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A QUALITY IMPROVEMENT INITIATIVE: Specialized Staff and a Dedicated ER Target Geriatric Patients Programs Reduce Hospital Admissions

Butcher, Lola

doi: 10.1097/01.NT.0000438838.77265.d6
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The article features two programs that aim to reduce hospital admissions and readmissions for elderly patients with cognitive issues: a senior emergency room (ER) that aims to make an emergency visit easier on the patient, thereby reducing the need for admission to the hospital, and a case management approach to help patients avoid the need for an ER visit in the first place.

As hospitals seek ways to improve the holistic care they deliver, innovative programs are being developed to target geriatric patients with Alzheimer's disease and other dementias — for good cause.

The total health care payments for US patients with dementia will exceed $203 billion this year, according to the Alzheimer's Association. The per-person health care and long-term care costs for Medicare patients with dementia topped $45,000 in 2008 — three times more than the costs for those without dementia.



One reason, said Luis Allen, MD, a psychiatrist at Florida Hospital in Orlando, is that health care services are not organized in the best way to help patients with dementia and their family caregivers.

As care for patients with dementia becomes more challenging — or cognitive decline exacerbates heart disease, diabetes, and other comorbidities that are common in that patient population — overwhelmed family members frequently head to the emergency room (ER) for help with a crisis. The ER visit, which can mean several hours in a chaotic waiting room, may add to the patient's distress, leading to a hospital admission.

To break that cycle, some hospitals are creating “senior ERs” that make an emergency visit easier on the patient, thereby reducing the need for admission to the hospital. Others are using a case management approach to help patients avoid the need for an ER visit in the first place.

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Before Florida Hospital opened its Maturing Minds Clinic in July 2012, the 30-day readmission rate for patients with dementia was 23.2 percent. A year later, the rate for patients served by the new clinic was 0 percent.

The key, Dr. Allen said, is providing a “one-stop shop” where patients with dementia and their family members can access care from a wide range of specialists and community resources, and receive the emotional support they need.

“In this day and age, we are all trying to move to more coordinated care, and that is what this offers,” he said.

The idea for the clinic emerged when Dr. Allen and others recognized patients with dementia frequently did not use community resources that could help address their challenges and that, even when home health services were in place, they did not get proper follow-up care after a hospital discharge. The result was a high rate of potentially avoidable readmissions.

The Maturing Minds Clinic targets patients with moderate dementia who suffer sleep disturbances, paranoia or other behavioral problems, as well as medical conditions that are exacerbated by their neurological condition.

The clinic team includes a geriatric psychiatrist, neuropsychologist, a behavioral specialist, neurologists, geriatricians, social workers, and an intake specialist, but the point person is the clinical coordinator — a nurse practitioner who is also a certified case manager with experience in geriatrics.

“The critical part [to making this work] is very simple; it's the clinical leader,” Dr. Allen said. “Sometimes that person is the only thing that helps the family member feel reassured in taking their loved one home.”

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As the clinical coordinator at the Florida Hospital Maturing Minds Clinic, Lloyda Baxter-Rose's role is to navigate patients and their caregivers through the medical system and provide ongoing support and education to patients and their families.

When a patient is accepted to the program, Baxter-Rose gathers and reviews his or her medical records and laboratory reports to learn about the patient's physical, psychological, and neurological conditions. She uses that information to initiate a care plan that prioritizes the patient's needs and she schedules their evaluation appointments accordingly.

“I am present at all specialist appointments with the patient's records so I'm able to communicate any concerns or issues to everyone on the team,” she said. “I'm with them the entire time, from the moment we speak on the phone all the way until the patient is stabilized.”

Her work often entails identifying and addressing barriers to care that may exist or may be overlooked. For example, when Baxter-Rose recently accompanied a patient and family caregiver to an appointment with a geriatrician, she learned that the patient's caregiver was allowing the patient with dementia to self-administer a medication that Dr. Allen, the psychiatrist, had prescribed. It was unclear if the patient was taking the prescribed dosage and the geriatrician was unable to determine if the medication was alleviating the symptoms Dr. Allen was trying to address.

