A Comparison of Emergency Medical Service Utilization in Assisted Living and Long-Term Care Facilities

The US population is projected to rise from just under 319 million people in 2014 to approximately 417 million people by 2060. Based on this prediction, the percentage of adults aged 65 and older is expected to increase from 15% to 24% during this time period.¹ Options for community-based residential care have expanded with the growth in this population. Assisted living facilities (ALFs) provide one option for individuals requiring assistance with personal care services, health-related services, room and board, or additional supervision.

The growth rate of this housing sector has risen—ALFs contributed to 75% of all new senior housing in 1998.² Many retired Americans favor the lower costs, home-like surroundings, and social care model of ALFs compared with the traditional medical model of a long-term care facility (LTCF). Based on 2012 data from the National Study of Long-Term Care Providers, approximately 713,300 of older Americans reside in the ALF setting.^3,4 Accordingly, the demographic and health-related composition of individuals residing in ALFs and LTCFs has become more interchangeable, however, this sector remains poorly described. Specifically the emergency health care utilization practices and experiences of this population have not been well documented in medical literature. Hospitalization poses a risk to frail older adults. Those with baseline functional impairment are at heightened risk for the development of iatrogenic syndromes such as falls, delirium, and pressure ulcers. In some cases, hospitalizations are potentially avoidable.^5,6 Accordingly, health systems and individual health care institutions have studied interventions aimed at preventing unnecessary utilization of the emergency department (ED) and other acute care services.⁷

When compared to data on ALF emergency service utilization, data from the LTCF population is more robust. Older adults in LTCFs are high users of emergency care services such as ambulance transport and diagnostic testing and have longer ED lengths of stay.⁸ LTCF residents are 80% more likely to be admitted to the hospital after presenting to the ED.⁸ Despite the demographic changes mentioned, there are few published studies characterizing ED use among ALF residents. A better understanding of the differences and similarities between ALF and LTCF residents utilizing emergency services could highlight more strategies to improve the quality and value of acute care delivered to older adults.

In this study, we sought to describe and compare the emergency care experiences and comorbidity characteristics of ALF residents vs LTCF residents by analyzing electronic medical records (EMRs) and ambulance transport records of residents taken to a large ED in the residential area. With a clearer understanding of ALF residents’ emergency services utilization, providers may be able to develop more tailored unnecessary hospitalization prevention strategies for this vulnerable population.

Methods

Participants and Study Design

This cohort study was performed solely via review of patient data abstracted from preexisting patient care reports and medical records. The study protocol was submitted to and approved by the Mayo Clinic Institutional Review Board.  

Data was taken from a larger retrospective cohort study, conducted between January 2012 and June 2015, that included adults aged 65 years and older who had transferred to a large ED of an academic medical center hospital from residential care facilities within Olmsted County, MN, via ambulance. In July 2015, Olmsted County had an estimated population of 151,436, 14% of whom were aged 65 years or older.⁹ The chosen ED—one of two EDs in the county—is the largest, a 51-bed facility that annually provides care for over 75,000 people.¹⁰ Olmsted County emergency ground transportation responds to over 65,000 emergency calls each year.¹¹

Specific data of LTCF and ALF residents who presented to the ED over a 3-year period from 2012 to 2015 were analyzed for the current study. Emergency transportation records of Olmsted County ambulance service and hospital EMRs were used to compare characteristics of ALF and LTCF residents. Elective and planned transfers to the hospital were excluded. EMR data included patient demographics, comorbidities, and length and outcome of hospital stays. Fall risk was recorded by the Hendrich Falls Risk Model documented by the nursing staff on admission to hospital.¹² The presence of advanced care directives or a Physician’s Orders for Life-Sustaining Treatment (POLST) in the EMR was also considered.¹³

Data Analysis

Demographic and health outcomes data were compared using univariate analysis with Pearson chi-square analysis for categorical variables (ie, sex, marital status, comorbid conditions, primary care physician [PCP] assigned, advance directive data) and logistic regression for continuous variables (ie, health service utilization). A value of P < .05 was considered significant. Multivariate analysis was also performed with categorical variables assigned number and frequencies. All analyses were conducted using JMP statistical software (SAS Institute Inc, Cary, NC).

