After hours, an elderly patient in the emergency department who is medically stable but unable to care for herself is requesting immediate nursing‑home placement before discharge; how should we proceed?

Emergency Department Discharge Planning for Elderly Patient Unable to Self-Care

This patient cannot be placed in a nursing home directly from the emergency department after hours—she requires either hospital admission for comprehensive discharge planning or safe discharge home with urgent home health services and next-day follow-up. 1

Immediate Assessment Required

The emergency physician must first determine whether this patient meets medical criteria for hospital admission versus safe discharge home with support services 2:

• Assess functional status: Can the patient perform basic activities of daily living (bathing, dressing, toileting, transferring, feeding)? 2
• Evaluate cognitive function: Is there delirium, dementia, or acute confusion that impairs safety judgment? 2
• Screen for high-risk features: Use a validated tool such as the Identification of Seniors At Risk (ISAR) screening—one or more positive responses indicates high-risk status requiring intervention 2
• Determine medical stability: Are vital signs stable, is there adequate pain control, and are there no acute medical issues requiring ongoing monitoring? 2

If Patient Meets Admission Criteria

Admit the patient to the hospital for comprehensive multidisciplinary discharge planning, which cannot be accomplished after hours from the ED 2:

• Hospital admission allows time for social work consultation, case management evaluation, and coordination with skilled nursing facilities during business hours 2
• Discharge planning should begin on admission day one and involve the patient, family, and interdisciplinary team 1
• A pre-discharge needs assessment must evaluate home environment, caregiver capacity, psychosocial needs, and required home modifications 2
• The team can arrange home assessment by occupational therapy to determine safety and equipment needs before any discharge 2

If Patient Is Medically Stable for Discharge

The patient cannot go directly to a nursing home from the ED—skilled nursing facility placement requires comprehensive evaluation, insurance authorization, and facility availability that cannot occur after hours 2, 3:

Immediate Actions Before ED Discharge

• Arrange urgent home health services to begin the next morning, including nursing assessment and aide services if available 2
• Schedule mandatory follow-up within 24-48 hours with primary care physician or geriatric clinic for comprehensive needs assessment 1
• Ensure a responsible adult accompanies the patient home and can provide overnight supervision—this is a mandatory safety requirement 1
• Provide written discharge instructions covering medications, warning signs requiring return to ED, and specific follow-up appointments with contact information 1

Next-Day Coordination (Business Hours)

The following morning, the primary care team or case manager must initiate formal discharge planning 2:

• Social work consultation to evaluate need for skilled nursing facility versus home care with support services 2
• Comprehensive functional assessment including ADL/IADL limitations, cognitive status, and caregiver availability 2
• Insurance authorization for skilled nursing facility if indicated—this process typically requires 24-72 hours 2
• Facility selection involvement: Patients and families should actively participate in selecting the specific nursing home, with access to quality data 3

Critical Safety Considerations

Common pitfalls to avoid 2:

• Never discharge an elderly patient unable to self-care without a responsible adult present at home 1
• Do not assume nursing home placement can occur emergently—it requires business-hour coordination, insurance approval, and facility bed availability 2, 3
• Avoid discharging without confirmed follow-up—schedule the appointment before the patient leaves the ED 1
• Recognize that ED visit itself is a "red flag" event signaling potential functional decline and need for increased support services 2

Communication Strategy for the Patient

Explain clearly and empathetically 2:

• "I understand you're concerned about managing at home. However, nursing home placement requires evaluation by social workers and case managers during business hours, which we cannot complete tonight in the emergency department." 2, 3
• "We have two safe options: either admit you to the hospital so our team can arrange proper placement over the next few days, or discharge you home tonight with urgent home health services starting tomorrow morning and a follow-up appointment within 24 hours." 2, 1
• "If you go home tonight, you must have someone stay with you, and we'll arrange for nurses to visit you at home starting tomorrow to assess what level of care you need." 2, 1

Documentation Requirements

Document the following in the medical record 2:

• Results of functional and cognitive screening (ISAR or equivalent tool) 2
• Discussion with patient/family about discharge options and their preferences 2
• Confirmation of responsible adult to accompany patient home if discharged 1
• Specific follow-up arrangements including date, time, provider name, and contact information 1
• Home health referral with anticipated start date 2