Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform Christine Hamilton PhD, Liza Ronda LCSW, Ula Hwang MD, Gallane Abraham MD, Kevin Baumlin MD, Barbara Morano LCSW, Denise Nassisi MD & Lynne Richardson MD To cite this article: Christine Hamilton PhD, Liza Ronda LCSW, Ula Hwang MD, Gallane Abraham MD, Kevin Baumlin MD, Barbara Morano LCSW, Denise Nassisi MD & Lynne Richardson MD (2015) The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform, Social Work in Health Care, 54:9, 849-868, DOI: 10.1080/00981389.2015.1087447 To link to this article: http://dx.doi.org/10.1080/00981389.2015.1087447
Published online: 13 Nov 2015.
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Date: 14 April 2016, At: 16:13
Social Work in Health Care, 54:849–868, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2015.1087447
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The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform CHRISTINE HAMILTON, PhD, LIZA RONDA, LCSW, ULA HWANG, MD, GALLANE ABRAHAM, MD, KEVIN BAUMLIN, MD, BARBARA MORANO, LCSW, DENISE NASSISI, MD, and LYNNE RICHARDSON, MD Department of Social Work Services, The Mount Sinai Hospital, New York, New York, USA
In the era of Medicaid Redesign and the Affordable Care Act, the emergency department (ED) presents major opportunities for social workers to assume a leading role in the delivery of care. Through GEDI WISE—Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements,—a unique multidisciplinary partnership made possible by an award from the Center for Medicare and Medicaid Innovation, social workers in The Mount Sinai ED have successfully contributed to improvements in health outcomes and transitions for older adults receiving emergency care. This article will describe the pivotal and highly valued role of the ED social worker in contributing to the multidisciplinary accomplishments of GEDI WISE objectives in this new model of care. KEYWORDS emergency department, emergency social worker, older adults, transitions of care
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BACKGROUND As has been widely noted, the emergency department (ED) represents a critical entryway into America’s health care delivery system for a substantial number of people (Abelson, 2013; Billings, Parikh, & Mijanovich, 2000; Received May 14, 2015; accepted August 24, 2015. Address correspondence to Christine Hamilton, PhD, The Mount Sinai Hospital, One Gustave L. Levy Place, Box 1252, New York, NY 10029, USA. E-mail: [email protected] 849
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Oetjen, Oetjen, Rotarius, & Liberman, 2010; Stempniak, 2013) who present with a range of needs that often go beyond immediate medical care, particularly in the case of older adults (Auerbach & Mason, 2010; Healy, 1981). As the U.S. population ages and the proportion of older adults requiring health care rises, the rate of older adult visits to the ED is increasing more rapidly than any other age group (Nolan, 2009). This is apparent in hospitals in New York City where 13.5% of Manhattan’s population is >65 years old (New York (City) Quick Facts from the US Census Bureau, 2010). Annually, The Mount Sinai Hospital ED cares for 14,000 patients >65 years old (approximately 38 patients per day), of whom 10,000 are over the age of 75 (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang, Shah, Han, Carpenter, Siu, & Adams, 2013b). Older adults who enter the ED often present with a multitude of medical and psychosocial problems, which are made more serious by delays in seeking care and often require a comprehensive geriatric assessment. (Lin et al., 2012). As Nolan (2009) has noted, the literature supports that many older adults often wait to visit the ED until their symptoms worsen. This is particularly the case with many East Harlem older adult residents to whom we provide care. East Harlem is a neighborhood on the upper east side of Manhattan, which is one of the five boroughs of New York City. Of its 122,920 residents, 50% of East Harlem’s residents are Latino, 32% are African American, 11.5% are White, 5.5% are of Asian descent, and 1% consists of other races. Just fewer than 30% of East Harlem’s residents live below the poverty level (US Census Bureau, 2010). When transitioning home from the ED, patients are often in need of multiple social services to ensure their safety at home. For this reason, the ED social worker conducts a comprehensive geriatric assessment with careful attention to the psychosocial challenges that may have contributed to the patient seeking ED care. Following this assessment, and after close collaboration with the interdisciplinary team, the social worker develops a discharge plan with the patient that addresses the social, psychological, and financial needs of the patient in addition to arranging services to address the nursing and custodial needs of the patient. As an academic medical center, we are constantly seeking new innovations to improve care and accommodate the changing needs of our patients. The initial process of engagement, establishing trust, and advocacy begins in the ED. In describing the operational process and dynamics of working with an older adult population, our goal is that you will understand the challenges and dynamics of transitions of care and the important role of the ED social worker.
PROBLEMS FOR OLDER ADULTS IN THE ED An urban ED is unlike any other area of the hospital. The pace and intensity can be challenging and entering into this environment can easily feel
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overwhelming (Richardson, 2010), particularly for older adult patients, many of whom arrive by ambulance without family present. As Adams and Gerson (2003) point out, “traditional ED care was designed for the acutely ill and injured patient, not a medically complicated, slow-moving, functionally impaired geriatric patient. The ED processes are usually inadequate and inhospitable for the older person” (p. 272). Thus, the ED can pose an increased risk to older adult patients both in the ED and following discharge when their care needs are not well matched with both the priorities of the ED and the way in which emergency care is delivered (Hwang & Morrison, 2007). To improve patient safety and satisfaction, in 2012 The Mount Sinai Hospital opened New York City’s first Geriatric ED, which consists of 14 treatment spaces with enhancements designed to reduce deliriumprovoking environmental stimuli and fall risks and to improve communication for the hearing and visually impaired. The implementation of a geriatric ED that addresses the special care needs of older patients has aided in addressing these challenges (Hwang & Morrison, 2007) and has the goal of improving outcomes in this high risk group. It is in this challenging environment that emergency physicians make one of the most expensive decisions in health care: to hospitalize or not (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang et al., 2013b). Patients generally fall into four categories: there are those who are critically ill and clearly need to be admitted; those who are acutely ill or injured, need to be evaluated in the ED, and can be discharged home; those who are not critically ill but have no other options other than the ED for their medical care and tend be discharged home once treated; and those “on the fence”—who may or may not be able to go home. This decision has major financial consequences for the health care system: Medicare beneficiaries 65 years and older account for 60% of all preventable admissions and account for over $20 billion of total annual hospital Medicare costs (Stranges & Stocks, 2008; Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles [Internet], 2012; Hwang et al., 2013b; Steiner, Barrett, & Hunter, 2010). Thus, the challenge became one of how to create safe discharge destinations out of the ED with the needed services and supports in place for the discharge to succeed. The Mount Sinai ED has developed a greater understanding of the risks associated with an ED visit, and GEDI WISE—Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements—has enabled the ED team to implement robust transitional care initiatives. Transitions of care is defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or levels of care within the same location” (Brock & Boutwell, 2012, p. 37). Thus, we consider it especially important to provide high quality transitional care for older adults with multiple chronic conditions and complex therapeutic regimes, as well as for their family
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caregivers. “A system that pays little attention to the continuing care needs of older adults and their family caregivers as they move across these various settings commonly leaves gaps in care” (Naylor & Keating, 2008). Inter-professional collaboration that incorporates principles of shared understanding of goals, good communication, and effective team meetings can improve patient outcomes and cost effectiveness of care (McPherson, Headrick, & Moss, 2001). In GEDI WISE, comprehensive assessments, which include screening and assessment tools, are conducted by the physician, nurse practitioner, bedside nurse, pharmacist, physical therapist, and the social worker. These are critical to overcoming the barriers to effective care transitions. Such barriers include the following: lack of a system in place to ensure care plan execution after discharge, a medication formulary that is not consistent between sites of care; and multiple case managers (Naylor & Keating, 2008, p. 69) also noted that social workers have long acknowledged the importance of collaboration, autonomy, and empowerment of patients and their families. Social workers contribute knowledge and expertise to many aspects of care, including the effects that transitional care has on families beyond physical ailments and the need for clear communication among patients, caregivers, and health care providers (as cited in Naylor & Keating, 2008 p. 69). Frail older adults, particularly those with cognitive impairment, have the most difficulty participating in the process, which may result in miscommunication of crucial information. Among examples of obstacles to safe transitions are problems with patient understanding. For example, Peikes (2013) refers to serious quality and safety problems during hospital discharge and following discharge. This is true regardless of the setting in which care is rendered. According to Peikes (2013) patients and caregivers who are anxious frequently do not understand medication instructions, how to take care of themselves, how to recognize medical warning signs, and when or how to follow up with their usual care provider, particularly if in crisis during an ED visit. “It is estimated, that between 15 and 45% of patients experience medication problems after discharge and do not receive appropriate follow-up care” (Peikes, 2013, p. 44). Studies have shown that deficiencies in appropriate medical follow-up and communication among health care providers are strongly associated with adverse events following ED discharge. For example according to Morano, Morano, Biese, Coleman, and Hwang (2015, p. 2) “older patients discharged to home from the ED are at a high risk of experiencing adverse outcomes, including receiving inappropriate medication, returning to the ED and death.” They further recommend that improving transitions between sites of care requires that the sending site educate the patient, conduct medication reconciliation with the current regimen, and make arrangements for the next level of care, whether the patient is returning to an identified primary care physician or sub-acute care facility. “Identifying and addressing the challenges that patients face after discharge from the ED may
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lead to improved health outcomes, and a decrease in return visits and hospitalization” (Morano et al., 2015, p. 8) Social workers are ideally suited to coordinate the care of the patient and provide smoother transitions.
