Older Adult Group Project

Improving Care Transition

🙠 🙢
Natalie Archuleta, Alex Frisby, Courtney Malinski, Sophie Setton,
Sam Wieland April 27, 2022

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Case Study Overview - Group E Case #4

Highlights of Case Study:

o Mr. George, 75 year old man who lives alone in Douglas,
AZ is being discharged after 2 days in the hospital after a
severe hyperglycemic episode
o Hx: hypertension, diabetes (diagnosed 4 years ago),
myocardial infarction 6 months ago (refused angioplasty),
sedentary lifestyle
o Medications: Atenolol and Glyburide for the last 12 years
o Symptoms: fatigue, blurred vision, polyuria, pain in legs,
numbness in feet
o Physical Exam: BP: 160/90, HR: 68 bpm, silver wiring and
exudates in the retinae, left carotid bruit, abdomen is
obese, trace pedal edema with diminished dorsalis pedis
pulses and diminished sensation to pinprick and vibration 2
 Case Study Overview - Group E Case #4

Highlights of Case Study cont’d:

o Weighs 251 pounds and is 5’ 8” - obese
o Family hx: Sister had diabetes since age 60
years, mother was diagnosed with diabetes at
age 78 years from hyperglycemic crisis
• Mother considered “slim”
o Pertinent lab values: Hemoglobin A1C - 10%,
HDL Cholesterol - 31 mg/dL, LDL Cholesterol -
155 mg/dL, Triglycerides - 298 mg/dL, Serum
Creatinine - 1.9 mg/dL
o Urinalysis: 2+ protein dipstick, no cells or casts 3
 What is Concerning about Case

🙡 “The incidence of chronic illness triples after age

45… most common chronic conditions in older
adults are hypertension, heart failure, coronary
artery disease, [COPD], cancer, diabetes, and
osteoarthritis”

🙡 Areas of Concern
o Physical complications r/t diabetes
o Limited health literacy
o Barrier to healthcare access

🙡 (Greenberg, 2020) 4
 Boost Model 8P’s
Problems with Meds

🙡 This patient takes atenolol and glyburide, which

has a moderately severe drug-drug
interaction. He may need to start taking
insulin due to his uncontrolled blood sugars.

🙡 Actions to take:
o Medication specific education using teach
back
o Follow-up call at 72 hours
o Assess medication compliance
(Greenberg, 2020; Micromedex, n.d.; Yen & Leasure, 2019) 5
 Boost Model 8P’s
Psychological

🙡 Mr. George’s chronic disease, sedentary

lifestyle, and social isolation puts this patient at
risk for depression.

🙡 Actions to take:
o Complete depression screening
o Involvement & awareness of support network
insured
o Encourage involvement in the community

(Greenberg, 2020; Gupta et al., 2020; National Institute on Aging, 2021) 6

Boost Model 8P’s
Principal DX

🙡 Primary diagnosis: diabetes

🙡 Actions to take:
o Diabetes specific education using teach back
o Review action plan for what to do and who to
contact with worsening/new symptoms
o Connect patient to community resources for
diabetic education

(‘Find a diabetes education program in your area’, n.d.; Greenberg, 2020; Sesti et al., 2018) 7
Boost Model 8P’s
Physical Limitations

🙡 This patient lives a sedentary lifestyle, has blurry

vision, pain when walking, and numbness in his
feet. This decreases his ability to perform
activities of daily living and leads to
deconditioning.

🙡 Actions to take:
o Assessment of home services to address
limitations and care needs
o Demonstrate exercises to complete at home
o Suggest PT/OT consult prior to DC (Greenberg, 2020; 8
Musich et al., 2018)
Boost Model 8P’s
Poor Health Literacy
🙡 The patient has blurred vision and exudate of the retina,
which can make it hard to read and see
🙡 The patient is 75 years old, and vision can decline with
aging, which also hinders reading
🙡 Actions to Take
o Develop a post hospital discharge care plan using the
teach back method
o Follow up phone call with Mr. George within 72hrs of
discharge to assess adherence to care plan

(Yen & Leisure, 2019; Harrison et al., 2011)

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Boost Model 8P’s
Patient Support
🙡 The patient lives alone in a remote part of a small town.
This will reduce his ability to have support from other
family or friends
🙡 Living in a remote part of a small town may limit access
to healthcare providers and services
🙡 Actions to Take
o Follow up phone call with primary care physician
within 7 days of discharge
o Provide resources regarding home care providers
available to patient
o Engage a transition coach

(Brooke et al., 2014; Mitzner et al., 2009; Kaldy, 2009)

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 Boost Model 8P’s
Prior Hospitalization

