Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20

Reducing Older Patients' Reliance on the Emergency Department H. Virginia McCoy PhD , C. William Kipp PhD & Melissa Ahern PhD To cite this article: H. Virginia McCoy PhD , C. William Kipp PhD & Melissa Ahern PhD (1992) Reducing Older Patients' Reliance on the Emergency Department, Social Work in Health Care, 17:1, 23-37, DOI: 10.1300/J010v17n01_02 To link to this article: http://dx.doi.org/10.1300/J010v17n01_02

Published online: 26 Oct 2008.

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Reducing Older Patients' Reliance on the Emergency Department H. Virginia McCoy, PhD C. William Kipp, PhD Melissa Ahem, PhD

ABSTRACT. Older adults tend to avoid mental health services and rely on hospital emergency departments for medicalization of these conditions. An intervention was designed for use in emergency departments to refer older adult patients with mental and social health problems to appropriate services within the hospital and community. Most of the patients in the study used the services to which they were referred; further, the intervention was found to decrease repeat utilization of the emergency department. Social work practice and policy implications of the findings are also discussed INTRODUCTION

This study examines the issue of medicalization of psychosocial problems as it relates to older adult utilization of the emergency department. H. Virginia McCov is affiliated with theFlorida International Universihr North campus, bepartmeni of Public Health, AC 11-335, North Miami, E-33181. C. William Kipp is Director, Department of Social Work at the Mount Sinai Medical Center of Greater Miami. Melissa Ahem is affiliated with the Department of Health Services Administration, Florida International University. The work reported here was research carried out by the Southeast Florida Center on Aging purmant to a contract with the Aging and Adult Services Rogram Office of the Florida Department of Health and Rehabilitative Services. The authors also wish to aclmowledge the work of the former Director of the Department of Social Work, George Krell, social workers at Mt. Sinai Medical Center and Lucky Lernieux, graduate assistant at Florida International University. Social Work in Health Care, Vol. 17(1) 1992 O 1992 by The Haworth Press, Inc. All rights reserved.

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The utilization of emergency health care services by older adults is of increasing interest to health care professionals and policymakers. The graying of the American population, the overcrowding of many of the nation's emergency departments, and dwindling resources place a serious strain on the U.S. health care system. Concepts of holistic practice and health symmetry may serve as a basis for a fair allocation of scarce resources. In order to formulate effective policies, we must examine both the pattems of use that occur in emergency departments as well as the phenomena that result from these utilization patterns. In this study, the authors review relevant literature, and subsequently develop and assess an intervention to reduce emergency department use by older patients. Because older adults tend to avoid community mental health services and present to the emergency department with physical and mental health oroblems. we desimed an intervention to interce~t these patients and &ect them to appropriate social and mental h e a i i services. We believed that Ulese patients could be better served by social services that meet mental health needs. In addition, this program offered the hope of reducing reliance on the emergency department. LITERATURE REVIEW According to the results of a 1989 survey conducted by the American Hospital Association, there were approximately 94.2 million patient visits to emergency departments, 9 percent more than in 1988 (Clark, 1990). The majority of these visits were for nonurgent care (Hurley et al., 1989). Emergency services continue to be disproportionately utilized by older adults (Ettinger et al., 1987). Given the increasing proportions of older adults in the population, plus this growing trend in emergency department utilization, it is likely that these older patients will continue to consume a disproportionate share of health services (Wolinsky et al., 1983). Studies also show that utilization patterns in the emergency department differ between older and nonolder adult population groups, particularly with regard to the severity of illness, type of illness, and the likelihood that illness will require hospitalization (Ettinger et al., 1987; Bassuk, Minden & Apsler, 1983; Eliastam, 1989). Specifically, geriatric patients often use the emergency department for somatic complaints, which reflect both medical and psychiatric disorders. In addition, although the nonurgent visit rate of older adults is lower than that of the

