EXECUTIVE SUMMARY
One consequence of the COVID-19 pandemic is the way older adults have neglected self-care.
- Elderly patients with comorbidities already face healthcare challenges that make self-care tricky. Since the pandemic began, patients also have neglected visiting healthcare providers out of fear of becoming infected.
- Case managers need to educate patients and their caregivers about the importance of seeking emergency and urgent medical care when their symptoms flare up.
- Family caregivers often need support from case managers, especially if they feel more isolated during the COVID-19 public health emergency.
The COVID-19 pandemic changed routine case management of older patients. Case managers were challenged to be even more creative in finding community resources and post-acute referrals for patients since many organizations were closed or limited in their services for months.
Connections with patients turned primarily to telehealth options, which meant some case managers needed to adjust how they communicated with clients or taught them self-care techniques. Educating patients also includes reminding them to stay safe from potential SARS-CoV-2 infection.
“Today, it’s unbelievably challenging to be an older adult living with multiple chronic conditions, and it’s equally challenging for their family caregivers,” says Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware professor in gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.
Hospital systems were the first to see the effects of COVID-19 on people living with chronic conditions, including heart disease and pulmonary issues. This included both the effects of older people hospitalized with the virus, as well as the overall effect of living with health problems during a frightening pandemic.
From March through early summer, hospital emergency departments (EDs) saw declines in cases, including heart attacks and strokes, says Lauren Delaney, RN, ACM, transitional care coordinator of the ED at Cleveland Clinic.
According to the Centers for Disease Control and Prevention (CDC), the National Syndromic Surveillance Program found a 42% decline in ED visits between March 31 and April 25 when compared with a similar period in 2019.1
Physicians, nurses, and case managers wondered why they were not seeing patients with the usual types of emergency conditions. They realized people were fearful about visiting a hospital during the pandemic. “There is a big impact on the way we provide care for patients during the pandemic,” Delaney says. Even in places where stay-at-home orders were lifted, people did not rush back to the ED, she notes.
The problem is that patients with chronic conditions sometimes need to visit an ED or urgent care center, and postponing it could place them at risk. It is up to case managers to educate their patients about how to maintain self-care to prevent problematic symptoms, and how to recognize when they need to see a doctor during an urgent or emergency situation.
“What is extremely important is how we educate our patients,” Delaney says.
On top of the new challenges in caring for patients with multiple comorbidities is the added comorbidity of COVID-19. Older survivors of the disease sometimes experience long-term health problems that also need care management.
Older patients with multiple chronic conditions who have survived hospitalization with COVID-19 often return home with major health problems, including breathing issues, Naylor says.
“Case management and care coordination are even more important today,” says Jean Scholz Mellum, PhD, RN, NEA-BC, assistant professor at Capital University in Columbus, OH. “Someone over age 65 with a history of asthma or a pulmonary disorder should not be going out much. If they do go out, they should wear masks and stay six feet away from others.”
Older patients need extra care and attention, and caring for them is rewarding, says Saket Saxena, MD, a geriatrician at the Cleveland Clinic.
“When you walk into a room and see someone who is in their 80s or 90s, whether it is a simple situation or a complicated situation, you can always bring value to their care,” Saxena says.
Case managers often educate patients’ caregivers on how to manage their family member’s symptoms, but this care coordination piece has been more challenging during the pandemic. Case managers often cannot meet the family in person and develop rapport and trust as easily as before. Also, family caregivers usually can use respite care and services from community-based organizations (CBOs), but access to these resources has been limited during the public health crisis.
“The unpaid family caregiver doesn’t always have the tools to access or go after the services they need,” says Karen B. Hirschman, PhD, MSW, term chair at the NewCourtland Center for Transition and Health, and research associate professor at the University of Pennsylvania School of Nursing. “Now, many of those services are not available, or are limited. The role of the case manager in supporting caregivers to access those services is essential.”
Another important role of the case manager is to provide patients with continuity during their healthcare journey, particularly for older patients. “Case managers are central as a trusted person throughout the journey for individuals in this new context, in which it is more challenging to access services,” Naylor says. “Patients might fear having people come into their homes.”
