Older Adult Group Project

Improving Care Transition

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

1
 Case Study Overview

🙡 Patient Information: George Garcia

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

🙡 Concern #1: Noncompliance

o Increase risk for hospital readmission

o Result in increase stress and decreased overall health

🙡 Concern #2: Lack of Support

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

🙡 Concern #3: Worsening Symptoms

o Indicate microvascular damage

o Continue to decrease quality of life if not addressed

(O’Connell, 2022) 3
 Boost Model 8P’s
Problems w Meds Psychological

● Problem Meds: Insulin and ● Psychological: Depression

Metformin ○ “I’m old – how’s any of that
○ High-risk medication supposed to help me at this
● Nursing Interventions: point?”
○ Medication reconciliation
● Nursing Interventions:
○ Depression screening
○ Specific education using Teach
○ Diabetic support group-TMC
Back
● Rationale:
● Rationale:
○ Assesses the need for
○ Interdisciplinary approach
psychiatric aftercare
involving patient care team ○ Awareness of support
including pharmacist network
○ Confirm education was
explained in a way the patient
understands (TMC Health, 2022)
(O’Connell, 2022)
4
 Boost Model 8P’s
Principal DX
🙡 Principal Dx: Uncontrolled
DM & Hyperglycemia
o High Risk for Stroke or MI
🙡 Nursing Interventions:
o Create an action plan for
worsening Sx
o Disease-specific education
using Teach Back
🙡 Rationale:
o Early detection and
treatment of strokes/MI or
neuropathy
o Emphasize importance of
DM management and long
term consequences
Physical Limitations
🙡 Limitations: Plan of Care
adherence & Personal Hygiene
🙡 Nursing Interventions:
o Assess need for home-health
o Engage family in post-
discharge plan of care
🙡 Rationale:
o Ensure adherence to plan of
care and assess safety of
living situation
o Increased support systems
• Promote lifestyle changes
& hygiene
(O’Connell, 2022) 5
 Boost Model 8P’s
Poor Health Literacy
🙡 Poor Health Literacy: Non-
adherence with medications &
follow up appointments
🙡 Nursing Interventions:
o Post hospital care plan
education using teach back
o Link to community resources
🙡 Rationale:
o Addresses the root cause for
why the patient has been
noncompliant
o Provides additional support
after discharge
Patient Support
🙡 Patient Support: Lives alone &
unclear how involved children will
be with care
🙡 Nursing Interventions:
o Involvement of home care
providers
o Schedule a phone call with
MD 3 days after discharge
🙡 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
🙡 Prior Hospitalization: Admitted
for an MI 6 months prior
o Refused angioplasty due to
no follow up appointment
🙡 Nursing Interventions:
o Schedule a phone call with
MD within 3 days of
discharge
o Set patient up with transition
coach post discharge
🙡 Rationale:
o Identifies discrepancies &
allows for patient questions
to be answered
o Provides assistance &
support in recovery process
Palliative Care
🙡 Palliative Care: At risk of death due
to uncontrolled T2DM
🙡 Nursing Interventions:
o Identify what patient’s goals are
following this hospitalization
o Facilitate discussion on how
palliative care could benefit
patient
🙡 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?

🙡 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
🙡 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
🙡Patient Focus
oHigh patient saturation → poor assessment of patient situation and
establishment of appropriate continuum of care
🙡Information and Information Technology
oVague, sometimes inapplicable discharge education pamphlets
oNo assistance with follow-up care post ED discharge
•Minimal 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