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EVOLUTION OF GEDI WISE PROGRAM AND ITS COMPONENTS The Mount Sinai Hospital has long recognized the difficulties faced by both older patients and caregivers in the ED, and has arranged for geriatricians to collaborate on patients in the ED for almost a decade. However, the Affordable Care Act (ACA) is the first comprehensive federal legislation to acknowledge gaps in the workforce of those caring for the older adult population (Stone & Bryant, 2012). Through the creation of the Center for Medicare and Medicaid Innovation (CMMI), which funded GEDI WISE, the ACA has made possible the biggest change in our ED discharge processes. Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States and experts estimate that 20% of U.S. hospitalizations are re-hospitalizations within 30 days of discharge (Rutherford, Nielsen, Taylor, Bradke, & Coleman, 2013). As indicated by the Institute for Healthcare Improvement: … poorly executed care transitions negatively affect patients’ health, wellbeing, and family resources and unnecessarily increase health care system costs. For individuals with multiple chronic conditions, this transition takes on greater importance. Research shows that one quarter to one third of these patients return to the hospital due to complications that could have been prevented. Unplanned re-hospitalizations may signal a failure in hospital discharge processes, patient ability to manage self-care, or the quality of care in the next community setting such as primary care, home health care, and skilled nursing facility. (Rutherford et al., 2013, p. 2)
Continuity in patients’ medical care is especially critical following a patient’s discharge. Our ED physicians, clinicians, and researchers were concerned about this and saw a need to address, from the ED, these 30-day re-visits and re-hospitalizations. The Mount Sinai Hospital in New York, in collaboration with St. Joseph’s Regional Medical Center in New Jersey and Northwestern Memorial Hospital in Illinois, applied for and received multi-million-dollar funding from CMMI. GEDI WISE is a geriatric-centered care model that targets Medicare patients by offering ED patients an integrated set of services and innovations. It incorporates workforce education, training, and the creation of evidence-based geriatric- specific clinical protocols; informatics support for patient care; and structural enhancements to improve patient care, safety, and satisfaction.
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GEDI WISE has three goals: to improve the quality of emergency care received by patients >65 years old who present in the ED, to improve the overall health of our aging population, and to reduce health care costs which are congruent with the ACA’s “triple aim “(Berwick, Nolan, & Whittington, 2008). This is accomplished by decreasing hospitalizations, 30-day re-admissions, return ED visits, unnecessary diagnostic and therapeutic services, medication errors, adverse events, falls, and other avoidable complications of older adults. An important component of these innovations is a geriatric care transitions team consisting of nurse practitioners, social workers, a geriatric ED pharmacist who sees patients that take 10 medications or more, and ED physical therapy consults for patients at risk for falls. ED social workers have played a key role in coordinating post-ED services to facilitate the transition home. Other GEDI WISE innovations include multidisciplinary clinical rounding on geriatric patients, intensive training for all ED staff on the special needs of older adults, clinical decision support in the electronic medical record for performing screening such as Identification of Seniors at Risk (ISAR) and patient alert notifications to the GEDI WISE team through a regional health information organization (RHIO) that supports a health information exchange (HIE) (Hwang, Shah, Han, Carpenter, Siu, & Adams, 2013a; Gutteridge, Genes, Hwang, Kaplan, Shapiro, & GEDI WISE Investigators 2014). The HIE network allows for an exchange of medical records between institutions and provides an effective way to communicate patients’ information. As it is increasingly recognized by the interdisciplinary team that a large number of these older adult patients are complex cases involving an array of multilevel factors beyond the scope of diagnosis alone, particularly when it comes to discharge plans, (Auerbach, Mason, & LaPorte, 2007), the social worker is seen as playing a critical role and serves as an important member of the multidisciplinary team in assisting physicians in determining the disposition of these patients. The GEDI WISE interdisciplinary approach clearly appreciates the value of social work services in navigating the complexities of the discharge process and helping to transition ED patients home.
WHAT WE DID AND HOW IT EVOLVED The unique skill set and knowledge base of social work meshes well with GEDI WISE goals. The ED offers social workers an opportunity to work in what is often the front line of health care—the patient’s first contact with the hospital. Traditional social work roles, such as crisis intervention, discharge planning, patient and family counseling, and community resource linkages assume greater importance in the context of an ED. According to Moore, Ekman, and Shumway (2012), the ED is a “critical intervention point for
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patients with multiple unmet medical, psychological and social needs, and little or no contact with service providers” (p. 140). The ED environment can become over-stimulating and non-conducive to the wellness of ED patients, especially older frail patients. Within this environment, the immediacy of the problem, the pressure to act quickly to alleviate stress and to discharge patients to more appropriate settings to free up beds for more acutely ill patients all require rapid and innovative responses on the part of the social worker. The social worker’s intervention can be invaluable in situations fraught with emotional stress (Healy, 1981). For patients who may potentially return home, the timeliness of psychosocial and safety assessments as well as communication among staff are essential components to effective and safe discharge planning. Social workers at The Mount Sinai Hospital have had a strong presence in the ED, actively participating in programs that preceded GEDI WISE. For example, as an increased number of patients were frequently returning to the ED, most of whom had significant social needs, the ED recognized a need to address this issue. In 2009, social work collaborated with an ED physician to address this concern and co-facilitated the Novel Interdisciplinary Care for Emergencies (NICE) program. The NICE program focuses on patients who have three or more ED visits for three consecutive months. Although the NICE team is composed of interdisciplinary staff, it is led by social work. Meetings are held regularly to identify patients who meet NICE criteria. These patients are flagged in the ED electronic medical record by a social worker and on return of the patient to the ED, a referral to social work is triggered, and social work meets with the patient to for an in-depth assessment. By meeting with each patient during the ED visits, social work has been able to analyze the root cause for their return and to reduce overall ED visits of NICE patients. Another example of a program in which social work has been key is the Care and Respect for Elders with Emergencies (CARE) program (Sanon, Baumlin, Kaplan, & Grudzen, 2014). CARE was the idea of the former vice chair of Emergency Medicine. Volunteers are trained to work with older adult patients in the ED. These volunteers provide patients age 65 years and older, who are at high risk for avoidable complications (e.g., falls, delirium), with bedside visits and engage them in activities. The goal of CARE has been to prevent these avoidable complications. Under the direction of the former vice chair of Emergency Medicine, the ED social worker along with the other members of the CARE advisory team (the volunteer director, physicians, and nurses) were at the forefront in the development of this program as a pilot initiative in 2010 after The Mount Sinai Hospital received a grant from an individual donor. From the onset, ED social work had a pivotal role in identifying and training volunteers, and purchasing all the materials to be used with patients such as hearing amplifiers, reading glasses and stress balls. Social work also compiled a fall risk prevention safety
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packet which was distributed to the volunteers to use with the patients. As a result of this program being a highly successful pilot, The Mount Sinai Hospital applied for and was awarded a volunteerism grant in 2011. The grant included funding for a CARE director, and the ED physician leadership hired a social worker for this role (a new position in the Volunteer Department that was independent and separate from the ED social worker’s role). We believe that the selection of a social worker for this position was a testament to the appreciation of the work that the ED social worker did as CARE was being developed and executed. Subsequently, CARE, the leadership of an MSW in the Volunteer Department has thrived and has become a fundamental component of the GEDI WISE model. As both the NICE and CARE programs illustrate, social work has been integral to important planning discussions and has been a strategic contributor prior to and with the roll out of GEDI WISE. As ED social workers offered to take on these types of tasks, they continued to align with the goals of ED leadership. Participating in this way enabled social work to be visible and to be a steadfast contributor within the interdisciplinary team. All of this laid the groundwork for developing trust and gaining the confidence to become a valued partner of the team. The more the team believed they could rely on social work, the more frequently social work was invited to assume important roles on committee projects and was sought out for case consultation. This concept is evident today as new projects continue to emerge within the ED for older adult patients. Since the inception of GEDI WISE, three additional pilot initiatives for older adults have been developed. They include: Transport Plus; Project Connect (Connecting Neighborhood Elderly to Community-based Teams); and Advanced Care Planning. Transport Plus is a program in which emergency medical technicians (EMTs), as they are transporting patients to their homes after an ED visit or hospitalization, review the patients’ discharge instructions and assess the safety of the patients’ home environment. When the GEDI WISE physicians were rolling out Transport Plus, the lead physician reached out to ED social work and asked us to provide input regarding factors that should be considered to prevent falls and promote a safe environment. Any concerns in the home trigger a referral to social work, and social work has embraced the responsibility of following up with these patients in the community. Project Connect is a new initiative that expands the GEDI WISE model to patients who are discharged home from the ED by providing referrals to identified community-based organizations. The goal of this project is to create lasting linkages between patients and community resources by developing a plan of care and overseeing its implementation of connecting patients to community based programs (e.g., senior centers, physical activity programs). The GEDI WISE social workers are responsible for screening appropriate patients, collecting baseline data and referring patients to Project Connect.