Results

Table 1 shows a complete breakdown of the resident demographics, service utilization, and clinical conditions of the populations studied.

Demographics

Twenty-one individuals were excluded from this study on the basis of elective or planned transfers to the ED or incomplete data recorded. A total of 43 patients were included in the final cohort of residents who visited the ED, from 12 different ALFs and seven different LTCFs. Of these 43 residents, 28 individuals were ALF residents (65%) and the remaining 15 patients resided in LTCFs (35%). The median (interquartile range) age of ALF residents was 86 years (79 to 91); LTCF residents were slightly younger with a median age of 79 years (72 to 89). There were an equal number of men and women within the ALF group. Most (n = 10, 67%) of the LTCF residents included were female.

Health Service Utilization

Review of EMRs regarding health service utilization between resident groups who visited the ED revealed that a designated PCP could not be identified in 43% of ALF residents
(n = 12). In the ALF group, 29% of residents (n = 8) were admitted to hospital during weekend/after-hours compared with 20% of LTCF residents (n = 3). The mean number of ED visits in the month prior did not differ significantly between the two groups, as shown in Table 1.

Comorbid Conditions

Review of medical comorbidities between resident groups who visited the ED showed that dementia, cancer, heart failure, coronary disease, and depression were commonly represented. In ALF residents, 43% (n = 12) had a history of non-skin malignancy compared with 27% of LTCF residents (n = 4). A diagnosis of heart failure was present in 36% of ALF residents (n = 10) compared with 20% of LTCF residents (n = 3), with similar proportions also diagnosed with coronary artery disease. Almost half of the patients included in the study were diagnosed with depression, 39% of those in ALF (n = 11) and 67% of those in LTCF (n = 10). Both cohorts had a similar risk of falls as per the Hendrich Falls Risk Model. A diagnosis of dementia was carried by 64% of ALF residents
(n = 18) and 33% of LTCF residents (n = 5).

Documentation of advance directives was recorded from the EMR, with 74% of ALF residents (n = 20) and 67% of LTCF residents (n = 10) having an advance directive on file. Of all residents in study, most of them (n = 32, 74%) did not have a documented POLST.

Discussion

In this small cohort of ED users from residential care facilities, residents of both ALFs and LTC facilities were similar in age and pattern of comorbidities. Although not statistically significant, it was observed that ALF residents tended to be older, be more medically complex, and have greater emergency care use than LTCF residents.

It is noteworthy that, even accounting for the small sample size, the data shows a trend for high medical complexity, particularly in the ALF cohort. This population was observed to have multimorbidity with coexisting conditions including heart failure, coronary artery disease, and depression. A recent large study in British Columbia showed a similar trend wherein a significantly higher rate of ED use by ALF residents was found compared with nursing home (NH) residents.¹⁴ Clinicians have previously commented on the challenges of monitoring ALF patients given that residences are often private and lack trained nursing staff and nighttime cover.¹⁵ As a result, these facilities are often limited in terms of evaluation and subsequent management plans that could be administered in the “community setting” and are left with little alternative to the ED. 

Data findings show that one-third of visits from ALFs to the ED occurred during weekends and after traditional clinic hours. Traditional primary care medical models featuring ambulatory clinic hours (8 am to 5 pm) may not meet the current and future needs of medically complex older adults. Groenewegan and colleagues describe crucial attributes of high-quality primary care to include person-centered accessibility, coordination of care, integration (across the health delivery system), and continuous care (between the patient and PCP).¹⁶ These features are even more essential among complex older patients at high risk for health deterioration. Traditional health care delivery systems designed for healthier individuals with single medical diagnoses fail to address the complex medical and social support challenges that many residential care residents struggle with. This is particularly relevant for older individuals with dementia for whom continuity of care has already been shown to impact health care utilization and cost.¹⁷ Innovative dementia care programs based around dementia care planning and caregiver support may offer an alternative care paradigm.¹⁸ Other emerging models of care featuring geriatricians working within interdisciplinary primary care teams, either as consultants or PCPs, have been shown to reduce use of medical services and delay time to NH placement.¹⁹ These models may work well with the ALF population as well. 

