When patients who are over age 65 come into the emergency department at St. Mary Mercy Livonia Hospital in Livonia, MI, they are triaged to a 14-bed dedicated senior emergency department unit designed to meet the special needs of the senior population.
“When we opened the first senior emergency department in Michigan, the staff knew immediately that it was the right thing to do. The senior population is different from younger adults. In addition to a range of medical issues, many seniors have chronic conditions, take multiple medications, have cognitive deficits and other behavioral health issues, and may be living in an environment that puts them at risk,” says Michelle Moccia, RN, program director of the senior emergency department at the 308-bed acute care hospital. St. Mary Mercy Livonia is a member of Trinity Health, a health system that includes 47 acute care hospitals as well as outpatient treatment centers, long-term care facilities, and home health and hospice programs in 10 states.
Trinity Health’s first senior emergency department was established in 2008 at Holy Cross Hospital in Silver Spring, MD. “It was so positive for patients and family members that the Trinity Health leadership decided to create a model that could be replicated in other hospitals,” says William Thomas, MD, an elder care expert who is working with Trinity Health on geriatric issues and development of the senior emergency department initiative. Taking the lead from Holy Cross’ senior emergency department initiative, Trinity Health and Saint Joseph Mercy Health System started implementing the model in 2010, opening the senior emergency department at St. Mary Mercy Livonia, and following quickly with seven more senior departments in eastern Michigan. To date, Trinity Health has developed 19 senior emergency departments in four states.
The senior emergency department is staffed by a core team trained to work with seniors, with other clinicians rotating through the area. Patients who are 65 and older who come into the emergency department receive the same assessments, even if the senior emergency department unit is full. The hospital is building a new area that will accommodate an additional 14 seniors.
“Most emergency departments are geared to treat adult patients for their chief complaint. In the senior emergency department, we go beyond that complaint, assessing and addressing additional issues affecting health and visits to the emergency department,” says Michael Calice, MD, FACET, emergency department medical director at St. Mary Mercy Livonia.
The team looks at the patients’ medication regimen, living conditions, and support system at home. As part of their assessment, the nurses take time to listen to the patients’ stories and determine their functional status. They conduct a depression screen and evaluate the patients for memory loss or cognitive issues that will need to be addressed when the patient is discharged. “We were surprised at the rate of depression among senior patients. But if we didn’t ask, we would never know,” Calice says.
If the nurse identifies any needs, he or she calls in a case manager or social worker to work with the patient. “We want our patients to live the best lives they can and stay resilient. Many times, it takes more than just treating them and sending them home with prescriptions,” says Sue Penoza, RN, MA, strategic planning director for Trinity Health.
The staff in the senior emergency department go beyond taking care of patients’ chief complaints, adds Julie Denomy, RN, care coordinator for St. Joseph Mercy-Port Huron senior emergency department.
“When we develop a care plan for a senior patient, we consider not only the disease, but look at the whole patient-mind, body, and spirit. This is a vulnerable adult population, and it takes spending time with them and their caregivers to find out what they need. We don’t just treat them and send them home. We do whatever is necessary to make sure the patients will do well when they go back into the community,” she says.
The staff in the senior emergency department take a team approach to patient care, Denomy says.
The case managers call the patients’ designated family contacts to get as much information as they can and to report on the patients’ emergency department visits, sometimes alerting them that their loved one may need a different living situation.
“Everyone on the staff is a transition coach. We try to help the patients and their caregivers learn to navigate the healthcare system and make sure they have everything they need,” Denomy says.
The senior emergency staff call back the majority of patients the next day to make sure they understand their discharge instructions and have been able to get their prescriptions filled.
“We want to make sure they understand their discharge instructions so they won’t come right back to the hospital. Often patients are confused about their medication and how they are supposed to take it. Some patients don’t schedule a follow-up visit with their physician or fail get their prescriptions filled for various reasons,” Denomy says. Case managers may call the caregivers or patients’ primary care physician if they or the patients have any concerns.
The expanded assessment has not increased patient length of stay in the emergency department, Moccia says. “At first, it took longer until the nurses became accustomed to the new assessment, but now it has become a habit as they talk to patients-even those who are under the age of 65,” Moccia says.
The hospital has partnered with the local emergency medical service to proactively identify problems with patients’ living situation. “When they go into the home of a senior, they take a quick look to see if there are safety issues, if there is food in the refrigerator, and if the house is heated or cooled. They report to us on what they find, and we work with the community agencies to get these patients the services they need,” Moccia says.
The emergency department team is working with a local home care agency who will contact the patient’s primary care physician for a referral if the emergency department staff feel it’s necessary.
The hospital has worked with local assisted living facilities, senior housing developments, and independent living facilities to ensure that when their residents need treatment, emergency department staff have all the information they need.
“We are working with these facilities to make sure that we can provide seamless care,” she says.
Source: Hospital Case Management, March 1, 2013
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