Emergency Department Care Coordination Program for Assisted Living Residents With Dementia: A Qualitative Study

Care transitions to the emergency department (ED) from assisted living centers (ALCs) for residents may include incomplete or inaccurate information during transfer. These transitions can be especially difficult for vulnerable populations, including persons living with dementia (PLWD).

To assess perceptions of complex care managers (CCMs) implementing a care coordination program designed to improve communication for transfers from ALCs to the ED.

This qualitative study analyzed semistructured video conference interviews with CCMs in February 2024. The ED early response program was available through a physician services group (Bluestone Physician Services), which provides care to residents in ALCs in Florida, Minnesota, and Wisconsin for patients in its accountable care organization. The physician services group identified the CCMs based on scheduling convenience. Data were analyzed in March and April 2024 using directed content analysis.

The ED early response program included electronic notification to the physician services group CCMs when a patient registered at an ED. CCMs then communicated via fax and telephone with the ED staff to provide key clinical information.

CCM-perceived strengths and weaknesses of the program.

Of 22 total CCMs, 12 participated in this study (employed as a CCM for a median [IQR] of 2 [1-3] years; 12 [100%] female) and identified populations that they perceived to especially benefit from the program, including PLWD, patients in hospice, and patients living in group homes. CCMs shared how they communicated with various ED staff, including nurses and physicians, and that receptivity varied among staff. Strengths of the program include CCM advocacy for patients and program adaptability. CCMs described areas of opportunity as lack of education about the program among ED staff and lack of 24-hour coverage for CCMs. Overall, the perception shared by the CCMs was that the program positively affected both the ED experience for patients and the facilitation of goal-concordant care.

In this qualitative study of a care coordination intervention, CCMs advocated for their patients remotely by filling information gaps, particularly for PLWD and patients in hospice, and perceived that the intervention was associated with improved patient care. CCMs also identified key areas for improvement, such as to increase ED staff awareness of the program and to expand program hours. This care coordination intervention may provide an opportunity to address gaps in care for individuals living in ALCs who present to the ED.