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While much of the COVID-19 media coverage has centered around hospitals, professionals in every health care setting are facing difficult care decisions because of the pandemic. Every day, many confront situations like those described below:

My practice administrator is at my door again telling me that more than half of yesterday’s visits were from older adults who are worried but have no symptoms of COVID-19. She tells me that we didn’t finish our afternoon session until 7:00 PM. Older adults (and some of their grandchildren!) were sitting in the waiting room for hours. The chances of spreading the virus seems too high and our clinicians and staff are overwhelmed. What can we do? 

                                                                               — A medical director in an ambulatory setting

 

Our emergency department is overwhelmed with symptomatic older adults. That’s appropriate. But I’m concerned about the asymptomatic older adults who are also showing up here. How can I help them stay healthy?

                                                                                              — An emergency department nurse

 

I looked at our census today and the percent of people over 65 has increased to 50 percent. Their length of stay was longer than those under 65 before COVID-19 and the average length of stay has been increasing each week. What can I do to keep capacity open for the people who need it most?

                                                                                                                      — A hospital physician

As I walked into my office this morning, there were staff and family members waiting to see me. They are scared. They fear for themselves and our older adult patients. I’m afraid of the virus taking off in our community. What can I do?

                                           —  A health care administrator in an inpatient rehabilitation facility

People aged 65 and older are understandably concerned about being at higher risk for serious illness from COVID-19. For those who need care, the priority is providing the right care, at the right time, and in the right setting. For those who do not, the challenge is protecting them from unnecessary coronavirus exposure.

To help health care professionals with situations like those described above, IHI's Age-Friendly Health Systems experts have developed the following guidance to help limit the exposure of older adults to COVID-19:

Overall Aim: Limit exposure of older adults to COVID-19 by reducing their need to present to the hospital, reducing hospitalizations and, if hospitalized or in post-acute or long-term care community, increase the rate of safe discharges.

GOAL IN THE COMMUNITY: Help older adults avoid coming into the emergency department (ED) by providing safe and effective alternatives.

1. Increase capacity for telemedicine urgent, semi-urgent visits, and visits for frail older adults
2. Increase virtual triage capacity to best assign patients to telemedicine treatment vs. ambulatory visits vs. coming to the ED
3. Create convenient COVID-19 testing options for all patients, including older adults.
4. Reliably ask and act on “What Matters” to the older adult including, but not limited to, advance care planning and support for respiratory infection/failure outside the hospital setting.
5. Defer elective ambulatory surgeries to reserve capacity, supplies, and equipment for high-need patients, especially older adults.

GOAL IN THE EMERGENCY DEPARTMENT: Help older adults transition out of the ED as quickly and safely as possible.

1. Create ED triage desk/location prior to entry into ED.
2. Change prioritization algorithms to account for age in addition to usual criteria for time to be seen, beds, isolation rooms, etc.
3. Increase clinical and social work/care coordination capacity in ED to help rapidly serve older adults and reduce time in ED overall, help get patients social supports needed to be treated out of hospital and arrange rapid follow–up appointments, including next-day telemedicine visits.

GOAL IN THE HOSPITAL: Help older adults transition as quickly and safely as possible when discharged from the hospital. 

1. Defer elective surgeries to reserve capacity, supplies, and equipment for high-need patients, especially older adults.
2. Increase social work and care coordination capacity to help safely transition patients to home and community-based environments with home care in place.
3. Increase collaboration with community-based organizations serving older adults and home care agencies.
4. Reliably ask and act on “What Matters” to the older adult including, but not limited to, advance care planning and support for respiratory infection/failure outside the hospital setting.

GOAL IN POST-ACUTE AND LONG-TERM CARE (PALTC): Reduce the spread of COVID-19 in PALTC settings.

1. When possible, people who were hospitalized and are recovering from moderately symptomatic COVID-19 should be discharged to home care with visiting nurse and home care agencies to minimize spread of the virus in PAC facilities and possible re-infection.
2. Increase capacity and capability to more frequently assess whether older adult is safer at home or in PALTC.
3. As appropriate, increase capacity and capability to move people home safely.
4. Reliably ask “What Matters” to older adults and their family caregivers including, but not limited to, advance care planning and support for respiratory infection/failure outside the hospital setting.
5. If it aligns with what matters to the older adult, provide end-of-life support that allows older adults who are not able to go home to stay in the PALTC rather than go to the hospital.

Leslie Pelton is a senior director at the Institute for Healthcare Improvement.