Older Adult Group Project:

Improving Care Transition

Morgan Campbell, Heather Gomez, Jack Hauser, Madisyn Holcomb, Grace Lund
November 15, 2022
 Case Study Overview - Ocotillo Group
Bela Jones - 81F, Black, Baptist, DNR, No Known Allergies
● Diagnosis: A-Fib with RVR
● History:
○ Breast cancer, several falls resulting in minor injuries,
occasional forgetfulness, no history of A-Fib
○ Widowed, refuses to seek medical care since death of Physical Findings:
husband - A&Ox3
○ Lives alone, son is primary caregiver - A-Fib at 75 BPM
● Admit 3 Days Ago: - BLE Pitting
○ Reported lightheadedness and weakness - A-Fib with Edema
RVR 170 BPM, put on Diltiazem Drip - +Hepatomegaly
○ 5x5cm mass in left breast with palpable nodes - - Dim Lung Bases
metastatic to liver and brain - prognosis ‘poor’ - MSE: 28/30
 What is Concerning About Case
1. Whether she will keep follow-up appointments (Tong et al., 2018)
a. This is worrying because…
i. She has new onset A-Fib
ii. She has follow-ups with oncology for her newly diagnosed
metastatic cancer
iii. She has stated her reluctance to go to the doctor
iv. She is being discharged home tomorrow
2. Recent increase in number of falls (Vaishya & Vaish, 2020)
a. This is worrying because…
i. She lives alone
ii. Some have resulted in being brought to Urgent Care
iii. Her cancer has metastasized to the brain - falls could get worse
iv. She is being discharged home tomorrow
 Boost Model 8P’s

Problems With Meds: Psychological:

● Patient has a Mini Mental Status Exam
● Currently not taking home meds. score of 28 and metastatic brain masses.
● Is currently on Diltiazem ● Patient has times of “forgetfulness”.
Actions: ● Patient spouse loss and distrust in health
care system
● Strategy to reduce adverse
● No depression screening
reactions
● Simplify medications and Actions:
scheduling ● Create an awareness of support network
● Assessment of need for psychiatric care
(CDC, n.d.; Depression and Older Adults, n.d.; Society of Hospital Medicine, n.d.)
 Boost Model 8P’s

Principal Diagnosis: Physical Limitations:

● A-Fib with RVR ● Hx of falls
○ HR 170 bpm ● Weakness
● Metastatic breast cancer ● Actions
○ Firm, palpable mass to L. ○ Fall prevention at home
breast ○ Assessment of ADLs,
○ Mets to brain and liver ensuring she has
○ Poor prognosis appropriate help at home
● Actions
○ Explaining diagnoses
○ Emotional support with
poor prognosis (Nipp et al., 2017; Mayo Clinic, 2022)
 Boost Model 8P’s

Poor Health Literacy: Patient Support:

● Lost husband to a “brain bleed” ● Widowed, lives alone
35 years ago ● Has a committed caregiver but
● Has not seen a doctor since lacks willingness to accept
● Actions: support
○ Apologize ● Actions:
○ Educate with teach-back ○ Recommend home health
○ Follow-up phone call post- care (Sacred Heart Home
discharge Healthcare, n.d.)
○ Follow-up phone call post-
discharge
 Boost Model 8P’s
Prior Hospitalization:
● Breast Cancer 40 years ago
○ Prognosis at the time,
Imaging, Follow-ups
● History of recent falls
requiring urgent care visits
● Late husband’s past
hospitalization went poorly
due to unsafe discharge
Palliative Care:
● Prognosis is “poor” and patient is
DNR, palliative care is a good
option.
● Determine safest, most comfortable
discharge for patient.
○ Family concerns vs. patient
statements
● Discuss concerning symptoms for
the patient and benefits of palliative
care (i.e. higher patient/family
satisfaction)
(Hughes & Smith, 2014).
 What P’s were Concerning or Overlooked?
1. Principal Diagnosis (Wurcel et al., 2019)
a. Given two new, serious diagnoses that require follow-up care/referrals
b. Metastatic breast cancer - ‘poor’ prognosis
c. Isolating herself from her support system
d. Distrust of doctors - may not go to follow-up appointments or referrals
e. Needs to understand diagnoses to make informed decisions about
preferred course of care
2. Palliative Care (Agarwal & Epstein, 2017)
a. No palliative care consult noted despite DNR and ‘poor’ prognosis
i. Would need this done before discharge to see course of care and
what referrals to make
 Reflection on Prior Rotations
Banner South - ER
● Top 2 microsystems needing improvement:
○ Patient Focus
■ Fast-paced environment so patients discharged with limited teach-
back
■ Rarely had family at bedside at time of discharge
○ Performance Results
■ Never contacted the patients post-discharge

