergency Department–Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial

“…9 Additionally, we established acceptability of GAPcare through detailed interviews and surveys with patients, caregivers, and clinicians. [9][10][11] Geriatric emergency medicine guidelines suggest that a multidisciplinary team composed of pharmacists and physical therapists could aid emergency physicians with fall assessments. 12,13 Pharmacist-led interventions that use motivational interviewing techniques to modify behavior surrounding medication use (medication therapy management) have been shown to be useful in reducing fall-risk-increasing medication 14,15 and adverse drug event-related health care visits.…”