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younger population, older adults have a longer length of stay in the emergency department, receive more diagnostic tests, and incur higher individual charges (Eliastam, 1989). Finally, studies have documented the tendency of older persons to seek care for mental health problems from primary care sources (Kiraly, 1982). Specifically, patients with Alzheimer's disease and related disorders, dementia, mental impairment, and signif~cantadjustment reactions to loss or illness apparently use the emergency department for these disorders (Eliastam, 1990). Two other studies indicate that older people may be suffering from varying degrees of undiagnosed emotional problems, especially, depression (Simpson & Wilson, 1982; Herst, 1983). Several researchers (Wulsin et al., 1988; Bass & Wade, 1 9 W Beiman et al., 1987) have discovered that up to 66 percent of adult and older patients who present with a typical chest pain in the hospital emergency department are actually suffering from depression, panic disorders, or other forms of somatization disorders. Furthermore, these psychosocial factors were seldom diagnosed by the emergency department physician, Studies that examine predictors of emergency department utilization by older adults show that some predictors are social rather than medical. A study by Coe et al. (1985) concluded that a principal determinant for increased utilization of emergency department services was whether an older adult person had family living in a nearby area. Older adults without family used the emergency department from 7 to 30 times more often than older adults with family in the area. Another study showed that older women who live alone tend to be less secure psychologically and are less likely to believe they will have someone to help them in a real or perceived emergency (Magaziner & Cadigan, 1989). In another study nutritional risk was shown to be the most important predictor of the total number of physician visits, visits to the emergency department, and the probability of hospital episodes (Wolinsky et al., 1983). Ethnicity and age were also found to be important predictors of emergency department use (White-Means, Thomton & Yeo, 1989). Finally, Andren and Rosenqvist (1985) found that older adult repeat users of the emergency department had a greater share of psychosocial problems in comparison to the general population. Repeat users were found to have feelings of loneliness, and to be living alone or receiving a disability pension. Habitual repeat visits to the emergency department by older adults can result from a chronic lack of teamwork between medical and psychiatric services in the health care setting (Bassuk, Minden, & Apsler, 1983). To more readily address the needs of older persons, health care professionals

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are often forced to define the social needs of older adults in medical terms (Azzarto, 1986).

METHODOLOGY

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Description of the Intervention We designed an intervention to reduce inappropriate use of the emergency department by older persons. All older patients (65 years and older) entering the emergency department at Mount Sinai Medical Center of Greater Miami on Miami Beach (MSMC) between October 1, 1988 and June 30, 1990, between the hours of 11 a.m. and 10 p.m., seven days per week, were screened and referred to the social worker on duty when they met the program criteria. Program admission criteria included: (1) absence of a medical condition requiring hospital admission; (2) a presenting problem not related to a trauma. Non-trauma emergency department admission cases are operationally d e f i as those coded 000-799, following ICD-9 classifications. This includes all classificationsof diseases, expect those coded 800-999 for injury and poisoning, which are defied as trauma cases; and (3) presence of a mental health problem, which could range from severe (psychotic behavior) to mild (adjustment reactions). All clients were assessed, counseled, and referred by a Masters level social worker (MSW) to services that met their social and mental health needs.

Data Collection All patients who met the program admission requirements were retrospectively reviewed for a period of six months prior to presentation in the emergency department, in order to determine if they had a history of emergency department utilization. This baseline data thus provided a comparison of patterns of emergency department utilization both before and after the intervention. Additionally, records were maintained on all referral services and on two follow-up contacts with the service agencies, to determine if the client was seen at the referral agency (see Figure 1).

Description of the Sample and Utilimtbn Paaerns The clients in the Emergency Department Mental Health Program had a mean age of 73 years and were primarily female (68.3 percent). There

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Emergency Dept.- Social Work Intervention with Clients, Including Assessment, Crisis

Referral to Mental Health Agencies

,

Agency Follow-Up 14 days

+

Client Follow-up 14 days

90 days

I

OUTCOMES Pattern of Utilization of Referral Service Change in Utilization of ER

were 457 clients who were referred to 581 services as a result of speaking with a social worker in the emergency department. Approximately 10 percent of referrals were to mental health agencies. Table 1 lists the types of services which were referred three or more times by the social worker. The majority of problems were resolved through social worker intervention in the emergency department and required no additional service. These services included crisis intervention and on-site counseling. Follow-up services that were needed most often were homemaker services, MSMC social worker outreach program, MSMC health clinics, and Meals on Wheels. Follow-up contacts were made 14 days after the referral to determine whether the clients used the service. These results are shown in Table 2. Thirty three percent of the referrals were used within 14 days. This rep-

SOCIAL WORK IN HEALTH CARE

'

I

Table 1.

