Transition Of Older Adults Research Articles

Post-hospitalization experiences of older adults diagnosed with diabetes: “It was daunting!”

Multimorbidity combined with geriatric syndromes in older adults with diabetes exacerbate their risks for poor post-discharge outcomes. The purpose of this study was to examine self-described hospital-to-home transition challenges encountered by older adults with a diagnosis of diabetes within the first 30 days following discharge. The qualitative responses for this paper emerged from a larger mixed methods study (n = 96) in which participants provided free responses specifying transition challenges during follow-up telephone interviews on the 7th day (n = 67) and 30th day (n = 55) post-discharge. Using inductive content analysis techniques four major themes emerged: a) “The daily stuff is difficult”; b) engineering care at home is complex; c) “life is very difficult”; and d) managing complex health problems is difficult. Findings suggest existing system-level metrics such as readmission rates fail to capture the complex and dynamic interplay of personal, family and social factors which complicate hospital-to-home transitions of older adults with pre-existing diabetes.

EXPLORING HOME HEALTH NURSE DECISION MAKING REGARDING VISIT PLAN DEVELOPMENT

Older adults are admitted to home health (HH) care from acute care settings with diverse needs, requiring different levels of care. However, it is unknown how nurses decide on visit patterns nor are there empirically derived clinical decision support tools to guide them. Using qualitative descriptive method, HH nurses’ decision making about the number and frequency of nursing visits when developing a visit plan was explored. Semi-structured interviews with HH nurses (N=30) employed full-time by three agencies were analyzed. Through content analysis three approaches emerged: nurses followed a systematic approach to develop visit plans and based their decisions on a central team’s recommendations, their professional evaluation, or their agency-specific guidelines. Factors considered included patient’s clinical status, learning style, and support system. Findings are contributing to a decision support tool that guides HH nurses in developing appropriate visit plans to ensure an optimal transition of older adults from hospital to home.

Experiences of Informal Caregivers of Older Adults Transitioned From Nursing Homes to the Community Through the Money Follows the Person Demonstration

ABSTRACTThis study examined experiences of 156 informal caregivers of older adults who transitioned to the community through the Connecticut Money Follows the Person (MFP) Rebalancing Demonstration after prolonged nursing home stays. Caregiver burden, positive aspects of caregiving, depressive symptoms, anxiety, and comparative subjective stress were examined in relation to caregiver demographics and care receiver characteristics with a cross-sectional survey. Caregivers reported low burden, depressive symptoms, and anxiety, and fairly high levels of positive aspects of caregiving and satisfaction with community services. Most caregivers were less stressed compared to the time the care recipient was in, or before they entered, a nursing home. Live-in caregivers experienced more positive aspects of caregiving, but adult children reported higher burden than other caregivers. Unmet service needs also increased caregiver burden. Programs like MFP are a viable option with broadly positive outcomes from a caregiver’s perspective. Enthusiasm for increasing access to community care is growing for older adults who otherwise would reside in nursing homes for extended periods. Identifying unmet service needs and needs for targeted functional support could further enhance caregiver experiences and contribute to the successful transition of older adults to the community.

The Evolving Role of Geriatric Emergency Department Social Work in the Era of Health Care Reform

In the era of Medicaid Redesign and the Affordable Care Act, the emergency department (ED) presents major opportunities for social workers to assume a leading role in the delivery of care. Through GEDI WISE—Geriatric Emergency Department Innovations in care through Workforce, Informatics and Structural Enhancements,—a unique multidisciplinary partnership made possible by an award from the Center for Medicare and Medicaid Innovation, social workers in The Mount Sinai ED have successfully contributed to improvements in health outcomes and transitions for older adults receiving emergency care. This article will describe the pivotal and highly valued role of the ED social worker in contributing to the multidisciplinary accomplishments of GEDI WISE objectives in this new model of care.

Design and Evaluation of a Prelicensure Interprofessional Course on Improving Care Transitions

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

Improving Health Care Transitions for Older Adults Through the Lens of Quality Improvement

Frail older adults tend to have multiple medical, cognitive, and functional problems. They are at increased risk of using health care services and may undergo multiple transitions from service to service. It is not difficult for patients and health care providers to articulate the consequences of poor health care transitions, which may include confusion in action plans (diagnoses, medications, care needs), potential errors during handoffs, avoidable delays and/or frustrations, adverse medical events, readmissions to the most recently used service, stress for health care staff, and, ultimately, mortality.1 One of the quality indicators of effective health care transitions is error reduction, and a common strategy to achieve this indicator involves medication reconciliation. The latter refers to “a formal process of obtaining a complete and accurate list of each patient’s current home medicationsdincluding name, dosage, frequency and routedand comparing the physician’s admission, transfer, and/or discharge orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders. Any resulting changes in orders are documented.”2 Medication discrepancies are associated with undesirable outcomes,3 and when these occur during points of health care transitions, they can be difficult to overcome. For instance, one Australian randomized controlled trial showed that the addition of a pharmacist transition coordinator when transferring from hospital to residential care could significantly improve a patient’s pain control while reducing hospitalization, but did not reduce adverse drug events, falls, immobility, worsening behaviors, or cognitive impairment.4 In this issue of the Journal, Sinvani et al5 report on an important study that looks at medication reconciliation as measured by discrepancies in subacute older patients at 3 points of care transition: hospital admission to discharge (time I), hospital discharge to skilled nursing facility (time II), and skilled nursing facility admission to discharge home or long term care (time III). The study question is clinically relevant, especially given the recent emphasis on quality improvement and patient safety.

Care Management and the Transition of Older Adults From a Skilled Nursing Facility Back Into the Community

After hospitalization, many older adults require skilled nursing care. Although some patients receive services at home, others are admitted to a skilled nursing facility. In the current fragmented health care system, hospitals are financially incentivized to discharge frail older adults to a facility for postacute care as soon as possible. Similarly, many skilled nursing facilities are incentivized to extend the posthospitalization period of care and to transition the patient to custodial nursing home care. The resulting overuse of institution-based skilled nursing care may be associated with various adverse medical social and financial consequences. Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.

Themes of rural health and aging from a program of research.

The culture and diversity of rural life and limitations of rural health systems to meet the changing health needs of an aging population lead to problems of obtaining appropriate care in rural America. In a program of nursing research involving three ethnographic studies in rural Colorado, transitions of older adults across differing levels of heath care were explored. The sample totaled 425 participants, of whom 25% were Hispanic. Five major themes emerged: circles of formal and informal care; integration of faith, spirituality, and family with health status; crisis nature of health care transitions; nursing homes as a housing option; and changing spirit of traditional rural nursing. Recommendations for providers included making their practices congruent with rural culture, being fully informed of available resources, facilitating acceptable health care decisions, and integrating physical, mental, and spiritual health care for elders and their families.

Facilitating Residential Transitions of Older Adults with Developmental Disabilities

Facilitating Residential Transitions of Older Adults with Developmental Disabilities