Older Adult Group

Project Improving
Care Transition
NURS 478

Tobias Edelstein, Jillian Ferre, Maryan

Hassan, Taylor Petty, Beloved Promise

November 30, 2022

 Case Study
Marguerite Trujillo
Overview
• 84-year-old female
• Spanish-speaking
• Altered mental status secondary to
UTI
• Near fall while hospitalized
• Social support: daughter Maria
• Plan: discharge home today
This Photo by Unknown author is licensed under CC BY.
What is • Fall Risk
Concerning
about Case? • Lack of medical translation

• Limited social support

(Alper et al., 2022)

(Agency for Healthcare Research and Quality, 2020)
(Hoffman et al., 2019)
 Problems with Medications:
Concerns:

Boost • Oxybutynin AE's; recommend bladder training (Burchum et al., 2022)

• Negative drug-drug interactions (IBM Micromedex, 2022)
• Risk Factors for Decreased Medication Adherence (Burchum et al., 2022)

Model Interventions:
• Assess pharmacy affordability and accessibility
• Eliminate unnecessary meds; Promote bladder training

8Ps • 72-hour follow-up call

Psychology
Concerns:
• No depression screen was conducted (Howarth-Maddison et al., 2021)
• A widow who lives alone (Park et al., 2018)

Interventions:
• Utilize the Geriatric Depression Scale to screen for depression (American Psychological Association,
2020).
• Gain a complete understanding of Ms. Trujillo's support system
• Recommend St. Thomas the Apostle Catholic Church
 Principle Diagnosis: Urinary Tract Infection

Boost Concerns:
o Inappropriate antibiotic use can result in worse infections

Model o No one consistently with her to check in daily

Interventions:

8Ps
o Schedule follow-up call to make sure antibiotics are being taken at home
o Teach about taking an entire dose of antibiotics
o Review UTI prevention

(Halpert, 2022) Physical Limitations

Concerns:
o Unsteady on feet, requires stand-by assist

Interventions:
o Calculate fall risk score, request PT/OT consult
o Assess DME needs, send home with an assistive device, use We Care Tucson
 Poor Health Literacy
Concerns
• Contributes to initial and readmission after discharge because of a lack of understanding of crucial health

Boost information, (Bailey, et al, 2015)

• Language barrier
• Risk factors for decreased health literacy

Model
• Direct correlation to 30-day readmission

Interventions
• Discharge instructions/education sheets

8Ps
• Use available and certified translation services only
• Local resources

Patient Support
Concerns
• Adequate support and caregiver capability (education) crucial for safety
• At-home safety is ensured with a Case manager or PT/OT consults
• Assessments of available support are often inadequate leading to readmissions (Kripilani, et al, 2014).
• Caregiver strain

Interventions
• Ensure patient has home caregiver and place consults PRN
• Ensure follow-up appointments and the ability to attend
 Prior Hospitalization
Boost Concerns (Bailey et al., 2015)
• No unplanned hospitalization identified in the 6 months prior to the current admission

Model
• Patients with poor health literacy have increased adverse effects and adherence to the discharge plan =
Readmission
• Goal: Identify readmission risks, and facilitate patient preparation and education

8Ps
Interventions
• Ensure follow-up phone calls to assess conditions, adherence to medication and treatment plan
• Utilize teach-back process to demonstrate their understanding of the discharge education, and identify
readmission risks
• Provide adequate education on the proper use of assistive devices through multimodal learning

Palliative Care
Concerns
• The patient is experiencing low quality of life due to being widowed, living alone, and lacking an adequate social
support system
• Goal: Improve the patient’s quality of life and support system

Interventions
• Identify potential barriers to self-management including limited community resources and lack of support
network
• Create an accessible patient-centered and patient—lead plan of care for patients to follow after discharge
 • Poor health literacy (Bailey et al., 2015)
What Ps were •
•
Caregiver knowledge not addressed despite patient reliance
Nearly impossible to assess the need for support or other factors with a

Concerning or language barrier

• Patient support (Williams et al., 2022)

Overlooked? •
•
Widowed and lives alone
Increased need for social support to help transition from the hospital

• Physical limitations
• Fall risk (Halpert, 2022)
• No assistive equipment for walking
 Reflection on Prior Rotations
Oro Valley ICU

Microsystem #1: Interdependence (Linton, 2018)

• No intensivist coordinating care
• Limited communication between specialties
• Little recognition of nurse's role

Microsystem #2: Information and Information Technology

• Nurse selects discharge topics for patient

• Lengthy information skimmed
• Communication interventions have been proven more effective (American Journal of Nursing, 2021)
Thank you for your attention!

Questions??