“There's a conflict between the patient who still wants independence and the family member who doesn't want to overstep boundaries and cause any more chaos and animosity,” Baxter-Rose said. “At that point, we have to look at culture, too. In her culture, most patients will follow direction from medical experts as opposed to their family members. I recommended that we arrange a Spanish-speaking homecare nurse and the patient agreed.”

It is also possible that the patient has trouble swallowing the medicine. So Baxter-Rose also arranged for a speech therapist to test her ability to swallow.

The homecare nurse is specifically assigned to ensure that the patient is getting the proper medication dose; Dr. Allen can then determine if the medication is working as intended.

In addition to overseeing the care plan, Baxter-Rose is alerted every time one of the Maturing Minds Clinic patients visits an emergency department within the Florida Hospital System. She connects with the hospital team and the family caregivers to help with the transition to home or nursing facility.

“When a patient is discharged from the hospital, they receive discharge instruction follow-up, but where do they start?” she said. “I come in and inform them, ‘this is where we should start, and this is what we need to do.’”

If a patient has not filled all prescriptions, she finds a way to get the medications. Or if a patient is homebound and the caregiver is unable to transport them to their follow-up medical appointment, Baxter-Rose arranges for the geriatric team home visit.

Her other role is to be a coach and a sounding board for overwhelmed family caregivers who need emotional support.

“Our caregivers call me all the time, and I'm able to answer their questions, encourage and empower them, or sometimes they just need me to sit and listen, to give them a half hour to vent and talk about the disease,” she said.

Dr. Allen and his colleagues started the Maturing Minds clinic because they realized that about 20 percent of Florida Hospitals' neurology inpatients exhibit behavioral problems that present challenges for their caregivers after they are discharged.

The clinic was established with a grant from Florida Hospital, which sought to reduce avoidable readmissions and improve the support available to patients with dementia.

The clinic's caseload is approximately 60 patients; if it grows beyond 100, additional nurse practitioners will have to be added, Dr. Allen said.



The most important success factor for the clinic is having the right clinical leader. “It has to be one person that feels comfortable dealing with behavioral issues, but also to have that medical geriatric background,” he said.

Another key to success is partnerships with organizations that already provide resources, such as caregiver education and home health services, for patients with dementia. The Maturing Minds team ensures timely access services and specialty care.

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In Northeast Ohio, two small hospitals — Bedford Medical Center and Richmond Medical Center — are using a different approach to prevent avoidable hospitalizations among their elderly patients. The two facilities, both part of the University Hospitals system, created a “Senior ER” designed to make the emergency visit less upsetting and help hospital staff assess and address the full range of patient needs.

Instead of sitting in a noisy waiting room, seniors who arrive at the ER at these hospitals are ushered into a quiet room with soft lighting, non-glare flooring, and special mattresses that are comfortable for people with arthritis and other conditions.

Both hospitals are located in communities with a high population of seniors, said Kim Kinder, a geriatric nurse practitioner at Bedford's Senior ER. She works with a social worker to provide age-sensitive care while identifying both health and social problems.

“They may have mobility issues, cognitive issues, and some family issues, and we want to make sure that we are hitting all of those issues in the brief amount of time we have in the ED,” she said.

Every patient aged 65 or older is screened using the Triage Risk Screening Tool (TRST) to identify challenges they may face, such as cognitive impairment, difficulty walking, or the use of five or more medications.

According to a 2003 paper in the journal Academic Emergency Medicine, older ED patients with two or more risk factors identified by TRST are at significantly increased risk for subsequent ER use, hospitalization, and nursing home admission within 30 days.

Having a social worker in the ED helps avert some admissions, Kinder says. For example, some patients do not need to be hospitalized, but they do need immediate assistance in finding a nursing home placement, arranging for home health care, or getting a walker or wheelchair to avoid falls.

For those patients who do avoid admission, Kinder or the social worker follows up with a telephone call in the next two days to see how they are doing and what additional support they need.

“This is all geared towards helping the families who are helping the patients to meet their needs,” she said.

This article is part of a continuing series of articles on quality improvement initiatives in neurology. The full archive of the series is available here:



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•. Meldon SW, Mion LC, Palmer RM, et al. A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 2003; 10(3):224–232; E-pub 2003 Jun 28.
    •. The Triage Risk Screening Tool:
      •. The Maturing Minds Clinic:
        © 2013 American Academy of Neurology