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Advanced Care Planning (ACP) is a new home care intervention that began in December 2014 and is being piloted in the ED with a hospital partner home care agency. ACP targets patients with multiple chronic diseases, rather than only including end-of-life patients. The patient who meets the medical criteria for ACP also has to be receiving the services of a certified home health agency. Similar to our role in Project Connect, the ED social workers are responsible for identifying patients who are appropriate candidates for the ACP intervention. In their everyday practice, these initiatives lend themselves to social work roles that deal with a broad range of concerns that defy tidy categorizations. During the psychosocial assessments, ED social workers are cognizant of the longstanding as well as the newer ED initiatives and match patients to the programs that are best suited to meet their needs. ED interventions often require social workers to wear many hats on any given day (e.g., problem solver, clinician, adviser, therapist, bereavement counselor, and home care liaison; Sheafor & Horejsi, 2007). The continuous involvement and presence of social work has strengthened the transitions between the ED and patients’ community-based supports.
PATIENT SUCCESSES The best mechanism for delivering geriatric health care is an interdisciplinary team consisting of nursing, physician, social work, physical therapy, and pharmacy to address the medically complex needs of most geriatric patients (Blewett, Johnson, McCarthy, Lackner, & Brandt, 2010). As noted earlier, the ED social workers are continuously in the forefront of new initiatives that have derived from GEDI WISE and have been instrumental in assessing and referring patients to these new initiatives. Social workers have persevered over the many challenges and are cognizant of the changing needs of our elderly population. To support the GEDI WISE goal of enhancing the patient’s ability to function safely at home and in the community, the ED social workers own the task of ensuring that routine as well as innovative solutions are being rendered; this is accomplished through consultations with the patient, the family as well as various service providers. Developing, coordinating and implementing transitional solutions that are satisfactory to the both patient and institution is the social worker’s charge, and may be considered a successful outcome when there is an avoidance of an admission and/or decline in turnaround visits to the ED (Auslander, 2000). For example, on a Friday afternoon before Memorial Day weekend, a patient required sub-acute rehabilitation. Once the admission paperwork was completed, it was nearing 5:00 p.m. The extended hours of the social worker allowed the coordination of care for this patient. In working with a nursing home facility partner, social work was able to maintain contact with the facility
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after-hours and to advocate for admission from the ED to the sub-acute rehabilitation facility later in the evening. The patient was able to be placed and an unnecessary admission was avoided. If this had not occurred, the patient would have been admitted and remained in the hospital until the following Tuesday. The patient wished to be placed as soon as possible so it was a win–win for the patient and for both institutions. The ED social workers have been focused on navigating obstacles and providing soon-to-be-discharged patients with the tools and resources to ensure that their transition from hospital to home is well supported so they are less likely to return to the ED. Follow-up calls, have become an integral part of the transitional process, in which social workers and nurse practitioners have a pivotal role in preventing patients from returning to the ED for non-emergent matters. Success can come in different forms, but one such example is with a patient, Mrs. B. The social worker made a follow-up call to a Mrs. B. on the day after discharge. The patient stated she still felt ill, was unable to pick up her medication due to snow and icy sidewalks, and was thinking of returning back to the ED. Both the GEDI WISE nurse practitioner and social worker spoke with the Mrs. B. Arrangements were made for her pharmacy to deliver her medication to the home. The social worker was able to expedite Mrs. B.’s primary care physician appointment to the next day. The nurse practitioner believed this was a safe plan, and the patient felt secure with this plan and opted to continue with her follow-up care as an outpatient and not return to the ED. The social worker and nurse practitioner were able to provide optimal coordination of care and seamless transitions of care. Social workers have been effective in communicating patient needs to other disciplines. In the case of another patient, Mrs. L., social work was asked to meet with a patient with confusion who entered the ED. The patient’s medical record from a very recent hospitalization indicated that Mrs. L. was self-care and did not indicate a diagnosis of dementia. During this current ED visit, however, Mrs. L. was unable to recall earlier events of her day, unable to state how many or which medications she was taking or to provide a time frame when the medications were last taken. Her delirium led the medical providers to deem it unsafe for her to return home and listed the patient for admission for altered mental status. The social worker met at length with the patient, and with the patient’s permission, spoke to the patient’s daughter on the telephone. The daughter reported that the patient was usually very alert and the way she was presenting in the ED was out of character for her. The social worker communicated this information to the physician and to the ED pharmacist. They spoke with the patient’s daughter on the telephone while the medical team continued to review tests results and treat the patient. The pharmacist and ED physician determined that the Mrs. L.’s delirium was the result of a reaction to prescription medications that she was taking. With medical and nursing treatment, the patient’s delirium began to clear and the
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option of the patient’s returning home became a possibility. The pharmacist created a labeled pillbox and offered this to the patient. After a few hours, the patient was stabilized and ready for discharge. The social worker educated Mrs. L. about the home care process and options available to her. With the patient’s consent, the social worker made a home care referral for medication management. With the medical team reassured that the patient would have assistance at home with her medication management, they felt that home was a safe discharge plan and canceled the inpatient admission. In this example, the partnership of the social worker and pharmacist along with the medical team enhanced patient care and promoted better health outcomes due to increased adherence to medicine regimes (Fouche, Butler, & Shaw, 2013). Another result of successful efforts by social work and the GEDI WISE interdisciplinary team has been the ability to place patients directly into nursing homes from the ED, an option that was only in its infancy before GEDI WISE. Placement can be a lengthy process that requires the collaboration of several disciplines in order to have a successful outcome. There are many detailed steps involved in nursing home admission protocols and, by the time an accepting facility is secured, many hours may have passed. By refining the practice of direct placements through GEDI WISE, social workers were addressing the need to move patients quickly from the ED. The concept that “success breeds success” has been evident in the team’s agreement to place patients into facilities from the ED. When the ED physicians saw that social work could be successful with direct ED to nursing home placements, they were increasingly open to the possibility that this can occur and now even initiate this plan as the reason for referral to social work. Since the inception of GEDI WISE, with the collaboration of ED social workers, case managers, physical therapists, and clinical staff, we have been able to transfer 42 patients directly from the ED to a nursing facility for either sub-acute rehabilitation or custodial long-term care. Providing better care for our older ED adults has allowed us to also enhance care for ED patients under 65 years of age, and we have discharged an additional 13 patients under the age of 65 to facilities during this same time period. Another essential aspect to successful nursing home placement was the development of strong collaborative relationships with local nursing homes that were amenable to working with social work for this purpose. ED social workers made visits to these facilities so that they could speak with first-hand knowledge about them. Additionally, the ED social workers and nursing home staff jointly developed workflows to expedite the admission process. ED social workers apply critical thinking skills and work creatively with patients to do whatever it takes to get a patient discharged home safely (Bergman, 1976). For example, a patient was being treated on a Saturday in the ED and was ready for release back to his adult home residence. The physician made a referral for discharge planning to social work. The ED social worker tried to reach the residence listed in the admission paperwork. After
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several hours of no call-backs, the ED team was ready to write orders for the patient to be admitted. When the social worker learned of this, he said, “Please wait. I have one more thing to try.” His plan involved physically going to the address listed in the patient’s chart in pursuit of making face-toface contact with someone who had the authority to approve the patient’s return. The social worker was successful, and the patient was able to be discharged back to his residence that day. ED Administration applauded this out-of-the-box solution. The ED physician said, “I love social workers. You always have a Plan B and when we present you with a challenge, you present us with a solution. You’re incredible, and we couldn’t do what we do without you.” Hence, the training and advocacy along with the perseverance of the social workers in GEDI WISE are increasingly recognized by the interdisciplinary team as value-added.
