BLUESTONE’S EMERGENCY DEPARTMENT EARLY RESPONSE PROGRAM - Promoting High-Quality and Safe Transitions - Session tips and next steps

Sep 28, 2026

Uploaded by Rhys

Almost half of Assisted Living Community (ALC) residents transfer to the emergency department each year, and for people living with dementia, collecting medical history can be difficult, contributing to prolonged ED stays and increased risks such as delirium or hospital-acquired infections. A Bluestone Physician Services ED early response program sends complex care managers electronic Admission, Discharge, and Transfer (ADT) notifications when patients register at the ED. During business hours, managers call using a script and send structured follow-up by fax. Semi-structured interviews with 12 managers identified themes of likely benefits for dementia and hospice patients, strengths in Bluestone-ED communication, and weaknesses including variable staff awareness and challenges optimizing call and fax timing.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Background and problem context

ED early response program design

ADT notification workflow

Calling script and fax follow-up

Feasibility and acceptability findings

Themes: dementia/hospice benefits

Strengths: improved communication

Weaknesses: staff awareness and timing

Adaptations, learnings, and impact planning

Tips for integrating real-time ADT notifications

Next steps for evaluation

Innovation in Aging, 2025, Vol. 9, No. S2 179 Abstract citation ID: igaf122.597 BLUESTONE’S EMERGENCY DEPARTMENT EARLY RESPONSE PROGRAM: PROMOTING HIGH-QUALITY AND SAFE TRANSITIONS Grace Wittenberg1, Martha Etzell2, Peter Serina3, Nichole Stetten1, Ann Reddy1, and Ellen McCreedy4, 1. Brown University, Providence, Rhode Island, United States, 2. Bluestone Physician Services, Stillwater, Minnesota, United States, 3. Salem Hospital, Salem, Massachusetts, United States, 4. Brown University, School of Public Health, Providence, Rhode Island, United States Almost half of all Assisted Living Community (ALC) residents transfer to the emergency department (ED) each year. For people living with dementia (PLWD), providing a medical history can be a challenge, resulting in prolonged stays and risk of delirium or hospital acquired infections. Bluestone Physician Services developed a ED early response program in which complex care managers (CCM) receive an electronic Admission, Discharge, and Transfer (ADT) notification when one of their patients registers at an ED. If the notification occurs during business hours, the CCMs call the ED using a script and follow-up with a structured fax. We conducted semi-structured interviews with 12 CCMs involved in the program to assess the feasibility and acceptability of the program. There were five themes: patients with dementia and those on hospice were especially likely to benefit from the program; strengths of the program, including increased communication between Bluestone and ED providers; 180 Innovation in Aging, 2025, Vol. 9, No. S2 weakness of the program, including a lack of awareness of the program among variable ED staff and challenges with timing the call and fax to maximize benefit. The CCMs also shared some learnings and adaptations that increased contact rate over time and individual success stories. In this session, we will also provide tips on how to integrate real-time ADT notifications into CCM workflows. Next steps include examining the ED provider, patient and caregiver perceptions of the program, quantifying the impact of the program on utilization, and analyzing how the program would perform in other health care settings.

FAQs

Why does the program focus on assisted living residents with dementia?

Transfers to the emergency department are common, and dementia can make medical history collection challenging. The program targets this to reduce prolonged stays and associated risks like delirium or hospital-acquired infections.

How does the ED early response program work during business hours?

Complex care managers receive electronic Admission, Discharge, and Transfer (ADT) notifications. If the patient registers during business hours, managers call the ED using a script and complete structured fax follow-up.

What challenges limited the program’s effectiveness according to care managers?

Care managers reported a lack of awareness of the program among variable ED staff. They also noted difficulties with timing the call and fax to maximize benefit.

Sep 28, 2026

Uploaded by Rhys