Older Adult Group Project

Improving Care Transition

🙠 🙢
Alize Bowman, Jing Lu, Lizzy Vega, Olivia Skelton, and Sara Young
November 16, 2022

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Case Study Overview

🙡 84-year-old female, presented to the hospital dehydrated

with leukocytes, nitrates, and proteinuria within her urine.
o Confused and non-compliant with medications
o Almost fell while ambulating
o Currently: A/O x4, full ROM, and BP is 138/74
o Discharge pending for this afternoon

Main Diagnosis: UTI, Dehydration

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What is Concerning about Case

🙡 Unsteady (fall in hospital)

o “Falls are leading cause of fatal injury” (Potter et al.,
2020, p. 188).
🙡 Needs a medical translator (spanish-speaking only)
o Family translator may withhold information, avoid
talking about uncomfortable topics (Halter, 2017, p.
111).
🙡 Inability to care for self at home

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 Boost Model 8P’s
Problems w/ Meds Psychological

🙡 Problems with Meds 🙡 Psychological

(Koren et al., 2019) o Assessment of need for
o Simplification of psychiatric care if not in
medication place
scheduling to o Involvement/awareness
improve adherence of support network
o Elimination of insured
unnecessary • Daughter Marissa
medications involved in care

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 Boost Model 8P’s
Principal DX Physical Limitations
🙡 Principal Diagnosis 🙡 Physical Limitations
o UTI prevention o Assessment of
strategies–disease home environment
specific education safety, need for
using Teach Back assistive devices
(Zeng et al., 2020). (Potter et al.,
o Action plan reviewed 2020, p. 188).
with pt and o Teaching with
daughter–may call Marissa to ensure
triage RN at El Rio safe ambulation
and transfers

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 Boost Model 8P’s
Poor Health Literacy Patient Support

🙡 Poor Health 🙡 Patient Support

Literacy o Follow-up phone
(Kim & Oh, 2020) call at 72 hours
o Committed to assess
caregiver adherence,
involved in complications,
planning. and compliance
o Post hospital o Engage a
care plan transition coach
education using
Teach Back
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 Boost Model 8P’s
Prior Hospitalization Palliative Care

🙡 Prior Hospitalization 🙡 Palliative Care

o Review reasons for o Assess need for
re-hospitalization in palliative care
the context of a prior services–increased
hospitalization mortality risk due to
o Follow-up phone call hx of falls (Berková, &
within 72 hours Berka, 2018).
o Identify goals of care
and therapeutic
options

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 What P’s were Concerning or Overlooked?

🙡 Physical Limitations 🙡 Poor Health Literacy

o Assessment of home
services
o Daughter’s ability to aid
mother after discharge
o Falls are a safety
concern for older adults
(Potter et al., 2020, p.
188).
o Post-hospital care plan
o Literacy: ability to
understand, make
decisions, weighs pros
and cons (Harding et
al., 2020, p. 19)

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Reflection on Prior Rotations

🙡 BUMC-T, needs to improve the microsystems of case

management and information flow patterns.

🙡 Case Managers 🙡 Information transfer

o Increase the o Information is often
number of case shared between
managers means providers and
less time per nurses at a very
patient (Teper et slow pace.
al., 2020) o Timely order
o Increased placement with
education for stricter deadlines
case managers
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Thank you for listening!

🙠 🙢
Questions?

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 References

Berková, M., & Berka, Z. (2018). Falls: a significant cause of morbidity and mortality in elderly

people.. Vnitrni lekarstvi, 64(11), 1076–1083. https://pubmed.ncbi.nlm.nih.gov/30606025/

Halter, M. (2017). Varcarolis' foundations of psychiatric mental health nursing. (8th ed.). Elsevier.

Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's medical-surgical

nursing. (11th ed.). Elsevier.

Kim, M. Y., & Oh, S. (2020). Nurses' Perspectives on Health Education and Health Literacy of Older

Patients. International journal of environmental research and public health, 17(18), 6455.

https://doi.org/10.3390/ijerph17186455

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 References

Koren, G., Nordon, G., Radinsky, K., & Shalev, V. (2019). Clinical pharmacology of old age. Expert

review of clinical pharmacology, 12(8), 749–755.

https://doi.org/10.1080/17512433.2019.1632188

Potter, P., Perry, A., Stockert, P., & Hall, A. (2020). Fundamentals of Nursing (10th Ed). Elsevier.

Teper, M. H., Vedel, I., Yang, X. Q., Margo-Dermer, E., & Hudon, C. (2020). Understanding barriers to

and facilitators of case management in primary care: A systematic review and thematic synthesis.

The Annals of Family Medicine, 18(4), 355-363. https://doi.org/10.1370/afm.2555

Zeng, G., Zhu, W., Lam, W., & Bayramgil, A. (2020). Treatment of urinary tract infections in the old

and fragile. World Journal of Urology, 38(11), 2709–2720.

https://doi.org/10.1007/s00345-020-03159-2
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