SYSTEM SUCCESSES Social workers have developed ways to improve existing practices and to expand and initiate new interventions to better address the needs of our older adult ED patients. Starting with our older adult database of community resources, which is still a work-in-progress, social work identified a need to create a centralized document that contained geriatric resources to assist older adults with these health-related changes. The concept is to incorporate resources ranging from legal and pharmacy services, to adult day programs that can be accessed internally by the medical team and eventually accessed by the community. Social workers have met with the East Harlem Community Action Board to discuss ways to best educate patients about available community services for older adults. In addition, social work has internally revamped our assessment tool to capture the safety needs of older adult patients in the ED by focusing on risks at home and in the community. Flagging these conditions for further assessment allows the social worker to implement the most appropriate intervention for their patients (Fulmer, 2012). The social work component of the GEDI WISE model has also been expanded to the Mount Sinai Rapid Evaluation and Treatment Unit (RETU), a 20-bed observation unit, adjacent to the ED that opened in February 2014. The RETU is designed to allow physicians to monitor and treat selected patients over an extended period of time where they can undergo further monitoring or testing before doctors decide whether they should be released or admitted (Jaffe, 2014). Instead of defaulting to an admission in these subsets of patients, the ED will consider an observational status for patients. In the RETU, social workers use the same GEDI WISE assessment model and interventions for every patient >65 years old. The social worker’s focus is on identifying and addressing any potential issues that may be barriers for a patient to return to the community.
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Collaboration not only exists within our geriatric emergency department but with other hospital innovative programs at The Mount Sinai Hospital. The ED has partnered with Martha Stewart Center for Living, a primary care practice at The Mount Sinai Hospital that specializes in caring for older adults with complex health care problems. The purpose of this partnership is to initiate and expedite both initial and follow-up primary care appointments. The ED social workers also have a very close relationship with Preventable Admissions Care Team (PACT) and Mount Sinai Care, the Accountable Care Organization (ACO) and the Mount Sinai Health Home. Due to the hospital’s advanced streamline process of identifying patients who enter the ED, social workers can quickly refer patients to their outpatient social workers to ensure that the transitional follow-up plan is in effect. All of our programs share the goal of preventing unnecessary re-admissions and work closely together. ED social workers inform PACT, the ACO, and Mount Sinai Health Home social workers when a patient enrolled in one of these programs arrives in the ED, and the ED social workers are also alerted if PACT, the ACO, or Mount Sinai Health Home patients are on their way to the ED. This reciprocal communication between programs regarding patients who are currently in the ED promotes strong coordination of care and serves to enhance the patient experience. The hospital has also built community-based relationships with neighboring residential facilities, home care vendors, and local community centers in order to increase accessibility and coordinate care for our patients. Social workers have been instrumental in coordinating with these liaisons and are highly skilled at seeking creative solutions to ensure safe transitions for our patients. Working well together is necessary for good quality of care; as health care professionals, we need to be competent team members (McPherson et al., 2001) in order to accomplish GEDI WISE goals.
CHALLENGES The journey to a highly functioning system has not been without challenges which include educating a large ED staff, hiring the right additional staff, and defining interdisciplinary roles. The inception of GEDI WISE meant that interdisciplinary staff, including social work, needed to be educated on geriatric care, to be conscious of ageism and aware of effective ways to communicate with the older adults. In order for GEDI WISE to be launched successfully, this complicated task needed to be completed prior to the commencement of the program. It required allotting time for staff to receive this training and to be facile with GEDI WISE interventions and protocols. The GEDI WISE award included two additional social work positions. With the increased staffing, the social workers’ schedules were changed to
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meet the needs of our patients. Social work coverage schedules shifted from a Monday through Friday 9–5 work day to a 12-hour/7-day-per-week schedule. It was difficult to find the right social workers to hire for GEDI WISE. The need to work effectively in complex interdisciplinary teams, to work in a timeefficient manner (Moore et al., 2012) with “high risk older adults who require complex discharge planning” (McCusker, Roberge, Vadeboncoeur, & Verdon, 2009) takes on greater importance in GEDI WISE. The challenge became not only finding someone who possessed all of the qualifications needed for the position, who was able/willing to work on weekends, but also finding “the right fit.” We did not accomplish this during our first round of hiring. The initial set of social workers were not medical social workers and found it both challenging to work so closely with a non-MSW interdisciplinary team and overwhelming to working with a population that required a broad range of both concrete and short-term counseling services. We learned that a successful GEDI WISE social worker must be flexible, be able to navigate through the unpredictability of a day and shift their priorities frequently, as well as be committed to working with a population that requires multifaceted interventions. An ability to appreciate the importance of metrics and evidenced-based outcomes is also important. The GEDI WISE social worker needs to demonstrate leadership qualities and can “approach each encounter with an awareness and purposeful use of themselves as influential change agents” (Applegate, 1988). Additionally, to be successful in contributing to the accomplishment of GEDI WISE goals, the social worker has to be innovative and work within a model that is still evolving and in flux. We were eventually able to find “star” social workers; they are well-suited and excited to work with our older ED adults and have been dedicated to the unique needs of this population. As a result of this process, a great deal was learned. Although communication has always been a crucial component to effective planning, ED social workers had to learn the streamlined process that was put into effect via our internal electronic medical record system, known as EPIC. ED Social workers are able to identify and flag patients who are at high risk and make quicker referrals to our internal innovation programs. Working with older adults in a far-reaching manner, places the concept of comprehensive planning and home safety at the forefront of social work assessments. Attempting to minimize the overlapping of informational inquiries to our patients, especially between social workers and nurse practitioners was initially a challenge. Since the role of a nurse practitioner was a new concept in the ED, finding a way to work most efficiently with them has been a work in progress. Both disciplines wanted to ensure that the needs of the patients were being met, as much pertinent information was being gathered to conduct comprehensive assessments, and that the patient was able to obtain the appropriate referrals and resources for an effective discharge plan. For example, the question of who would ask about “activities of daily living and ability
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to manage at home, living environment” was relevant to both disciplines. It became evident that something needed to be corrected when patients would ask, “Why are so many people asking me the same questions. Why don’t you read my chart?” It was quickly realized that it would be more beneficial for the patient if both the social worker and nurse practitioner met with patients jointly to minimize repetition of information. When this was not feasible, a plan was devised in which the social worker would focus on the psychosocial aspects of care such as mental health issues, identifying social supports, financial management, and the home environment while the nurse practitioner focused on medical management and functional status such as mobility and activities of daily living. There is immediate, real-time social worker to nurse practitioner hand-offs (and vice versa) as well as daily ongoing communication between these two disciplines. Prior to GEDI WISE, group meetings were held on an as-needed basis. With GEDI WISE, social workers now formally collaborate with interdisciplinary partners during daily GEDI WISE ED rounds to discuss patient care. Social work is an integral part of addressing psychosocial barriers and challenges as well as the discharge planning process, and it has been apparent that social work’s input was a vital component during the daily discussions. As a team, it was decided that the meetings would be held at the same hour every week day. However, this initially presented a challenge to the social workers as it was difficult from a time-management perspective to accommodate a new daily meeting when their schedules were already packed. However, by having a consistent daily time and focus along with limiting rounds to a prescribed amount of time, these meetings were incorporated into the social workers’ daily routine. Occasionally, when social workers are involved in complex patient care interventions, social workers may alternate in attendance so as not to interrupt workflow or over-burden a colleague. The future of emergency care will require that ED staff recognize and understand that older adults have physiological and psychosocial problems that present differently than in a younger population. The older adult is susceptible to particular risks related to poly-pharmacy, depression, delirium, and inadequate assistance in managing their activities of daily living (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang et al., 2013b). The Mount Sinai Hospital has provided comprehensive training on geriatric models of care and GEDI WISE program goals, screening tools, care protocols and data collection. Specifically, the social workers received additional training on topics such as: depression in the older adult; ageism and communication; transitions of care; the effects of care coordination on hospitalization; quality of care and health expenditures among Medicare beneficiaries; city, state and national resources available to older adults; and improving health outcomes with aging populations. These trainings have helped to promote conceptualization of the multifaceted problems our
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patients face and forward thinking on the part of our social workers in the areas of patient need, dispositions, transitions, and coordination of care. Our ED social workers have integrated this knowledge and assumed a leading role in discussing GEDI WISE interventions in educational forums at both a local and a national level such as webinars and conferences with others in field of social work. ED social workers have also volunteered to train medical residents on appropriate social work geriatric referrals and in defining the social work role, have provided a social work perspective to medical research students on older patients, and have presented to CARE volunteers and social work interns.
