Retrospective Review of an Emergency Department–Based Care Coordination Program for Preventing Admissions of Older Adults

Older patients are at increased risk for potentially preventable hospital admissions due to complex medical and social needs. Care coordination (CC) programs have had some success in preventing admissions when they help meet patients’ unmet social needs and incorporate case management. Care coordinators cross-trained in social work and case management may help identify and address these needs, supporting safe discharge and avoiding admission. We sought to develop and describe a CC intervention in the Emergency Department targeting potentially preventable admissions among older adults.

This was a retrospective review of a care coordination intervention implemented in the ED of an urban academic medical center from June 20, 2025 to October 3, 2025. Cross-trained care coordinators assessed ED patients aged ≥65 years based on clinical referrals, conducted comprehensive evaluations, and facilitated care planning, referrals, and discharge support. Data were collected retrospectively on patient demographics, interventions delivered, and hospital admission outcomes. Prevented admissions were preliminarily flagged by CC clinical judgement. Physician reviewers performed chart review to judge whether admission was prevented.

A total of 371 geriatric patients were assessed by care coordinators during the study period, and 52 patients from the group were flagged by CC as prevented admissions. Of these 52, 49 (83%) patients were discharged after the CC intervention. Consensus opinion of physician reviewers was that 19 interventions either likely or definitely prevented admissions. Many of these prevented admissions were a result of arranging placement in a Skilled Nursing Facility directly from the ED.

Implementation of cross-trained care coordinators in the ED prevented 19 admissions of older adults over the 15-week study period. Further controlled studies are needed to assess cost effectiveness and the impact of this intervention relative to more standard deployments of care coordination, but preventing admissions of older adult patients remains difficult.