FEASIBILITY OF CARE COORDINATION TO REDUCE UNNECESSARY HOSPITALIZATION FOR ASSISTED LIVING RESIDENTS

Sep 28, 2026

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Almost half of Assisted Living Community (ALC) residents visit emergency departments annually, with more visits and longer stays than community-dwelling older adults. Alzheimer’s disease and related dementias (ADRD) increase risks such as delirium, falls, and accelerated decline linked to ED use. Bluestone Accountable Care Organization implemented ED Early Response, a care coordination program delivering structured information to ED providers within 120 minutes. Feasibility and adherence were assessed between Nov 2023 and Jun 2024 across eligible ED visits.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Abstract

Background and Rationale

Intervention: ED Early Response

Methods and Enrollment

Feasibility and Adherence Findings

1232 Innovation in Aging, 2025, Vol. 9, No. S2 Abstract citation ID: igaf122.4120 FEASIBILITY OF CARE COORDINATION TO REDUCE UNNECESSARY HOSPITALIZATION FOR ASSISTED LIVING RESIDENTS Ann Reddy1, Laura Dionne1, Grace Wittenberg1, Peter Serina2, Nate Hunkins3, Martha Etzell3, Aimee VanDenberghe3, and Ellen McCreedy4, 1. Brown University, Providence, Rhode Island, United States, 2. Salem Hospital, Salem, Massachusetts, United States, 3. Bluestone Physician Services, Stillwater, Minnesota, United States, 4. Brown University, School of Public Health, Providence, Rhode Island, United States Almost half of Assisted Living Community (ALC) residents visit the emergency department (ED) yearly, experiencing more visits and longer stays compared to community-dwelling older adults. People living with Alzheimer’s disease and related dementias (ADRD) are at greater risk for delirium, falls, and accelerated decline associated with increased ED visits. Each transition provides an opportunity for care coordination and avoidance of unnecessary hospital admission. Bluestone Accountable Care Organization developed ED Early Response, a care coordination program. Care managers provide timely, structured information to ED providers via phone and fax within 120 minutes of ED registration. We assessed the feasibility of, and adherence to, the program. Between November 2023 and June 2024, we enrolled 1,376 patients with 1,989 eligible ED visits (mean: 1.4 visits per patient), 1,237 ED visits for patients with ADRD and 752 ED visits for patients without ADRD. Qualifying visits occurred during working hours (8 a.m. - 4 p.m.), with 82.5% of visits (n = 1,641) identified via electronic admission, discharge, and transfer notifications, and 17.5% of visits (n = 348) identified through direct communication between ALCs and care managers. Care managers successfully provided real-time information to ED providers for 44% of the eligible ED visits (547 of 1,237) for patients with ADRD, and for 40% of visits (304 of 752) for patients without ADRD. Care managers self-reported a hospital avoidance rate of 11% . While adherence was lower than anticipated, early structured communication could reduce unnecessary hospital admissions for ALC residents.

FAQs

Why focus on care coordination for assisted living residents?

ALC residents frequently visit emergency departments, and transitions create opportunities to coordinate care and avoid unnecessary hospital admissions.

What is the ED Early Response program?

It is a care coordination program where care managers provide timely, structured information to ED providers by phone and fax within 120 minutes of ED registration.

What did the feasibility assessment show?

Care managers successfully provided real-time information for a portion of eligible ED visits, and adherence was lower than anticipated, but early structured communication could still reduce unnecessary hospital admissions for ALC residents.

Sep 28, 2026

Uploaded by Ivy