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CONCLUSION Funding for the GEDI WISE project will come to a close on June 30, 2015, and outcome data will be available after the project ends. The GEDI WISE model, however, will be the gateway for future expansion of this care model to potentially include high risk patients
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform Christine Hamilton PhD, Liza Ronda LCSW, Ula Hwang MD, Gallane Abraham MD, Kevin Baumlin MD, Barbara Morano LCSW, Denise Nassisi MD & Lynne Richardson MD To cite this article: Christine Hamilton PhD, Liza Ronda LCSW, Ula Hwang MD, Gallane Abraham MD, Kevin Baumlin MD, Barbara Morano LCSW, Denise Nassisi MD & Lynne Richardson MD (2015) The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform, Social Work in Health Care, 54:9, 849-868, DOI: 10.1080/00981389.2015.1087447 To link to this article: http://dx.doi.org/10.1080/00981389.2015.1087447
Published online: 13 Nov 2015.
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Date: 14 April 2016, At: 16:13
Social Work in Health Care, 54:849–868, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2015.1087447
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The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform CHRISTINE HAMILTON, PhD, LIZA RONDA, LCSW, ULA HWANG, MD, GALLANE ABRAHAM, MD, KEVIN BAUMLIN, MD, BARBARA MORANO, LCSW, DENISE NASSISI, MD, and LYNNE RICHARDSON, MD Department of Social Work Services, The Mount Sinai Hospital, New York, New York, USA
In the era of Medicaid Redesign and the Affordable Care Act, the emergency department (ED) presents major opportunities for social workers to assume a leading role in the delivery of care. Through GEDI WISE—Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements,—a unique multidisciplinary partnership made possible by an award from the Center for Medicare and Medicaid Innovation, social workers in The Mount Sinai ED have successfully contributed to improvements in health outcomes and transitions for older adults receiving emergency care. This article will describe the pivotal and highly valued role of the ED social worker in contributing to the multidisciplinary accomplishments of GEDI WISE objectives in this new model of care. KEYWORDS emergency department, emergency social worker, older adults, transitions of care
department
BACKGROUND As has been widely noted, the emergency department (ED) represents a critical entryway into America’s health care delivery system for a substantial number of people (Abelson, 2013; Billings, Parikh, & Mijanovich, 2000; Received May 14, 2015; accepted August 24, 2015. Address correspondence to Christine Hamilton, PhD, The Mount Sinai Hospital, One Gustave L. Levy Place, Box 1252, New York, NY 10029, USA. E-mail: [email protected] 849
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Oetjen, Oetjen, Rotarius, & Liberman, 2010; Stempniak, 2013) who present with a range of needs that often go beyond immediate medical care, particularly in the case of older adults (Auerbach & Mason, 2010; Healy, 1981). As the U.S. population ages and the proportion of older adults requiring health care rises, the rate of older adult visits to the ED is increasing more rapidly than any other age group (Nolan, 2009). This is apparent in hospitals in New York City where 13.5% of Manhattan’s population is >65 years old (New York (City) Quick Facts from the US Census Bureau, 2010). Annually, The Mount Sinai Hospital ED cares for 14,000 patients >65 years old (approximately 38 patients per day), of whom 10,000 are over the age of 75 (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang, Shah, Han, Carpenter, Siu, & Adams, 2013b). Older adults who enter the ED often present with a multitude of medical and psychosocial problems, which are made more serious by delays in seeking care and often require a comprehensive geriatric assessment. (Lin et al., 2012). As Nolan (2009) has noted, the literature supports that many older adults often wait to visit the ED until their symptoms worsen. This is particularly the case with many East Harlem older adult residents to whom we provide care. East Harlem is a neighborhood on the upper east side of Manhattan, which is one of the five boroughs of New York City. Of its 122,920 residents, 50% of East Harlem’s residents are Latino, 32% are African American, 11.5% are White, 5.5% are of Asian descent, and 1% consists of other races. Just fewer than 30% of East Harlem’s residents live below the poverty level (US Census Bureau, 2010). When transitioning home from the ED, patients are often in need of multiple social services to ensure their safety at home. For this reason, the ED social worker conducts a comprehensive geriatric assessment with careful attention to the psychosocial challenges that may have contributed to the patient seeking ED care. Following this assessment, and after close collaboration with the interdisciplinary team, the social worker develops a discharge plan with the patient that addresses the social, psychological, and financial needs of the patient in addition to arranging services to address the nursing and custodial needs of the patient. As an academic medical center, we are constantly seeking new innovations to improve care and accommodate the changing needs of our patients. The initial process of engagement, establishing trust, and advocacy begins in the ED. In describing the operational process and dynamics of working with an older adult population, our goal is that you will understand the challenges and dynamics of transitions of care and the important role of the ED social worker.
PROBLEMS FOR OLDER ADULTS IN THE ED An urban ED is unlike any other area of the hospital. The pace and intensity can be challenging and entering into this environment can easily feel
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overwhelming (Richardson, 2010), particularly for older adult patients, many of whom arrive by ambulance without family present. As Adams and Gerson (2003) point out, “traditional ED care was designed for the acutely ill and injured patient, not a medically complicated, slow-moving, functionally impaired geriatric patient. The ED processes are usually inadequate and inhospitable for the older person” (p. 272). Thus, the ED can pose an increased risk to older adult patients both in the ED and following discharge when their care needs are not well matched with both the priorities of the ED and the way in which emergency care is delivered (Hwang & Morrison, 2007). To improve patient safety and satisfaction, in 2012 The Mount Sinai Hospital opened New York City’s first Geriatric ED, which consists of 14 treatment spaces with enhancements designed to reduce deliriumprovoking environmental stimuli and fall risks and to improve communication for the hearing and visually impaired. The implementation of a geriatric ED that addresses the special care needs of older patients has aided in addressing these challenges (Hwang & Morrison, 2007) and has the goal of improving outcomes in this high risk group. It is in this challenging environment that emergency physicians make one of the most expensive decisions in health care: to hospitalize or not (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang et al., 2013b). Patients generally fall into four categories: there are those who are critically ill and clearly need to be admitted; those who are acutely ill or injured, need to be evaluated in the ED, and can be discharged home; those who are not critically ill but have no other options other than the ED for their medical care and tend be discharged home once treated; and those “on the fence”—who may or may not be able to go home. This decision has major financial consequences for the health care system: Medicare beneficiaries 65 years and older account for 60% of all preventable admissions and account for over $20 billion of total annual hospital Medicare costs (Stranges & Stocks, 2008; Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles [Internet], 2012; Hwang et al., 2013b; Steiner, Barrett, & Hunter, 2010). Thus, the challenge became one of how to create safe discharge destinations out of the ED with the needed services and supports in place for the discharge to succeed. The Mount Sinai ED has developed a greater understanding of the risks associated with an ED visit, and GEDI WISE—Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements—has enabled the ED team to implement robust transitional care initiatives. Transitions of care is defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or levels of care within the same location” (Brock & Boutwell, 2012, p. 37). Thus, we consider it especially important to provide high quality transitional care for older adults with multiple chronic conditions and complex therapeutic regimes, as well as for their family
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caregivers. “A system that pays little attention to the continuing care needs of older adults and their family caregivers as they move across these various settings commonly leaves gaps in care” (Naylor & Keating, 2008). Inter-professional collaboration that incorporates principles of shared understanding of goals, good communication, and effective team meetings can improve patient outcomes and cost effectiveness of care (McPherson, Headrick, & Moss, 2001). In GEDI WISE, comprehensive assessments, which include screening and assessment tools, are conducted by the physician, nurse practitioner, bedside nurse, pharmacist, physical therapist, and the social worker. These are critical to overcoming the barriers to effective care transitions. Such barriers include the following: lack of a system in place to ensure care plan execution after discharge, a medication formulary that is not consistent between sites of care; and multiple case managers (Naylor & Keating, 2008, p. 69) also noted that social workers have long acknowledged the importance of collaboration, autonomy, and empowerment of patients and their families. Social workers contribute knowledge and expertise to many aspects of care, including the effects that transitional care has on families beyond physical ailments and the need for clear communication among patients, caregivers, and health care providers (as cited in Naylor & Keating, 2008 p. 69). Frail older adults, particularly those with cognitive impairment, have the most difficulty participating in the process, which may result in miscommunication of crucial information. Among examples of obstacles to safe transitions are problems with patient understanding. For example, Peikes (2013) refers to serious quality and safety problems during hospital discharge and following discharge. This is true regardless of the setting in which care is rendered. According to Peikes (2013) patients and caregivers who are anxious frequently do not understand medication instructions, how to take care of themselves, how to recognize medical warning signs, and when or how to follow up with their usual care provider, particularly if in crisis during an ED visit. “It is estimated, that between 15 and 45% of patients experience medication problems after discharge and do not receive appropriate follow-up care” (Peikes, 2013, p. 44). Studies have shown that deficiencies in appropriate medical follow-up and communication among health care providers are strongly associated with adverse events following ED discharge. For example according to Morano, Morano, Biese, Coleman, and Hwang (2015, p. 2) “older patients discharged to home from the ED are at a high risk of experiencing adverse outcomes, including receiving inappropriate medication, returning to the ED and death.” They further recommend that improving transitions between sites of care requires that the sending site educate the patient, conduct medication reconciliation with the current regimen, and make arrangements for the next level of care, whether the patient is returning to an identified primary care physician or sub-acute care facility. “Identifying and addressing the challenges that patients face after discharge from the ED may
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lead to improved health outcomes, and a decrease in return visits and hospitalization” (Morano et al., 2015, p. 8) Social workers are ideally suited to coordinate the care of the patient and provide smoother transitions.