Service Referrals

t 3

N=581

Service

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Home Health Care Home Advantage HHC Other HHC Medicare Private Home Care custom care Other Private or Custodial Home Care communitv Services HRS Protective Service Hospsice Outpatient Meals on Wheels Homemaker Service MSMC Indigent Fund MSMC Social Worker Outreach structured Day Care Social Security or Medicaid I Office MSMC Clinics Other community service\

Percent 2.1 1.0

1.6 1.6 0.5 0.5 0.9

6.2 0.5 4.3 5.0

Discharae Transwortation Taxi slip Ambulance

5.0 1.6

Out~atientMental Health Referral Jewish Family & Child. Agcy Private Mental Health Other Mental Health Referral

1.9 2.8 0.5

PMD Agency Contacts Adjustment to Chronic Ill. Organic Mental Disorder Mental Health Consult Resolved in Hospital

1

:::

'

,

0.5 0.5 0.5 1.0 0.9 36.1

service Mentioned Once or Twice Other

14.9 -

Total services

100.0

McCoy, Kipp, and Ahem

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Table.2. Fourteen-Day Follow Up of Referrals N=581

Service

Frequencv

Percent

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Home Health Care Hone Advantage HHC Regency HHC Other HHC Medicare Private Home Care Custom Care Atlas Home Services Other Private or Custodial Home Care Durable Medical Eauipment Foster Other Nursina Homes Miami Jewish Home

h

~osp.

-

ACLF Carlyle on the Bay

Communitv Services United Way HRS Protective Service Community Shelter Hospsice Outpatient Meal Site Meals on Wheels Homemaker Service MSMC Indigent Fund MSMC Social Worker Outreach Structured Day Care Indigent Burial Service MSMC Clinics Other Community Service Discharae T r a n s p e Taxi Slip Ambulance Outoatient Mental Health Referral Outoatient M.H. Referral ~riiateMental Health

4 1

2.7 0.7

1

0.7

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Table 2 (continued) Service

Freouency

Percent

1

Other

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PMD other Resolution Resolved i n ~ o s p i t a l Informal Family Network Left Against Med. Advice Unknown Contact Contact indicated, but type unknown Total S e r v i c e s .. .

resents 132 clients (28.9 percent) who were seen by the social worker in the emergency department. The services that were used most often included MSMC C l i c s , Other Community Services, MSMC Center Social Worker Outreach Program, and Taxi Service. The second follow-up contact with the service referral was made 90 days after referral to determine whether the client was still using the service. Of those who utilized the service within the first 14 days, 65 (43.3 percent) of the services were still being used. Some of these services were one-time use only services (burial services, indigent fund) and were thus ineligible for a 9@day follow-up contact. When these 19 services are abstracted from the 150 total, 49.6 percent of the services were still being used after 90 days. Table 3 shows the services these clients were using. Mount Sinai clinics and social worker outreach were used most often, followed by transportation services. Among clients who had not used the service within the Fist 14 days, only two were indicated as using the services at the 90day follow-up call (one to transportation, one to MSMC C l i c s ) . RESULTS The major outcome in which we were interested was whether the clients who were seen by the social worker in the emergency department used the emergency department again following intervention between October 1988 and July 1990. An examination of emergency department admission dates for the six month baseline period before entering the program found evidence that 71 percent were repeat emergency depart-

M-. Table 3.

Kipp, and Ahern

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Ninety-Day Follow Up of Referrals N=581

~erhce

'

Fremency

.

Percent

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Home Health Care Home Advantage HHC Regency HHC Other HHC Medicare I

Private Home Care Custom Care Atlas Home Services Other Private or Custodial Home Care

2 1

3.1

2

3.1

Nursins Homes Miami Jewish Home & Hosp.

