Feasibility of Care Coordination to Reduce Unnecessary Hospitalization For Assisted Living Residents

TL;DR

This study explores how care coordination in assisted living communities can help reduce unnecessary hospital visits for residents, especially those with dementia.

Contribution

The study introduces and evaluates a care coordination program to reduce hospital admissions for assisted living residents during emergency department visits.

Findings

Care managers successfully communicated with emergency departments for 44% of dementia-related visits and 40% of non-dementia visits.

Self-reported hospital avoidance rate was 11%, suggesting potential for reducing unnecessary admissions.

Most eligible visits (82.5%) were identified through electronic notifications, while 17.5% required direct communication.

Abstract

Almost half of Assisted Living Community (ALC) residents visit the emergency department (ED) yearly, experiencing more visits and longer stays compared to community-dwelling older adults. People living with Alzheimer’s disease and related dementias (ADRD) are at greater risk for delirium, falls, and accelerated decline associated with increased ED visits. Each transition provides an opportunity for care coordination and avoidance of unnecessary hospital admission. Bluestone Accountable Care Organization developed ED Early Response, a care coordination program. Care managers provide timely, structured information to ED providers via phone and fax within 120 minutes of ED registration. We assessed the feasibility of, and adherence to, the program. Between November 2023 and June 2024, we enrolled 1,376 patients with 1,989 eligible ED visits (mean: 1.4 visits per patient), 1,237 ED visits for patients with ADRD and 752 ED visits for patients without ADRD. Qualifying visits occurred during working hours (8 a.m. - 4 p.m.), with 82.5% of visits (n = 1,641) identified via electronic admission, discharge, and transfer notifications, and 17.5% of visits (n = 348) identified through direct communication between ALCs and care managers. Care managers successfully provided real-time information to ED providers for 44% of the eligible ED visits (547 of 1,237) for patients with ADRD, and for 40% of visits (304 of 752) for patients without ADRD. Care managers self-reported a hospital avoidance rate of 11%. While adherence was lower than anticipated, early structured communication could reduce unnecessary hospital admissions for ALC residents.