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Learning Objectives• State the potential risks factors in
transitioning across healthcare settings for older adults.
• Describe different evidence-based practice (EBP) care transition models used in different settings (acute/subacute care, long-term care, home care).
• Recognize the key roles and functions of the geriatric nurse in optimizing care across the continuum.
Learning Objectives (cont’d)
• Define terms utilized for care settings.
• Contrast and compare settings available for older adult living.
• Contrast settings of care in which nurses care for older adults.
Continuum of Care• Healthcare policy
– Patient Protection and Affordable Care Act
• Risk in care transitions– Key risk factors
• Inadequate client and family education• Poor communication between providers and clients• Poor coordination of care• Medication discrepancies• Lack of follow up• Health literacy issues• Lack of support systems• Cultural barriers
Continuum of Care (cont’d)
• Information exchange– Communication insures optimal exchange of
key patient information– Relationships between healthcare providers
that promote information exchange improve safety
• Transitional care models– Acute care– Home care– Long-term care
Continuum of Care (cont’d)
• Healthcare settings (Figure 25-1, P. 862)– Acute care hospital– Acute rehabilitation– Transitional/progressive care unit– Long-term acute care hospital– Home health care
Managing Long-Term Needs
• Long-term care facility (LTCF)– Provide care for older adults or anyone who has
lost ability for self-care due to illness, disability, or advanced dementia
• Alzheimer’s/memory care facilities– Dedicated units within LTCF for people with
mid- to late-state Alzheimer’s and other dementias
• Eden Alternative– Transform institutional approaches to care in a
community where “life is worth living”
Maintaining Independence: Living Options for Older Adults
• Adult day services– Helps older adults remain in their homes
• Assisted living facility– For older adults who can function on their own but
need some assistance with ADLs
• Coming Home Project: Affordable Assisted Living – Caring for rural America
• Green House concept– A home in the community
Maintaining Independence: Living Options for Older Adults (cont’d)
• Independent living– home ownership, apartment, retirement
communities, subsidized government housing
• Continuing care retirement community– Continuum of care from independent living to
skilled nursing care
• Foster care or group homes– Alternative to nursing home
• Naturally occurring retirement community
A Shift in Living Arrangements
• Elder cottage housing opportunity (ECHO)– Free-standing, mobile, modular-type homes that
can be transformed to be temporarily placed on a caregiver’s property to maintain safety for the older adult requiring assistance while allowing for privacy and independence
– Uses technology tailored to the specific needs of the individual, based on the resident’s and caregiver’s requirements
– Can remotely monitor the resident through sensors that alert caregivers.
– Smart Home Technology
End-of-Life Care Options
• Hospice care– Holistic, interdisciplinary care that helps the
dying person “live until they die.”– Pain management and comfort care– Settings
• Hospice facility• Nursing home unit• Home-care
Nursing Responsibility in Transitioning Care
• Nurses contribute to safety and continuity of care for their patients upon discharge or transfer to another care setting– Interagency transfer
• Detailed transfer form• Verbal report
– Discharge to home• Detailed discharge instructions to patient
and caregiver
Caring for the Caregiver
• Respite care– Provides much-needed time off for family
members who care for someone who is ill, injured, frail, debilitated, or demented.
– Can be provided in an adult day facility, in the home of the person being cared for, or in an assisted living or long-term care facility.
– Not covered by Medicare or Medicaid