1

1.5

1

1.5

65

100.0

ACLF Carlyle

1.5

on the Bay

Communitv Services Hospsice Outpatient Meal Site Meals on Wheels Homemaker Service MSMC Social Worker Outreach Structured Day Care MSMC Clinics other Community Service Discharae Trans~ortation Taxi slip Ambulance Other Resolved in Hospital Unknown Contact Contact indicated, but type unknown Total Services

ment users. The most simcant outcome related to this study, however, is that 28 percent of program participants has used the emergency department prior to entering the program but did not use the emergency department after entering the program. The remaining 43 percent of patients had repeated use of the emergency department six months before and after entering the program. The median number of admissions for these patients was 3.0. The modal

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frequency of use of Ed of before and after repeat users was twice (44.4 percent), followed by 3 times (26.1 percent) and 4 times (10.6 percent). These patients (180 total) had a total of 693 admissions, counting those before and after entering the program.

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DZSCUSSZON An emergency department is an important link between the acute hospital and the community in which they operate. Studies indicate substantial use of the emergency department for non-emergent care. Because the emergency department is utilized as a primary care setting in which access and coordination of services play an important role, it is critical that emergency department administrators and clinicians be cognizant of the implications of this responsibility. Practice Zmplications

The results show that using a social worker as a wre member of the emergency department team enables more efficient use of resources especially in assessing older patients who will not be admitted to the hospital. Conceptually, this population represents two groupings. The first group comprises older patients who medicalize or somaticize their psychosocial problems. The second group involves chronically ill patients who are non-compliant with treatment regimes for psychosocial reasons. While focusing on the potential emotional problems of the patient, the social workers in the study also assessed other environmental or systemic factors that may have placed older persons at risk for inappropriate utilization of the emergency department. The social worker, by training and practice, is particularly well prepared to address the various contextual factors involved in inappropriate emergency department use. In addition to assessing for risk, the social workers in the program offered direct intervention in the form of crisis management, brief counseling, and concrete services. In the present study, the majority of identified problems were resolved through direct crisis intervention and on-site counseling. wdeed, most older patients in the study who were referred to a community mental health facility did not utilize the service. Herst (1983) states that older patients generally fear public recognition as a psychiatric patient, thus the "medicalization" of their problems in the emergency department. These factors, along with o w own study results, point toward the need for hospital emergency departments to develop the

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capacity to integrate both mental health and health emergency services to function as access points for the comprehensive psychosocial and physical health care needs of older people. Another critical role provided by the social worker in this study is discharge planning. Discharge planning is a transitionary process. Its goal is to optimize the available coping resources of the patient and family by providing community linkages when natural helping networks, such as family or friends, are unable or unavailable to provide service. Discharge planning for older patients in particular, is a very wmplex, albeit therapeutic process (Blazyk & Canavan, 1985) depending upon the functional and cognitive ability of the patient. Unfortunately, with the cutbacks in community-based social services, most agencies are not able to provide timely services for the fast-paced discharge planning needs of the hospital emergency department. Long waiting lists for such basic publically funded services as Meals on Wheels, homemakers, and day care is the rule. Another barrier in the public sector is that providers often offer service options in line with the reimbursement policies of Medicare, Medicaid and private insurers. Thus, the medicalization of community and social services occurs. The current study supports other research (Hereford, 1988) that indicates a strong need for programs which supplement traditional service offerings with non-medical concrete services such as home-related services, personal assistance services, and transportation services. In spite of these barriers, this study and other research findings support the premise that quality discharge planning is an important service both to older emergency department patients and to the hospital in terms of reduced length of stay, wst control, liability risk and inappropriate utilization (McDonnell, 1985; Berkman, 1984; Caputi & Heiss, 1984; Berkman, Bedell, Parker et al., 1988). There are two unique features related to the current study which deserve special attention: fust is access to the services of a communitybased outreach social worker in the MSMC Department of Social Work, which was provided through a community development grant provided by the City of Miami Beach. This was the second most utilized service by older patients in the study, and involved one to five follow-up visits to the patient's home for both evaluation for provision of community services and short term counseling. Other studies also indicate that this type of non-medical follow-up may be related to reduced emergency department utilization by older patients (McDonnell, 1985; Hereford, 1989). This short-term "case management" capability allowed us to provide needed support services which normally would not be covered by

