Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: The SIGNET model

Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve cas e finding of at-risk older adults and provide comprehensive assessment in t he ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at-risk older ED patients, ( 2) improve care planning and referral for those returning home, and (3) cre ate a coordinated network of existing medical and community services. The f our sites are a 1,000-bed teaching center, a 700-bed county teaching hospit al, a 400-bed community hospital, and a health maintenance organization (HM O) ED site. Ten community agencies also participated in the study: four age ncies associated with the hospital/HMO sites, two nonprofit private agencie s, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical n urse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary p hysicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully i mplemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding an d community linkage programs for at-risk older adults are feasible in the E D setting.