Area Agency on Aging Service Navigator ED Referral Program
Social determinants of health (SDOH) are non-medical factors that impact healthy living and quality of life, including environment, social, education, access to quality healthcare and economic conditions. It is estimated that half of older adults aged 50 or older with poor mental or physical health conditions visited the ED in the past two years, and older adults over 85 years visit the ED twice as often as younger older adults. Emergency departments (EDs) may be used more frequently by some older adults as a proxy to general healthcare and provide an opportune setting to connect older adult patients in need of SDOH services with community-based agencies to provide the need support. Older adults with lower quality SDOH were found to frequent EDs disproportionately more than healthier counterparts, increasing their risk of poor outcomes.
To improve the referral process, we are embedding the Service Navigator (SN) program from the Area Agency on Aging South-Central Connecticut (AOASCC) into the ED clinical workflow.
AOASCC’s service navigators incorporate both medical and non-medical wrap around services, addressing all daily living needs and provides critical links to community-based services and supports including the following:
- Service navigators address health related social needs helping older adults (60 and older) and people with disabilities (18 and older) remain safely at home with critical supports. Navigators assess needs and manage enrollment for a range of services including Medicaid Home and Community-Based Services (HCBS) that help individuals remain at home (e.g., CT Home Care Program for Elders, PCA Waiver, Community First Choice). Additional services include respite services for caregivers, medical transportation (including a trained chaperone to accompany the patient), enrollment in home delivered meals, grocery delivery and SNAP enrollment as well housing and financial assistance.
- Service navigators provide complex navigation and care management services including application assistance, case management, options counseling, case counseling, and short-term support. These programs help address depression, loneliness, and social isolation in older adults.
- Service navigators also help clients and caregivers regarding health insurance, Medicare, Medicaid, Long-Term Care, and other community services.
We aim to examine the feasibility of integrating the Service Navigator program of the Area Agency on Aging of South-Central Connecticut (AOASCC) into the emergency department workflow. Planned analyses include evaluating the feasibility of the program among ED staff by measuring acceptability, adoption, appropriateness, and fidelity; and the effect of the SN referrals on patients’ health and social outcomes; and the ED return visit rates for patients enrolled into the SN program.
For more information on the Service Navigator program, please visit https://www.aoascc.org/services/service-navigation/