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Medicare or Medicaid, but which probably contributed to reduction of emergency department use. Second, referral to the MSMC geriatric health clinic for follow-up primary care was an important resource in reducing emergency department utilization. As documented previously, lack of access to primary care combined with a lack of social supports in the community, is related to emergency department utilization by older people. Policy Implications The current exploratory study, with its limited resources of staffing and time, resulted in a 28 percent reduction in the number of persons utilizing the emergency department for non-emergent reasons. Furthermore, the patients in the study comprised a high risk group of individuals with a six month previous history of emergency department use. Assuming an average non-emergent emergency department charge per visit in the range of $500, and this program saved two visits per person, the total savings approaches a quarter of a million dollars. If programs such as this were in place in hospital emergency departments nationally, the saving to the Medicare program would be significant. But the policy issue at hand is broader than cost savings alone. With increasing demands related to an aging population, and shrinking available resources, resources must be allocated among many societal and health care needs. This will require breaking down the barriers between health care and social policy that limit holistic practice. The concept of health symmetry (Callahan, 1990) could be important as a Litmus test in such an effort. Symmetry is the concept of striking a balance between extending a l i e and assessing the quality of that lie. Symmetrical outcomes should foster the overall well-being of persons, not just a single dimensional improvement that benefits one aspect of a person's well-being at the expense of others. In other words, a holistic concept of health can serve as the basis for a fair allocation of scarce community resources. Although such holistic approaches benefit both the patient through greater access to needed social services, and the Medicare program through reduced expenditures, three barriers must be addressed. Fist, there are few direct economic incentives for the hospital to promote social services in the emergency department. Hospitals get reimbursed through Medicare for most visits whether or not they are medically urgent. Health care policymakers must make the integration of social and health care services more economically viable to individual hospitals by realistically reimbursing for such services. Concurrently, expensive medi-

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cal tests and procedures should be evaluated in light of costs and outcomes. Economic and structural limitations for community based home care social services must be overcome. The current system is based almost solely on a medical model which is reinforced by an acute-care oriented financing system. Traditional services should be supplemented with'additional, non-medical services that are currently unavailable or not funded by Medicare. The goal is to encourage various types of community oriented home care agencies to offer more holistic service delivery, of the type offered by the MSMC outreach social worker, which could be more adequately meet the comprehensive needs of older patients. Third, social service agencies must be funded at a level which would allow them to adequately respond to the immediate needs of the acute care hospital emergency department. Certainly such fundiig could be justified based upon the concept of both social symmetry and cost benefit analysis. Since the hospital emergency department is often the point at which such services are brokered, perhaps public funding mechanisms could tie them closer together.

SUMMARY This study's fiidings indicate the need, both in terms of symmetry and cost analysis, to recognize that emergency departments play an important role in the access of primary care and the coordination of services for older people for both medical and psychosocial problems. The potential for these roles needs to be further studied and expanded in order to provide quality, coordinated care for older people. Several specific recommendations can be made. 1. Integrate mental health, social and medical emergency services to serve as points of access for comprehensive services for older people. 2. Offer counseling and crisis intervention services in the emergency department, where older people are more likely to utilize them. 3. Support continuing education in gerontology for all emergency \ services providers. 4. Where feasible, maintain =-hour emergency services for psychosocial problems. 5. Provide financial incentives for hospitals to provide social services to older people in the emergency department.

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6. Eliminate artificial, medically oriented barriers to social sekices for older people, utilizing as criteria the concepts of social symrnetry and cost containment. 7. Work toward making community-based social service agencies more responsive to the immediate and %-hour needs of older persons presenting in an emergency department. 8. Develop and implement outcome-oriented tracking systems for emergency department patients and organizations that provide services. 9. Provide further research focused on determining the characteristics of repeat emergency department users to determine whether a program could be developed to identify and intervene with them before they reach the emergency department.

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Reducing older patients' reliance on the emergency department.

Older adults tend to avoid mental health services and rely on hospital emergency departments for medicalization of these conditions. An intervention w...
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