Older Adult Group Project

Improving Care Transition

🙠 🙢
Cole Harmon, Ally Kerner, Celia Pikowski, Francelia Sanchez
November 15, 2022

1
 Case Study Overview

o Patient Information: George Garcia

o Age: 69 years
o Admitting diagnosis: uncontrolled DM & hyperglycemia
o Admitting Symptoms:
o Fatigue, blurred vision, diffuse abdominal pain
o Numbness and sharp pain in legs and feet
o Social Status:
o Widower, lives with dog
o 6 living children
o Other Pertinent Information:
o MI 6 months ago
o Noncompliant with MD follow up post MI
o Noncompliant with all medications
o Discharge Plans:
o To home in 2 days (Adobe Stock, n.d.)
o One of his children will be picking him up
2
What is Concerning about Case

o Concern #1: Noncompliance

o Increase risk for hospital readmission
o Result in increase stress and decreased overall health

o Concern #2: Lack of Support

o Further complicates noncompliance issue
o Will need additional support from health care team
upon discharge

o Concern #3: Worsening Symptoms

o Indicate microvascular damage
o Continue to decrease quality of life if(O’Connell,
not addressed
2022) 3
 Boost Model 8P’s
Problems w Meds
o Problem Meds: Insulin and
Metformin
o High-risk medication
o Nursing Interventions:
o Medication reconciliation
o Specific education using
Teach Back
o Rationale:
o Interdisciplinary approach
involving patient care team
including pharmacist
o Confirm education was
explained in a way the
patient understands
Psychological
o Psychological: Depression
o “I’m old – how’s any of that
supposed to help me at this
point?”
o Nursing Interventions:
o Depression screening
o Diabetic support group-TMC
o Rationale:
o Assesses the need for
psychiatric aftercare
o Awareness of support
network
(TMC Health, 2022)
(O’Connell, 2022) 4
 Boost Model 8P’s
Principal DX Physical Limitations
o Principal Dx: Uncontrolled DM o Limitations: Plan of Care
& Hyperglycemia adherence & Personal Hygiene
o High Risk for Stroke or MI o Nursing Interventions:
o Nursing Interventions: o Assess need for home-health
o Create an action plan for o Engage family in post-
worsening Sx discharge plan of care
o Disease-specific education o Rationale:
using Teach Back o Ensure adherence to plan of
o Rationale: care and assess safety of
o Early detection and living situation
treatment of strokes/MI or o Increased support systems
neuropathy o Promote lifestyle changes
o Emphasize importance of & hygiene
DM management and long-
term consequences (O’Connell, 2022) 5
 Boost Model 8P’s
Poor Health Literacy
o Poor Health Literacy: Non-
adherence with medications &
follow up appointments
o Nursing Interventions:
o Post hospital care plan
education using teach back
o Link to community resources
o Rationale:
o Addresses the root cause for
why the patient has been
noncompliant
o Provides additional support
after discharge
Patient Support
o Patient Support: Lives alone &
unclear how involved children will
be with care
o Nursing Interventions:
o Involvement of home care
providers
o Schedule a phone call with
MD 3 days after discharge
o Rationale:
o Increases likelihood of
compliance with care
o Allows for adjustments to be
made in plan of care
(O’Connell, 2022) 6
 Boost Model 8P’s
Prior Hospitalization
o Prior Hospitalization: Admitted
for an MI 6 months prior
o Refused angioplasty due to
no follow up appointment
o Nursing Interventions:
o Schedule a phone call with
MD within 3 days of
discharge
o Set patient up with transition
coach post discharge
o Rationale:
o Identifies discrepancies &
allows for patient questions
to be answered
o Assists & supports in
recovery process
Palliative Care
o Palliative Care: At risk of death due
to uncontrolled T2DM
o Nursing Interventions:
o Identify what patient’s goals are
following this hospitalization
o Facilitate discussion on how
palliative care could benefit
patient
o Rationale:
o Allows patient & healthcare
team to work towards common
goal
o Furthers patient’s understanding
of their available options
(O’Connell, 2022) 7
What P’s were Concerning or Overlooked?

o Problems with Meds

o The patient has a history of noncompliance with medications
and his attitude towards taking medications is concerning
o A conversation should have taken place prior to discharge to
ensure a strong understanding of his medications
o Patient Support
o The patient lives alone and, despite having adult children,
there appears to be very little support once discharged
o A lack of a support system makes it difficult to maintain the
required regimen for recovery to heal and prevent further
issues

(O’Connell, 2022) 8
Reflection on Prior Rotations

Oro Valley Hospital – ED

Microsystems
oPatient Focus
oHigh patient saturation → poor assessment of patient situation and
establishment of appropriate continuum of care
oInformation and Information Technology
oVague, sometimes inapplicable discharge education pamphlets
oNo assistance with follow-up care post ED discharge
oMinimal assistance with access to resources
oCerner :(
(Johnson, 2003) 9
References

Adobe Stock. (n.d.). Older Hispanic Male [Photograph]. Retrieved November 13 2022 from,

https://magazine.medlineplus.gov/article/older-hispanic-adults-may-be-more-prone-to-frailt

Johnson, J. (2003, Feb. 21). Clinical microsystems assessment tool.

https://d2l.arizona.edu/d2l/le/content/1159525/viewContent/13594168/View.

O’Connell, M. (2022, October 26). Older adult group project improving care transitions.

[PowerPoint slides]. College of Nursing, University of Arizona.

https://d2l.arizona.edu/d2l/le/content/1159525/viewContent/12513515/View

TMC Health. (2022). Diabetes education. 10