In this study, the proportion of patients with dementia in the ALF cohort was higher than previously reported data and warrants attention.²⁰ This finding is similar to another study, which also found higher rates of hospitalization among residents with dementia living in ALF vs those in LTCFs. Their finding was attributed to greater nursing demands, inability to provide certain therapeutic interventions, and progression to more dependent physical state,²¹ which could have significant implications for clinical practice in the region of this study. Dementia diagnosis is a common reason for the initial move to an ALF or LTCF, particularly where there has been a precipitating event such as a hospitalization or an acute medical event.²² This growing and already medically vulnerable population will need closer attention as it makes increased demands on the health care system, particularly in the case of the ALFs. 

In this study, much of the ALF cohort did not have a designated PCP documented in the EMR nor a recorded advance directive despite their high risk for health deterioration. Without an advance care plan or longitudinal care provider familiar with their conditions and care preferences, it could be postulated that a proportion of visits to the ED could have been avoided. It should be noted that, according to NH regulation in Minnesota, it is not a requirement for a NH resident to have an advance directive in place. State regulations only say that providers should include advance directive details in their records if available.²⁰ But Minnesota statute states that NHs must ensure that each resident has a designated physician appointed to oversee medical care during their stay in the facility.²³ The designated physician serves as a safety net and advocate for the resident. Yet, as mentioned above, many ALF residents in this study did not have such an advocate. ALF residents have a critical need for a longitudinal care provider, familiar with their medical history, health care preferences, and wishes, but a startling proportion of the ALF cohort had no identifiable physician or advance practice provider. 

Currently, there are no financial incentives for either ALFs or LTCFs to participate in studies aimed at prevention of potentially avoidable emergency service utilization. This is due to change soon for LTCFs; they may incur financial penalties for readmissions to hospital as a result of the Protecting Access to Medicare Act of 2014, part of which allows for skilled nursing facilities to be accountable for 30-day readmissions.²⁴ However, penalties will not be applied to ALFs, even though these communities are continuing to grow and become home to greater numbers of older individuals with significant care needs. Despite the lack of urgency impending penalties inspire, providers should still aim to develop strategies to improve the provision of medical care in the ALF population in order to reduce costly unnecessary hospitalizations, ED visits, and readmissions for ALF residents. Improvement strategies may come in the form of alternative care models, like those noted previously, or through innovative interventions such as telemedicine in ALFs, which has been shown to be successful in reducing annual ED use in some senior living communities.²⁵ 

Some study limitations should be addressed, the most notable of which is the small sample size; as data was obtained from retrospective review of ambulance records, this limited the sample size. Also, patients transferred to the other smaller ED in Olmsted County or those who arrived via other transportation were not identified. Recent research has noted that a small but still significant number of older adults in residential care facilities such as ALFs are also current drivers, so it is possible this would have added to the numbers.²⁶ A further limitation worth observing is that most of the older population in Olmsted County is of white race and European ancestry impacting the generalizability of the data to other populations across the United States (this data on ethnicity/race was not able to be included in the study as it was not reliably collected for the study cohort). The strengths of this study lie in the robust and unified EMRs, which permitted access to clinical and demographic data as well as nursing assessments and advance directive data. 

Conclusion

This study serves as an initial look at the characteristics of ED service users from ALFs and LTCFs in Olmsted County, MN. New ALFs are opening daily across the United States and house a burgeoning population of medically complex individuals. These findings provide insights into the chronic conditions, such as dementia and heart failure, that providers need to target in these facilities, and in the ALF population in particular, to attempt to better coordinate care and reduce potentially avoidable ED visits. 

References

1. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014-2060, Current Population Reports. U.S. Census Bureau, Washington, DC;2014.

2. Spitzer WJ, Neuman K, Holden G. The coming of age for assisted living care: new options for senior housing and social work practice. Soc Work Health Care. 2004;38(3):21-45.

3. Harris-kojetin L, Sengupta M, Park-Lee E, Valverde R. Long-term care services in the United States: 2013 overview. Vital Health Stat 3. 2013;37:1-107.

4. Caffrey C, Harris-Kojetin L, Rome V, Sengupta M. Characteristics of residents living in residential care communities, by community bed size: United States, 2012. NCHS Data Brief. 2014(171):1-8.