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EVOLUTION OF GEDI WISE PROGRAM AND ITS COMPONENTS The Mount Sinai Hospital has long recognized the difficulties faced by both older patients and caregivers in the ED, and has arranged for geriatricians to collaborate on patients in the ED for almost a decade. However, the Affordable Care Act (ACA) is the first comprehensive federal legislation to acknowledge gaps in the workforce of those caring for the older adult population (Stone & Bryant, 2012). Through the creation of the Center for Medicare and Medicaid Innovation (CMMI), which funded GEDI WISE, the ACA has made possible the biggest change in our ED discharge processes. Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States and experts estimate that 20% of U.S. hospitalizations are re-hospitalizations within 30 days of discharge (Rutherford, Nielsen, Taylor, Bradke, & Coleman, 2013). As indicated by the Institute for Healthcare Improvement: … poorly executed care transitions negatively affect patients’ health, wellbeing, and family resources and unnecessarily increase health care system costs. For individuals with multiple chronic conditions, this transition takes on greater importance. Research shows that one quarter to one third of these patients return to the hospital due to complications that could have been prevented. Unplanned re-hospitalizations may signal a failure in hospital discharge processes, patient ability to manage self-care, or the quality of care in the next community setting such as primary care, home health care, and skilled nursing facility. (Rutherford et al., 2013, p. 2)
Continuity in patients’ medical care is especially critical following a patient’s discharge. Our ED physicians, clinicians, and researchers were concerned about this and saw a need to address, from the ED, these 30-day re-visits and re-hospitalizations. The Mount Sinai Hospital in New York, in collaboration with St. Joseph’s Regional Medical Center in New Jersey and Northwestern Memorial Hospital in Illinois, applied for and received multi-million-dollar funding from CMMI. GEDI WISE is a geriatric-centered care model that targets Medicare patients by offering ED patients an integrated set of services and innovations. It incorporates workforce education, training, and the creation of evidence-based geriatric- specific clinical protocols; informatics support for patient care; and structural enhancements to improve patient care, safety, and satisfaction.
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GEDI WISE has three goals: to improve the quality of emergency care received by patients >65 years old who present in the ED, to improve the overall health of our aging population, and to reduce health care costs which are congruent with the ACA’s “triple aim “(Berwick, Nolan, & Whittington, 2008). This is accomplished by decreasing hospitalizations, 30-day re-admissions, return ED visits, unnecessary diagnostic and therapeutic services, medication errors, adverse events, falls, and other avoidable complications of older adults. An important component of these innovations is a geriatric care transitions team consisting of nurse practitioners, social workers, a geriatric ED pharmacist who sees patients that take 10 medications or more, and ED physical therapy consults for patients at risk for falls. ED social workers have played a key role in coordinating post-ED services to facilitate the transition home. Other GEDI WISE innovations include multidisciplinary clinical rounding on geriatric patients, intensive training for all ED staff on the special needs of older adults, clinical decision support in the electronic medical record for performing screening such as Identification of Seniors at Risk (ISAR) and patient alert notifications to the GEDI WISE team through a regional health information organization (RHIO) that supports a health information exchange (HIE) (Hwang, Shah, Han, Carpenter, Siu, & Adams, 2013a; Gutteridge, Genes, Hwang, Kaplan, Shapiro, & GEDI WISE Investigators 2014). The HIE network allows for an exchange of medical records between institutions and provides an effective way to communicate patients’ information. As it is increasingly recognized by the interdisciplinary team that a large number of these older adult patients are complex cases involving an array of multilevel factors beyond the scope of diagnosis alone, particularly when it comes to discharge plans, (Auerbach, Mason, & LaPorte, 2007), the social worker is seen as playing a critical role and serves as an important member of the multidisciplinary team in assisting physicians in determining the disposition of these patients. The GEDI WISE interdisciplinary approach clearly appreciates the value of social work services in navigating the complexities of the discharge process and helping to transition ED patients home.
WHAT WE DID AND HOW IT EVOLVED The unique skill set and knowledge base of social work meshes well with GEDI WISE goals. The ED offers social workers an opportunity to work in what is often the front line of health care—the patient’s first contact with the hospital. Traditional social work roles, such as crisis intervention, discharge planning, patient and family counseling, and community resource linkages assume greater importance in the context of an ED. According to Moore, Ekman, and Shumway (2012), the ED is a “critical intervention point for
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patients with multiple unmet medical, psychological and social needs, and little or no contact with service providers” (p. 140). The ED environment can become over-stimulating and non-conducive to the wellness of ED patients, especially older frail patients. Within this environment, the immediacy of the problem, the pressure to act quickly to alleviate stress and to discharge patients to more appropriate settings to free up beds for more acutely ill patients all require rapid and innovative responses on the part of the social worker. The social worker’s intervention can be invaluable in situations fraught with emotional stress (Healy, 1981). For patients who may potentially return home, the timeliness of psychosocial and safety assessments as well as communication among staff are essential components to effective and safe discharge planning. Social workers at The Mount Sinai Hospital have had a strong presence in the ED, actively participating in programs that preceded GEDI WISE. For example, as an increased number of patients were frequently returning to the ED, most of whom had significant social needs, the ED recognized a need to address this issue. In 2009, social work collaborated with an ED physician to address this concern and co-facilitated the Novel Interdisciplinary Care for Emergencies (NICE) program. The NICE program focuses on patients who have three or more ED visits for three consecutive months. Although the NICE team is composed of interdisciplinary staff, it is led by social work. Meetings are held regularly to identify patients who meet NICE criteria. These patients are flagged in the ED electronic medical record by a social worker and on return of the patient to the ED, a referral to social work is triggered, and social work meets with the patient to for an in-depth assessment. By meeting with each patient during the ED visits, social work has been able to analyze the root cause for their return and to reduce overall ED visits of NICE patients. Another example of a program in which social work has been key is the Care and Respect for Elders with Emergencies (CARE) program (Sanon, Baumlin, Kaplan, & Grudzen, 2014). CARE was the idea of the former vice chair of Emergency Medicine. Volunteers are trained to work with older adult patients in the ED. These volunteers provide patients age 65 years and older, who are at high risk for avoidable complications (e.g., falls, delirium), with bedside visits and engage them in activities. The goal of CARE has been to prevent these avoidable complications. Under the direction of the former vice chair of Emergency Medicine, the ED social worker along with the other members of the CARE advisory team (the volunteer director, physicians, and nurses) were at the forefront in the development of this program as a pilot initiative in 2010 after The Mount Sinai Hospital received a grant from an individual donor. From the onset, ED social work had a pivotal role in identifying and training volunteers, and purchasing all the materials to be used with patients such as hearing amplifiers, reading glasses and stress balls. Social work also compiled a fall risk prevention safety
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packet which was distributed to the volunteers to use with the patients. As a result of this program being a highly successful pilot, The Mount Sinai Hospital applied for and was awarded a volunteerism grant in 2011. The grant included funding for a CARE director, and the ED physician leadership hired a social worker for this role (a new position in the Volunteer Department that was independent and separate from the ED social worker’s role). We believe that the selection of a social worker for this position was a testament to the appreciation of the work that the ED social worker did as CARE was being developed and executed. Subsequently, CARE, the leadership of an MSW in the Volunteer Department has thrived and has become a fundamental component of the GEDI WISE model. As both the NICE and CARE programs illustrate, social work has been integral to important planning discussions and has been a strategic contributor prior to and with the roll out of GEDI WISE. As ED social workers offered to take on these types of tasks, they continued to align with the goals of ED leadership. Participating in this way enabled social work to be visible and to be a steadfast contributor within the interdisciplinary team. All of this laid the groundwork for developing trust and gaining the confidence to become a valued partner of the team. The more the team believed they could rely on social work, the more frequently social work was invited to assume important roles on committee projects and was sought out for case consultation. This concept is evident today as new projects continue to emerge within the ED for older adult patients. Since the inception of GEDI WISE, three additional pilot initiatives for older adults have been developed. They include: Transport Plus; Project Connect (Connecting Neighborhood Elderly to Community-based Teams); and Advanced Care Planning. Transport Plus is a program in which emergency medical technicians (EMTs), as they are transporting patients to their homes after an ED visit or hospitalization, review the patients’ discharge instructions and assess the safety of the patients’ home environment. When the GEDI WISE physicians were rolling out Transport Plus, the lead physician reached out to ED social work and asked us to provide input regarding factors that should be considered to prevent falls and promote a safe environment. Any concerns in the home trigger a referral to social work, and social work has embraced the responsibility of following up with these patients in the community. Project Connect is a new initiative that expands the GEDI WISE model to patients who are discharged home from the ED by providing referrals to identified community-based organizations. The goal of this project is to create lasting linkages between patients and community resources by developing a plan of care and overseeing its implementation of connecting patients to community based programs (e.g., senior centers, physical activity programs). The GEDI WISE social workers are responsible for screening appropriate patients, collecting baseline data and referring patients to Project Connect.