🙡 The patient has a history of poorly managed type 2 diabetes

mellitus, hypertension, and hyperlipidemia. He refused
treatment for his myocardial infarction 6 months ago.
🙡 Actions to Take:
o Educate patient about daily blood pressure monitoring
and emphasize importance of keeping a log to show his
PCP. Patient will then restate the main points of this
education.
o Discuss a heart healthy diet that includes fruits,
vegetables, nuts, fish, and minimizes salt and processed
foods
o Encourage pt. about talking to PCP for indicated
operations/ tests for heart health
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(American Heart Association, 2021)
 Boost Model 8P’s
Palliative Care

🙡 Mr. George’s health prognosis is not good if he continues

to neglect it. Palliative care may be indicated in the future.
🙡 Actions to Take:
o Establish a home health routine with the patient before
discharge
o Discuss options such as SNF, home health, or
caretaker to help patient with health care needs

(Kok et al., 2015)

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 What P’s were Concerning or Overlooked?

Almost all of the 8 “P’s” in the BOOST Model Assessment

tool are of high concern for this patient which could very
much likely lead to an adverse post-discharge event.
However, there are 3 “P’s” that are most concerning and
can easily be overlooked following discharge.

Most concerning P’s in the BOOST Model for Mr. George

o Poor health literacy
o Principal diagnosis
o Palliative care

(Centers for Disease Control and Prevention, 2021; Greenberg, 2020; Health Literacy in healthy people 2030,
n.d.; U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, 2012)13
Reflection on Prior Rotations

We feel that the orthopedic unit at Banner Main could use

improvement in the microsystems involving the
interdisciplinary communication between providers and
nurses, and the interactions/involvement with outpatient
clinics and facilities post discharge. Improvement of these
microsystems will provide safe transition for future discharges
because we observed that these microsystems are the most
involved and in charge of planning patient discharge.

o Microsystem #1: Orthopedic practice team on D2N

Banner Main (interdisciplinary communication)
o Microsystem #2: Outpatient clinics/facilities post discharge
communication with case management
(Clinical microsystem assessment tool: IHI, n.d.)
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 References

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Brooke, B. S., Stone, D. H., Cronenwett, J. L., Nolan, B., DeMartino, R. R., MacKenzie, T. A., Goodman, D. C., &
Goodney, P. P. (2014). Early primary care provider follow-up and readmission after high-risk surgery. JAMA
surgery, 149(8), 821–828. https://doi.org/10.1001/jamasurg.2014.157

Centers for Disease Control and Prevention. (2021, October 1). Health literacy: Accurate, accessible and
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Coffey, C., Greenwald, J., Budnitz, T., & Williams, M. (2013). Project Boost Implementation Guide, Second Edition.
Philadelphia; Society of Hospital Medicine.

Find a diabetes education program in your area. Association of diabetes care & education specialists. (n.d.).
Retrieved April 14, 2022, from https://www.diabeteseducator.org/living-with-diabetes/find-an-education-program

Greenberg, S. A. (2020). In Harding, M., Kwong, J., Hagler, D., Roberts, D., Reinisch, C. (Eds.) Chronic Illness and
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 References

Gupta, D. D., Kelekar, U., & Rice, D. (2020). Associations between living alone, depression, and falls among
community-dwelling older adults in the US. Preventive Medicine Reports, 20(101273).
https://doi.org/10.1016/j.pmedr.2020.101273

Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of postdischarge telephonic
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Kaldy, J. (2009). Transition Coaching is Good For Patients. Health care workers can empower residents, patients,
and families to be self advocates. Caring for the Ages, 10(12), 5. https://doi.org/10.1016/S1526-4114(09)60319-X

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National Institute on Aging. (2021). Depression and Older Adults. U.S. Department of Health and Human Services.
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Micromedex®. (electronic version). (n.d.). IBM Watson Health, Greenwood Village, Colorado, USA. Retrieved April
11, 2022, from https://www-micromedexsolutions-com.ezproxy3.library.arizona.edu/

Mitzner, T. L., Beer, J. M., McBride, S. E., Rogers, W. A., & Fisk, A. D. (2009). Older Adults' Needs for Home Health
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https://doi.org/10.1177/154193120905301118
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https://doi.org/10.1016/j.gerinurse.2017.08.002

Sesti, G., Antonelli Incalzi, R., Bonara, E., Consoli, A., Giaccari, A., Maggi, S., Paolisso, G., Purrello, F.,
Vendemiale, G., & Ferrara, N. (2018). Management of diabetes in older adults. Nutrition, Metabolism, and
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Yen, P. H., & Leasure, A. R. (2019). Use and Effectiveness of the Teach-Back Method in Patient Education and
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