The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more “palliative care triggers” on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

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Preliminary report of a palliative care and case management project in an emergency department for chronically ill elderly patients.

The number of chronically ill and disabled elderly people with complex medical, psychosocial and financial needs is rapidly growing The elderly population has been steadily increasing in the United States due to the efforts of modern medicine and disease prevention techniques The elderly will now live for three to six years prior to death with increasing levels of disability (Fried, 2002) The US health-service was designed several decades ago when life expectancy was shorter and the duration of disability before death was brief Its emphasis on curative and disease focused interventions is poorly aligned with the complex healthcare needs of the elderly and their caregivers Shorter lengths of stay in acute care hospitals and limitations in eligibility to even the most basic levels of homecare render frail elderly patients more susceptible to the complications of multiple competing chronic illnesses Increased disability, poly-pharmacy, strained resources and caregiver systems, limited knowledge and precarious decisional capacity are complications not addressed by traditional models of health-service, thus resulting in episodic, unplanned delivery of service and preventable hospitalizations with a focus on individual diagnoses In order that elderly patients may be better served, complex case management models will need to be integrated into primary care delivery and specialty palliative care programs across multiple healthcare settings In this chapter we will describe the demographic data that support the development of such models and some of the key elements that are integral to the provision of case management to elderly patients at the end-of-life

https://link.springer.com/content/pdf/10.1007%2F978-0-387-70875-1_11.pdf

Franca Martino-Starvaggi

Papers

Palliative Care and the Elderly: Complex Case Management