Older Adult Group Project

Improving Care Transition

🙠 🙢
Isabel Annett, Katya Kirkland, Sarah Medeiros, Brittney Olivares, Kiana Wentzel

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Presentation Overview
● Introduction-Katya
● Case Overview-Brittney
● What’s Concerning-Isabel
● Boost Model
○ Meds and Psychosocial-Brittney

○ Principle Dx and Physical Limitations-Isabel

○ Poor Health Literacy and Patient Support-Sarah

○ Prior Hospitalization and Palliative Care-Sarah

● Most Concerning/Overlooked P’s-Kiana

● Reflection on Prior Rotation-Katya
● Conclusion-Kiana
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 Case Study Overview

● Bela Jones, 81 y/o female

● Medical Hx: Breast cancer x40 years,
frequent falls, distrust of healthcare providers
● Admitting Dx: A-fib with RVR (FreePik, 2022)

● No current medications
● Assessment: 5x5 mass of left breast, A&O x3, A-fib with a rate of 75
● Social Status: Widow of 35 years, lives alone, son is the primary
caregiver
● Discharge Plan: Discharge home tomorrow with referral to oncologist
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What is Concerning about Case
● Low trust for physicians
○ Follow-up with oncologist

○ Follow-up about cardiac condition

○ Trust is critical for adherence to treatment regimens and doctor’s visits

over time (Netemeyer et al., 2019).

● Resistant to moving in with son
○ Falls

○ Forgetfulness

○ Chronic medical conditions, old age, and living alone are risk factors for

falls (Zhou et al., 2018).

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 Boost Model 8P’s
Problems w Meds Psychological
● No discharge medications started ● Negative perception of aging
○ Advocate for the patient to the
(World Health Organization
physician the onset of [WHO], 2016)
medications such as Digoxin, ○ Pima council on aging
for heart rate control (January et (support group)
al., 2014). https://pcoa.org/ways-we-help/

● Dangers of not being discharged ● Negative perception of

with medications for Atrial healthcare (Netemeyer et al.,
fibrillation 2019)
○ Educate the patient on the ○ Develop patient-nurse
increased risk for stroke due to relationship based on
atrial fibrillation (Verdino R. J. trust
(2015). 5
 Boost Model 8P’s
Principal DX Physical Limitations
● A-fib with RVR ● Son says she cannot care for
○ Talk to doctor about possible

cardiovascular complications
and follow-up (Bassand et al.,
2019)
○ Discuss having son take her
to her follow up appointments
○ Educate patient on heart
condition and assess
knowledge and what she
values (Lane et al., 2015).
herself properly
● Falls
○ Suggest installation of
handrails in the home
(Komisar et al., 2021)
○ Advocate to arrange for
a home aide
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 Boost Model 8P’s
Poor Health Literacy Patient Support
● Unaware of severity of ● Pt needs to feel heard
condition (MacLeod et al., ● Social services/case
2017) management
● Difficulties with memory (Bronstein et al.,
(Liu et al., 2019) 2015)
● Resistance towards health ● Chaplain (Hall &
care workers due to history Powell, 2021)
of husband’s treatment

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 Boost Model 8P’s
Prior Hospitalization Palliative Care
● Goes to urgent care for ● Poor prognosis
minor injuries/falls (Lytras ● Palliative care consult
et al., 2022)
○ Safety check house (Roberts et al., 2021)
(rugs, stairs) ● No pain medications
○ Walking aid prescribed at discharge
○ How often does son (Scarborough & Smith,
visit? 2019)
● Life alert necklace
(Agboola et al, 2017)
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What P’s were Concerning or Overlooked?

● Discharge plan not congruent with patient values

○ Low trust in physicians
○ Not likely to follow discharge plan
● No discharge plan for new dx of Afib (January et al., 2014)
○ No discharge medications or consultations arranged
● Not addressing safety needs (Lytras et al., 2022)
○ Equipment
○ Home safety evaluation
○ Living alone
○ Frequent falls 9
Reflection on Prior Rotations

● Unit: Telemetry at Northwest Medical Center

● Microsystems: Cardiovascular surgery team, telemetry unit
staff nurses
● Improvement for safe discharge: medication teaching
● Medication teaching: improves patient outcomes post-
discharge and prevents readmission (Ovalo, 2012)

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Conclusion

● Bela Jones
○ 81 y/o female
○ Dx of Afib with RVR
○ Recurrent cancer
● Discharge planning needs to be tailored to patient specific
needs
● Interdisciplinary teams need to work together to ensure
patient safety and understanding

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 References
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