5. Ouslander JG, Naharci I, Engstrom G, et al. Lessons learned from root cause analyses of transfers of skilled nursing facility (SNF) patients to acute hospitals: transfers rated as preventable versus nonpreventable by SNF staff. J Am Med Dir Assoc. 2016;17(7):596-601.

6. Walsh EG, Wiener JM, Haber S, Bragg A, Freiman M, Ouslander JG. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and home- and community-based services waiver programs. J Am Geriatr Soc. 2012;60(5):821-829.

7. Ouslander JG, Bonner A, Herndon L, Shutes J. The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc. 2014;15(3):162-170.

8. Wang HE, Shah MN, Allman RM, Kilgore M. Emergency department visits by nursing home residents in the United States. J Am Geriatr Soc. 2011;59(10):1864-1872.

9. United States Census Bureau. QuickFacts: Olmsted County, Minnesota. US Census Bureau website. https://www.census.gov/quickfacts/fact/table/olmstedcountyminnesota/PST045216. Updated July 1, 2016. Accessed September 20, 2017. 

10. Mayo Clinic. Mayo Clinic website. https://www.mayoclinic.org/. Accessed September 20, 2017.

11. Mayo Clinic. Patient and Visitor Guide: Mayo Clinic Medical Transport. Mayo Clinic website. https://www.mayoclinic.org/patient-visitor-guide/medical-transport/emergency-ground-transport-gold-cross. Accessed September 20, 2017.

12. Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16(1):9-21.

13. Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012;79(7):457-464.

14. McGregor MJ, McGrail KM, Abu-Laban RB, et al. Emergency department visit rates and patterns in Canada’s Vancouver coastal health region. Can J Aging. 2014;33(2):154-162.

15. Sloane PD, Zimmerman S, Perez R, et al. Physician perspectives on medical care delivery in assisted living. J Am Geriatr Soc. 2011;59(12):2326-2331.

16. Groenewegen PP, Dourgnon P, Gress S, Jurgutis A, Willems S. Strengthening weak primary care systems: steps towards stronger primary care in selected Western and Eastern European countries. Health Policy. 2013;113(1-2):170-179.

17. Amjad H, Carmichael D, Austin AM, Chang CH, Bynum JP. Continuity of care and health care utilization in older adults with dementia in fee-for-service Medicare. JAMA Intern Med. 2016;176(9):1371-1378.

18. Tan ZS, Jennings L, Reuben D. Coordinated care management for dementia in a large academic health system. Health Aff (Millwood). 2014;33(4):619-625.

19. Phelan EA, Balderson B, Levine M, et al. Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative. J Am Geriatr Soc. 2007;55(11):1748-1756.

20. Overview of assisted living: A collaborative research project of AAHSA, ASHA, ALFA, NCAL & NIC. Stratton Publishing & Marketing Inc; 2009.

21. Sloane PD, Zimmerman S, Gruber-Baldini AL, Hebel JR, Magaziner J, Konrad TR. Health and functional outcomes and health care utilization of persons with dementia in residential care and assisted living facilities: comparison with nursing homes. Gerontologist. 2005;45 Spec No 1(1):124-132.

22. Rockwood J, Richard M, Garden K, Hominick K, Mitnitski A, Rockwood K. Precipitating and predisposing events and symptoms for admission to assisted living or nursing home care. Can Geriatr J. 2014;17(1):16-21.

23. Minnesota Administrative Rules, Chapter 4658, Nursing Homes. 2016; https://www.revisor.mn.gov/rules/?id=4658. Accessed September 22, 2017.

24. Carnahan JL, Unroe KT, Torke AM. Hospital readmission penalties: coming soon to a nursing home near you! J Am Geriatr Soc. 2016;64(3):614-618. 

25. Gillespie SM, Shah MN, Wasserman EB, et al. Reducing emergency department utilization through engagement in telemedicine by senior living communities. Telemed J E Health. 2016;22(6):489-496.

26. Lum HD, Ginde AA, Betz ME. Older adult drivers living in residential care facilities. Ann Longterm Care. 2015;23(7):21-26.