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Advanced Care Planning (ACP) is a new home care intervention that began in December 2014 and is being piloted in the ED with a hospital partner home care agency. ACP targets patients with multiple chronic diseases, rather than only including end-of-life patients. The patient who meets the medical criteria for ACP also has to be receiving the services of a certified home health agency. Similar to our role in Project Connect, the ED social workers are responsible for identifying patients who are appropriate candidates for the ACP intervention. In their everyday practice, these initiatives lend themselves to social work roles that deal with a broad range of concerns that defy tidy categorizations. During the psychosocial assessments, ED social workers are cognizant of the longstanding as well as the newer ED initiatives and match patients to the programs that are best suited to meet their needs. ED interventions often require social workers to wear many hats on any given day (e.g., problem solver, clinician, adviser, therapist, bereavement counselor, and home care liaison; Sheafor & Horejsi, 2007). The continuous involvement and presence of social work has strengthened the transitions between the ED and patients’ community-based supports.
PATIENT SUCCESSES The best mechanism for delivering geriatric health care is an interdisciplinary team consisting of nursing, physician, social work, physical therapy, and pharmacy to address the medically complex needs of most geriatric patients (Blewett, Johnson, McCarthy, Lackner, & Brandt, 2010). As noted earlier, the ED social workers are continuously in the forefront of new initiatives that have derived from GEDI WISE and have been instrumental in assessing and referring patients to these new initiatives. Social workers have persevered over the many challenges and are cognizant of the changing needs of our elderly population. To support the GEDI WISE goal of enhancing the patient’s ability to function safely at home and in the community, the ED social workers own the task of ensuring that routine as well as innovative solutions are being rendered; this is accomplished through consultations with the patient, the family as well as various service providers. Developing, coordinating and implementing transitional solutions that are satisfactory to the both patient and institution is the social worker’s charge, and may be considered a successful outcome when there is an avoidance of an admission and/or decline in turnaround visits to the ED (Auslander, 2000). For example, on a Friday afternoon before Memorial Day weekend, a patient required sub-acute rehabilitation. Once the admission paperwork was completed, it was nearing 5:00 p.m. The extended hours of the social worker allowed the coordination of care for this patient. In working with a nursing home facility partner, social work was able to maintain contact with the facility
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after-hours and to advocate for admission from the ED to the sub-acute rehabilitation facility later in the evening. The patient was able to be placed and an unnecessary admission was avoided. If this had not occurred, the patient would have been admitted and remained in the hospital until the following Tuesday. The patient wished to be placed as soon as possible so it was a win–win for the patient and for both institutions. The ED social workers have been focused on navigating obstacles and providing soon-to-be-discharged patients with the tools and resources to ensure that their transition from hospital to home is well supported so they are less likely to return to the ED. Follow-up calls, have become an integral part of the transitional process, in which social workers and nurse practitioners have a pivotal role in preventing patients from returning to the ED for non-emergent matters. Success can come in different forms, but one such example is with a patient, Mrs. B. The social worker made a follow-up call to a Mrs. B. on the day after discharge. The patient stated she still felt ill, was unable to pick up her medication due to snow and icy sidewalks, and was thinking of returning back to the ED. Both the GEDI WISE nurse practitioner and social worker spoke with the Mrs. B. Arrangements were made for her pharmacy to deliver her medication to the home. The social worker was able to expedite Mrs. B.’s primary care physician appointment to the next day. The nurse practitioner believed this was a safe plan, and the patient felt secure with this plan and opted to continue with her follow-up care as an outpatient and not return to the ED. The social worker and nurse practitioner were able to provide optimal coordination of care and seamless transitions of care. Social workers have been effective in communicating patient needs to other disciplines. In the case of another patient, Mrs. L., social work was asked to meet with a patient with confusion who entered the ED. The patient’s medical record from a very recent hospitalization indicated that Mrs. L. was self-care and did not indicate a diagnosis of dementia. During this current ED visit, however, Mrs. L. was unable to recall earlier events of her day, unable to state how many or which medications she was taking or to provide a time frame when the medications were last taken. Her delirium led the medical providers to deem it unsafe for her to return home and listed the patient for admission for altered mental status. The social worker met at length with the patient, and with the patient’s permission, spoke to the patient’s daughter on the telephone. The daughter reported that the patient was usually very alert and the way she was presenting in the ED was out of character for her. The social worker communicated this information to the physician and to the ED pharmacist. They spoke with the patient’s daughter on the telephone while the medical team continued to review tests results and treat the patient. The pharmacist and ED physician determined that the Mrs. L.’s delirium was the result of a reaction to prescription medications that she was taking. With medical and nursing treatment, the patient’s delirium began to clear and the
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option of the patient’s returning home became a possibility. The pharmacist created a labeled pillbox and offered this to the patient. After a few hours, the patient was stabilized and ready for discharge. The social worker educated Mrs. L. about the home care process and options available to her. With the patient’s consent, the social worker made a home care referral for medication management. With the medical team reassured that the patient would have assistance at home with her medication management, they felt that home was a safe discharge plan and canceled the inpatient admission. In this example, the partnership of the social worker and pharmacist along with the medical team enhanced patient care and promoted better health outcomes due to increased adherence to medicine regimes (Fouche, Butler, & Shaw, 2013). Another result of successful efforts by social work and the GEDI WISE interdisciplinary team has been the ability to place patients directly into nursing homes from the ED, an option that was only in its infancy before GEDI WISE. Placement can be a lengthy process that requires the collaboration of several disciplines in order to have a successful outcome. There are many detailed steps involved in nursing home admission protocols and, by the time an accepting facility is secured, many hours may have passed. By refining the practice of direct placements through GEDI WISE, social workers were addressing the need to move patients quickly from the ED. The concept that “success breeds success” has been evident in the team’s agreement to place patients into facilities from the ED. When the ED physicians saw that social work could be successful with direct ED to nursing home placements, they were increasingly open to the possibility that this can occur and now even initiate this plan as the reason for referral to social work. Since the inception of GEDI WISE, with the collaboration of ED social workers, case managers, physical therapists, and clinical staff, we have been able to transfer 42 patients directly from the ED to a nursing facility for either sub-acute rehabilitation or custodial long-term care. Providing better care for our older ED adults has allowed us to also enhance care for ED patients under 65 years of age, and we have discharged an additional 13 patients under the age of 65 to facilities during this same time period. Another essential aspect to successful nursing home placement was the development of strong collaborative relationships with local nursing homes that were amenable to working with social work for this purpose. ED social workers made visits to these facilities so that they could speak with first-hand knowledge about them. Additionally, the ED social workers and nursing home staff jointly developed workflows to expedite the admission process. ED social workers apply critical thinking skills and work creatively with patients to do whatever it takes to get a patient discharged home safely (Bergman, 1976). For example, a patient was being treated on a Saturday in the ED and was ready for release back to his adult home residence. The physician made a referral for discharge planning to social work. The ED social worker tried to reach the residence listed in the admission paperwork. After
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several hours of no call-backs, the ED team was ready to write orders for the patient to be admitted. When the social worker learned of this, he said, “Please wait. I have one more thing to try.” His plan involved physically going to the address listed in the patient’s chart in pursuit of making face-toface contact with someone who had the authority to approve the patient’s return. The social worker was successful, and the patient was able to be discharged back to his residence that day. ED Administration applauded this out-of-the-box solution. The ED physician said, “I love social workers. You always have a Plan B and when we present you with a challenge, you present us with a solution. You’re incredible, and we couldn’t do what we do without you.” Hence, the training and advocacy along with the perseverance of the social workers in GEDI WISE are increasingly recognized by the interdisciplinary team as value-added.
