In spite of the shifts in health care emphasizing community and ambulatory services, the emergency department (ED) continues to be a portal of entry into the health care system for many ill elderly and use of the ED is often a sentinel event marking increased frailty, decline, and institutionalization. The present study proposes to formally evaluate a recently awarded Robert Wood Johnson clinical demonstration grant (SIGNET), based in the ED, aimed at maintaining frail elderly in the community setting.
The aims of this proposed study are to compare the effectiveness of usual ED care (UC) to the comprehensive case finding, community linkage ED intervention (SIGNET) on the following outcomes: subsequent ED use, unplanned hospitalizations, and/or nursing home services and community service use. The secondary aims include comparisons of the UC and SIGNET groups on perceived health status; satisfaction; and costs. Other secondary aims include identifying the feasibility, sensitivity, and specificity of the screening processes and identifying individual predictors for utilization of community services. The proposed study is a randomized controlled trial of 800 subjects, who are 65 years of age or older, enter the ED and are discharged back to the community setting. The study will take place at two ED sites. All subjects will undergo and eligibility screening and then randomized to UC or SIGNET. All subjects will receive a baseline evaluation. Those randomized to UC will receive standard ED care. Those randomized to SIGNET will, in addition to standard ED care, receive a comprehensive geriatric assessment by a master's prepared geriatric nurse specialist, who will identify unmet geriatric health and social service needs. Based on the comprehensive assessment, referrals to liaison personnel from the participating community agencies will be made. All subjects will receive two follow-up telephone interviews at one and three months post index ED visit to determine ongoing health services utilization, function, and satisfaction. The advantages of this study is the opportunity to evaluate a funded intervention program, identify triage risk screening measures to identify at-risk elders in the ED, and to identify factors influencing utilization of subsequent health care services, ranging from ED visits to home care visits.
