Establishing a Case‐Finding and Referral System for At‐Risk Older Individuals in the Emergency Department Setting: The SIGNET Model

Abstract

Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at-risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at-risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000-bed teaching center, a 700-bed county teaching hospital, a 400-bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at-risk older adults are feasible in the ED setting.

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

“…Unlike previously published PC screening tools, this one should not require a provider to perform an additional patient interview, nor should it require a PC specialist or case manager for completion. 15,69,70,72 Ultimately, for this screening tool to increase rates of PC consultation as well as decrease the long latency between hospital admission and PC consultation, the results of the screening tool must be put to use. Multiple interventions based on this screening tool are conceivable.…”

“…All ED PC referral or integration projects that we examined had some measure of success in terms of increasing PC evaluation and referral from the ED. [69][70][71][72][73] Common weaknesses of prior efforts included absence of evidenced-based development of an ED-specific screening tool, narrow inclusion criteria (i.e., cancer patients only), use of lengthy PC patient assessment tools, and reliance on additional staff to perform screening.…”

Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

“…10 Evidence of supplemental insurance was evaluated with items from the Medical Expenditure Panel Survey. 16 Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form.…”

“…Elders who receive case management services, including risk assessment and follow-up health education, experience fewer hospitalizations and have lower healthcare costs. [7][8][9][10][11][12][13] For older adults who are within several months of death, hospice may offer an opportunity for coordination of care and homecare services that would otherwise be unavailable. This is because of decreased eligibility for homecare since the Balanced Budget Act.…”

Community emergency medicine: Benefits and challenges of screening for elder abuse in the emergency department of a developing country

“…Older patients represent a large bulk of the population arriving in emergency departments (EDs) all over the world. [1] They use hospitals more frequently than younger patients, have more hospital admissions from the ED and more prolonged hospital stays. [2] Elder abuse is defined as a single, or repeated, act which causes harm or distress to an older person and it can occur within any relationship where there is an expectation of trust from the elder person's perspective.…”