SYSTEM SUCCESSES Social workers have developed ways to improve existing practices and to expand and initiate new interventions to better address the needs of our older adult ED patients. Starting with our older adult database of community resources, which is still a work-in-progress, social work identified a need to create a centralized document that contained geriatric resources to assist older adults with these health-related changes. The concept is to incorporate resources ranging from legal and pharmacy services, to adult day programs that can be accessed internally by the medical team and eventually accessed by the community. Social workers have met with the East Harlem Community Action Board to discuss ways to best educate patients about available community services for older adults. In addition, social work has internally revamped our assessment tool to capture the safety needs of older adult patients in the ED by focusing on risks at home and in the community. Flagging these conditions for further assessment allows the social worker to implement the most appropriate intervention for their patients (Fulmer, 2012). The social work component of the GEDI WISE model has also been expanded to the Mount Sinai Rapid Evaluation and Treatment Unit (RETU), a 20-bed observation unit, adjacent to the ED that opened in February 2014. The RETU is designed to allow physicians to monitor and treat selected patients over an extended period of time where they can undergo further monitoring or testing before doctors decide whether they should be released or admitted (Jaffe, 2014). Instead of defaulting to an admission in these subsets of patients, the ED will consider an observational status for patients. In the RETU, social workers use the same GEDI WISE assessment model and interventions for every patient >65 years old. The social worker’s focus is on identifying and addressing any potential issues that may be barriers for a patient to return to the community.
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Collaboration not only exists within our geriatric emergency department but with other hospital innovative programs at The Mount Sinai Hospital. The ED has partnered with Martha Stewart Center for Living, a primary care practice at The Mount Sinai Hospital that specializes in caring for older adults with complex health care problems. The purpose of this partnership is to initiate and expedite both initial and follow-up primary care appointments. The ED social workers also have a very close relationship with Preventable Admissions Care Team (PACT) and Mount Sinai Care, the Accountable Care Organization (ACO) and the Mount Sinai Health Home. Due to the hospital’s advanced streamline process of identifying patients who enter the ED, social workers can quickly refer patients to their outpatient social workers to ensure that the transitional follow-up plan is in effect. All of our programs share the goal of preventing unnecessary re-admissions and work closely together. ED social workers inform PACT, the ACO, and Mount Sinai Health Home social workers when a patient enrolled in one of these programs arrives in the ED, and the ED social workers are also alerted if PACT, the ACO, or Mount Sinai Health Home patients are on their way to the ED. This reciprocal communication between programs regarding patients who are currently in the ED promotes strong coordination of care and serves to enhance the patient experience. The hospital has also built community-based relationships with neighboring residential facilities, home care vendors, and local community centers in order to increase accessibility and coordinate care for our patients. Social workers have been instrumental in coordinating with these liaisons and are highly skilled at seeking creative solutions to ensure safe transitions for our patients. Working well together is necessary for good quality of care; as health care professionals, we need to be competent team members (McPherson et al., 2001) in order to accomplish GEDI WISE goals.
CHALLENGES The journey to a highly functioning system has not been without challenges which include educating a large ED staff, hiring the right additional staff, and defining interdisciplinary roles. The inception of GEDI WISE meant that interdisciplinary staff, including social work, needed to be educated on geriatric care, to be conscious of ageism and aware of effective ways to communicate with the older adults. In order for GEDI WISE to be launched successfully, this complicated task needed to be completed prior to the commencement of the program. It required allotting time for staff to receive this training and to be facile with GEDI WISE interventions and protocols. The GEDI WISE award included two additional social work positions. With the increased staffing, the social workers’ schedules were changed to
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meet the needs of our patients. Social work coverage schedules shifted from a Monday through Friday 9–5 work day to a 12-hour/7-day-per-week schedule. It was difficult to find the right social workers to hire for GEDI WISE. The need to work effectively in complex interdisciplinary teams, to work in a timeefficient manner (Moore et al., 2012) with “high risk older adults who require complex discharge planning” (McCusker, Roberge, Vadeboncoeur, & Verdon, 2009) takes on greater importance in GEDI WISE. The challenge became not only finding someone who possessed all of the qualifications needed for the position, who was able/willing to work on weekends, but also finding “the right fit.” We did not accomplish this during our first round of hiring. The initial set of social workers were not medical social workers and found it both challenging to work so closely with a non-MSW interdisciplinary team and overwhelming to working with a population that required a broad range of both concrete and short-term counseling services. We learned that a successful GEDI WISE social worker must be flexible, be able to navigate through the unpredictability of a day and shift their priorities frequently, as well as be committed to working with a population that requires multifaceted interventions. An ability to appreciate the importance of metrics and evidenced-based outcomes is also important. The GEDI WISE social worker needs to demonstrate leadership qualities and can “approach each encounter with an awareness and purposeful use of themselves as influential change agents” (Applegate, 1988). Additionally, to be successful in contributing to the accomplishment of GEDI WISE goals, the social worker has to be innovative and work within a model that is still evolving and in flux. We were eventually able to find “star” social workers; they are well-suited and excited to work with our older ED adults and have been dedicated to the unique needs of this population. As a result of this process, a great deal was learned. Although communication has always been a crucial component to effective planning, ED social workers had to learn the streamlined process that was put into effect via our internal electronic medical record system, known as EPIC. ED Social workers are able to identify and flag patients who are at high risk and make quicker referrals to our internal innovation programs. Working with older adults in a far-reaching manner, places the concept of comprehensive planning and home safety at the forefront of social work assessments. Attempting to minimize the overlapping of informational inquiries to our patients, especially between social workers and nurse practitioners was initially a challenge. Since the role of a nurse practitioner was a new concept in the ED, finding a way to work most efficiently with them has been a work in progress. Both disciplines wanted to ensure that the needs of the patients were being met, as much pertinent information was being gathered to conduct comprehensive assessments, and that the patient was able to obtain the appropriate referrals and resources for an effective discharge plan. For example, the question of who would ask about “activities of daily living and ability
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to manage at home, living environment” was relevant to both disciplines. It became evident that something needed to be corrected when patients would ask, “Why are so many people asking me the same questions. Why don’t you read my chart?” It was quickly realized that it would be more beneficial for the patient if both the social worker and nurse practitioner met with patients jointly to minimize repetition of information. When this was not feasible, a plan was devised in which the social worker would focus on the psychosocial aspects of care such as mental health issues, identifying social supports, financial management, and the home environment while the nurse practitioner focused on medical management and functional status such as mobility and activities of daily living. There is immediate, real-time social worker to nurse practitioner hand-offs (and vice versa) as well as daily ongoing communication between these two disciplines. Prior to GEDI WISE, group meetings were held on an as-needed basis. With GEDI WISE, social workers now formally collaborate with interdisciplinary partners during daily GEDI WISE ED rounds to discuss patient care. Social work is an integral part of addressing psychosocial barriers and challenges as well as the discharge planning process, and it has been apparent that social work’s input was a vital component during the daily discussions. As a team, it was decided that the meetings would be held at the same hour every week day. However, this initially presented a challenge to the social workers as it was difficult from a time-management perspective to accommodate a new daily meeting when their schedules were already packed. However, by having a consistent daily time and focus along with limiting rounds to a prescribed amount of time, these meetings were incorporated into the social workers’ daily routine. Occasionally, when social workers are involved in complex patient care interventions, social workers may alternate in attendance so as not to interrupt workflow or over-burden a colleague. The future of emergency care will require that ED staff recognize and understand that older adults have physiological and psychosocial problems that present differently than in a younger population. The older adult is susceptible to particular risks related to poly-pharmacy, depression, delirium, and inadequate assistance in managing their activities of daily living (Center for Medicare and Medicaid Innovation. Health Care Innovation Award project profiles, 2012; Hwang et al., 2013b). The Mount Sinai Hospital has provided comprehensive training on geriatric models of care and GEDI WISE program goals, screening tools, care protocols and data collection. Specifically, the social workers received additional training on topics such as: depression in the older adult; ageism and communication; transitions of care; the effects of care coordination on hospitalization; quality of care and health expenditures among Medicare beneficiaries; city, state and national resources available to older adults; and improving health outcomes with aging populations. These trainings have helped to promote conceptualization of the multifaceted problems our
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patients face and forward thinking on the part of our social workers in the areas of patient need, dispositions, transitions, and coordination of care. Our ED social workers have integrated this knowledge and assumed a leading role in discussing GEDI WISE interventions in educational forums at both a local and a national level such as webinars and conferences with others in field of social work. ED social workers have also volunteered to train medical residents on appropriate social work geriatric referrals and in defining the social work role, have provided a social work perspective to medical research students on older patients, and have presented to CARE volunteers and social work interns.
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CONCLUSION Funding for the GEDI WISE project will come to a close on June 30, 2015, and outcome data will be available after the project ends. The GEDI WISE model, however, will be the gateway for future expansion of this care model to potentially include high risk patients
