How home care agencies can reduce emergency room visits for their clients

What sends older clients to the emergency room

Falls. More than one in four people 65 and older fall each year, and falling once doubles the chance of falling again. Falls by older adults lead to about 4.5 million emergency department visits a year, 1.4 million of which end in a hospital stay, and nearly 319,000 older people are hospitalized for hip fractures each year (CDC).

Medicines. In national data for 2013 and 2014, adults 65 and older accounted for 34.5% of emergency department visits for adverse drug events and were the most likely to be admitted, 43.6% of the time; three classes of medicine, anticoagulants, diabetes medicines and opioid painkillers, were involved in 59.9% of their visits (Shehab and colleagues, JAMA 2016). An earlier study estimated 99,628 emergency hospitalizations a year for adverse drug events in adults 65 and older; nearly two thirds came from unintentional overdoses, and four medicines or classes, warfarin, insulins, oral antiplatelet drugs and oral diabetes drugs, were involved in 67% of them (Budnitz and colleagues, NEJM 2011).

Both are areas where the people who see the client most often, your caregivers, can make a difference.

1. Screen for fall risk, and act on it

CDC's STEADI initiative (Stopping Elderly Accidents, Deaths & Injuries) asks clinicians to screen older adults for fall risk, assess the risk factors that can be changed, and intervene (CDC). An agency can take the first step itself: CDC's Stay Independent checklist has 12 yes-or-no statements, from “I have fallen in the past year” to “I often have to rush to the toilet”, and a score of 4 or more means the person may be at risk for falling and should talk to their doctor (CDC). Run it at intake and at each care review, and share the result with the family and the client's doctor.

Two kinds of intervention have strong evidence:

• Exercise. A Cochrane review found that exercise reduces the rate of falls by 23% in older people living in the community (59 studies, high-certainty evidence), and balance and functional exercises by 24% (Sherrington and colleagues, 2019). Caregivers can encourage the exercises a doctor or physical therapist prescribes and make time for them in the visit.
• Fixing hazards at home. Another Cochrane review found that assessing and fixing fall hazards in the home probably reduces the rate of falls by 26%, and by 38% in people at higher risk, such as those who fell in the past year, were recently in hospital or need support with daily activities; it made no difference for people not selected for risk (Clemson and colleagues, 2023). Clients who need help with daily activities are in that group. Loose rugs, poor lighting and the route to the bathroom at night are where to start.

2. Support medicines within your state's rules

What a non-medical caregiver may do with medicines depends on your state, so check its rules first. Within them, three habits target the drugs behind most of those visits:

• Keep a current medicine list in the care plan, and share it with the family and with anyone who treats the client in an emergency.
• Ask for a review when a new prescription starts or after a hospital stay; CDC's advice to older adults is to ask a doctor or pharmacist to review their medicines (CDC).
• Report warning signs the same day: missed or doubled doses, unusual bruising or bleeding in someone on a blood thinner, shakiness, sweating or confusion in someone with diabetes, new dizziness or drowsiness.

3. Report changes the same day

Caregivers see a client more often than anyone else on the care team, so they are often the first to notice that something is off. A short change-in-condition routine turns that into action before it becomes an emergency:

• What to report: new confusion, not eating or drinking, a new pain or swelling, being unsteady, a fall even without injury, a medicine problem.
• Who to tell, and how fast: the care manager, the same day, who decides whether to call the family, the client's doctor or a nurse line.
• What to write down: what was seen, when, and what was done, in the care record.

A fall without injury still counts: falling once doubles the chance of falling again (CDC). When it is an emergency, call 911 first.

4. Shorten the time on the floor

Not every fall can be prevented, so the next question is how long a client lies on the floor before anyone knows. In a UK study of people over 90, 30% of those who fell lay on the floor for an hour or more; lying there a long time was strongly associated with serious injury and admission to hospital, and call alarms were not used in most of those cases (Fleming and Brayne, BMJ 2008).

Agencies shorten that wait with check-in calls at the riskiest hours, alert buttons for clients who will wear them, and room sensors that need nothing from the client. Senecta, which makes plug-in pods that agencies offer under their own name, is one of those: its pods use thermal sensing, sound and AI to notice a possible fall in the room, ask the client “Are you okay?”, and call your agency or the family if the answer is not a clear yes. Monitoring does not prevent a fall, and no system catches every one; its job is to make sure someone knows. How to keep watch between visits compares the options.

5. Plan the days after a hospital or ER visit

The days after a hospital or emergency visit are when a care plan most often needs to change: new medicines, new limits, a client weaker than before. Ask for the discharge instructions and the new medicine list, update the care plan before the next visit, and run the fall-risk checklist again; a fall in the past year alone scores 2 of the 4 points that suggest risk (CDC). If the visit followed a fall, What to tell a family after a client falls alone covers the conversation and the review.

Measure it

• ER visits and hospital stays per 100 clients each quarter, and what caused each one.
• Falls, with and without injury, and how long it took someone to reach the client.
• Screening: the share of clients with a fall-risk checklist in the last six months.
• Reporting: changes reported the same day, and what happened next.

A number that falls over a year is something families and referral partners understand.

Further reading

• How a home care agency can keep watch between caregiver visits
• What to tell a family after a client falls alone
• Between visits: the hours no home care schedule covers
• Thermal sensors for home care: what they see, and what they miss

Questions agency owners ask

Can a non-medical home care agency reduce ER visits?

It can influence the causes it sees most often: falls, problems with medicines and changes nobody reported. It cannot treat illness, and some ER visits are the right decision.

How many ER visits do falls cause among older adults?

About 4.5 million emergency department visits a year in the US, 1.4 million of which end in a hospital stay, according to the CDC.

Does fall monitoring prevent falls?

No. Exercise and fixing hazards at home reduce falls; monitoring is about how quickly someone knows after a fall happens.

What fall-risk screening can a home care agency use?

CDC's Stay Independent checklist: 12 yes-or-no statements, where a score of 4 or more means the person may be at risk for falling and should talk to their doctor.