(Clinical microsystem assessment tool: IHI, 2022)

 References

Agarwal, R., & Epstein, A. (2017). The role of palliative care in oncology. Seminars in Interventional Radiology, 34(04), 307–312.

https://doi.org/10.1055/s-0037-1608702

Brain metastases - Symptoms and causes. (2022, October 25). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/brain-

metastases/symptoms-causes/syc-20350136

Burchum, J.R. & Rosenthal, L.D. (2019). Lehne’s pharmacology for nursing care (10th ed.). Elsevier.

Center for Disease Control and Prevention. (n.d.). Adverse drug events in adults.

https://www.cdc.gov/medicationsafety/adult_adversedrugevents.html

Clinical microsystem assessment tool: IHI. Institute for Healthcare Improvement. (2022). Retrieved November 15, 2022, from

https://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx

Depression and older adults. (n.d.). National Institute on Aging. https://www.nia.nih.gov/health/depression-and-older-adults

 References

Hughes, M. T., & Smith, T. J. (2014). The growth of palliative care in the United States. Annual Review of Public Health, 35(1), 459–

475. https://doi.org/10.1146/annurev-publhealth-032013-182406

IBM Micromedex. (n.d.). Micromedex. Retrieved November 14, 2022, from

https://www-micromedexsolutions-com.ezproxy4.library.arizona.edu/micromedex2/librarian/CS/AD7A0C/ND_PR/evidencexpe

rt/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/BE8FFA/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/

evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=%20Diltiazem%20&UserSearc

hTerm=%20Diltiazem%20&SearchFilter=filterNone&navitem=searchALL#

Mayo Clinic, (2022). Fall prevention: simple tips to prevent falls.

https://www.mayoclinic.org/healthy-lifestyle/healthy-aging/in-depth/fall-prevention/art-20047358

Memory, forgetfulness, and aging: What’s normal and what’s not? (n.d.). National Institute on Aging.

https://www.nia.nih.gov/health/memory-forgetfulness-and-aging-whats-normal-and-whats-not
 References

Nipp, R., D., Greer, J. A., El-Jawahri, A., Moran, S. M., Traeger, L., Jacobs, J. M., Jacobsen, J. C., Gallagher, E. R., Park, E. R., Ryan,

D. P., Jackson, V. A., Pirl, W. F., & Temel, J. S. (2017). Coping and prognostic awareness in patients with advanced cancer.

Journal of Clinical Oncology, 35, 22(2551-2557). https://doi.org/10.1200/JCO.2016.71.3404

Sacred Heart Home Healthcare. (n.d.). Retrieved November 14, 2022, from https://sacredhearthh.com/?

utm_source=gmb&utm_medium=Yext

Society of Hospital Medicine. (n.d.). The 8P screening tool: Identifying your patient’s risks for adverse events after discharge

[Infographic]. D2l.arizona.edu. Retrieved November 15, 2022, from

https://d2l.arizona.edu/d2l/le/content/1159525/viewContent/13594159/View

Tong, L., Arnold, T., Yang, J., Tian, X., Erdmann, C., & Esposito, T. (2018). The association between outpatient follow-up visits and all-

cause non-elective 30-day readmissions: A retrospective observational cohort study. PLOS ONE, 13(7), e0200691.

https://doi.org/10.1371/journal.pone.0200691
 References

Vaishya, R., & Vaish, A. (2020). Falls in older adults are serious. Indian Journal of Orthopaedics, 54(1), 69–74.

https://doi.org/10.1007/s43465-019-00037-x

Wurcel, V., Cicchetti, A., Garrison, L., Kip, M., Koffijberg, H., Kolbe, A., Leeflang, M., Merlin, T., Mestre-Ferrandiz, J., Oortwijn, W.,

Oosterwijk, C., Tunis, S., & Zamora, B. (2019). The value of diagnostic information in personalised healthcare: A

comprehensive concept to facilitate bringing this technology into healthcare systems. Public Health Genomics, 22(1–2), 8–15.

https://doi.org/10.1159/000501832