The notion of having a trusted person help the older adult and caregiver is essential. “The core role of case management is to coordinate services. Coordinating services in this context is made much more difficult because some of those services are not accessible,” Naylor explains. “In certain communities, it’s really challenging to access some of those fundamental services and be able to operate in this rapidly dynamic environment, where some communities’ rates of coronavirus are rising. It’s shutting down some community-based services or making them more difficult to access. It will really test the case manager to figure out how to pull services together that patients need.”
Another common theme in the pandemic is loneliness, particularly among older adults. For months, including after some parts of the country reopened and young people engaged in regular activities, older adults stayed isolated. They avoided hugging grandchildren and eating dinner with their children and friends. For older adults with chronic illnesses, this isolation could be even more acute. Isolation also could increase their stress levels.2
Because older Americans are staying isolated longer, they are more likely to experience stress for a longer period. Also, there is uncertainty about when they can resume their usual social interactions. All these issues increase distress.
“Distress occurs the longer we’re in a situation — the duration of the stressor and the intensity of the stressor — and this probably is one of the most intense stressors we’ve ever experienced,” said Laurie Chaikind McNulty, LCSW-C, wellness advisor in the office of intramural training and education at the National Institutes of Health. McNulty, who also is a clinical therapist at Jonah Green and Associates of Brookeville, MD, spoke at an Office of Human Research Protections web conference on April 24.
Anxiety increases when there is less predictability, more uncertainty, and less control over the stressor, McNulty added.
Some stress is related to the fear of COVID-19, which can cause certain patients to delay seeking care when they have symptoms of a serious illness. “Patients are already coping with complex care needs: heart failure, chronic obstructive pulmonary disease, diabetes,” Naylor says. “Now, they’re in an environment where there is this tremendous concern or fear about when they begin to develop symptoms worrisome to them and fear of accessing traditional health services, like going to the emergency room. Even if they have trouble breathing, they’re concerned about going into an environment where they might contract the virus.”
Case managers’ phone calls to patients can help reduce loneliness and stress. Case managers also can encourage distant family members to call the patients more frequently. (See methods for case management of older adults in age of COVID-19 in this issue.)
“We encourage families to check on those loved ones, to increase those phone calls, or go by the house and stand at the window and just wave,” says Sheila Haynes-Baisden, BSN, CCM, transitional care coordinator of the ED at the Cleveland Clinic.
“I call the families, with the patient’s permission, and talk to the patient and family to see how we can connect those loved ones to be the patient’s support since they can’t have physical support,” she says.
Social isolation is quite real for many patients, Naylor says. “If there’s a caregiver in the house, then they’re feeling socially isolated as well. To not be able to access social support and, now, not feeling well and having concerns about contracting the virus can make it worse.”
“I think we’ll continue to see an increase in people not accessing care when they really need it for their other health conditions,” Hirschman says.
The pandemic is requiring case management to change rapidly, Hirschman notes. For instance, case managers might not be able to visit patients’ homes as easily as they did before. Instead, they have to reinvent how they provide case management, support, and education to patients.
Older patients might resist asking their children for emotional support — even during the COVID-19 crisis. “A lot of times, elderly patients have an attitude of ‘Don’t contact my kids because they’re busy raising their families,’” Delaney says.
Their adult children likely are willing to step in and help once they understand what parents need, she adds.
It is the case manager’s role to help bring families together, even when they also must be physically distant, Haynes-Baisden says. “We wear many hats,” she says.
Case managers also can suggest that patients learn how to use videoconferencing so they can see their grandchildren and interact with them through technology, Delaney says.
“FaceTime, Zoom — that’s a really great way to keep in touch with your family,” she says.
- Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 pandemic on emergency department visits – United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699-704.
- Berg-Weger M, Morley JE. Loneliness and social isolation in older adults during the COVID-19 pandemic: Implications for gerontological social work. J Nutr Health Aging 2020;24:456-458.
