Older Adult Group Project:

Improving Care Transitions

🙠 🙢
Christine Anaya, Kirsten Ludwig, Meera Govin, Ilse Grijalva, Kaitlin Ulias
November 16, 2022

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Case Study Overview

🙡 Patient - 72 yo male, full code, NKA,

widower, lives alone, Protestant, white
🙡 Admit Dx - Fall, brought to the ED by a
friend who expressed concerns regarding
ability to care for himself
o Concerns r/t safe driving, deterioration of
memory, difficulty walking d/t hip pain,
inability to run his business, incontinence,
medication competency concerns
🙡 Past Medical History - chronic left hip pain,
BPH, dementia, overactive bladder
🙡 Medications - Tamsulosin, Donepezil,
Oxycodone/Acetaminophen,
Cyclobenzaprine, Tolterodine 2
What is Concerning about Case

o Medication Issues and Polypharmacy Post-Discharge

• Drug interaction
• Verbalizes different dosages
• Risk for falls and overdose
o Insufficient Patient Understanding of Care and Care Needs
• Unsafe driving and denying it
• Lack of self-care in ADL’s
• Decline in memory

(Kripalani et al., 2007), (The National Council of Aging, 2021) 3

Boost Model 8P’s
Problems w Meds Psychological
Medication Problems
● Polypharmacy
● Pt cannot match the correct indication with each medication
● Wrong medication or mixtures in the bottle
Nurse Actions: consult with pharmacy, 72 hour follow up, annual
wellness checkups
Relevance: ensures patient safety of medications, addresses
concerns/side effects

Psychological Problems
● Progressive decline/inability to care for self
● Family history of Alzheimer’s Disease
● Memory impairment- Dementia
Nurse Actions: assess need for psychiatric help, caregiving services
Relevance: pairs patient with proper resources and help at home

(Havrilla & Johnston, 2022), (Malone, 2021) 4

Boost Model 8P’s
Principal DX Physical Limitations

🙡 Principal Dx: recent fall and possible Alzheimer’s/Dementia

o RN Actions: create an action plan, discuss goals of care, and
provide a senior home safety checklist for fall prevention.
o Relevance: ensures that there is an action plan set, prevent
another fall with fatal injuries, and gives them a baseline for
home safety.

🙡 Physical Limitation: trouble walking, walks with a cane, and

limited ROM/pain in left hip
o RN Actions: involve case management, provide information
local home services, and a 72 hour follow up
o Relevance: case management will help create plans and are a
liaison for cost effective-care. A 72-hour follow up help identify
any new barriers

(City of Tucson, 2014), (Placita In Home Care, 2022), (Society of

Hospital Medicine, 2013), (Western Governors University, 2022) 5
Boost Model 8P’s
Poor Health Literacy Patient Support

Poor Health Literacy

Recalls all medications but does not know indication for each, family
history of Alzheimer’s
● Nurse Actions: provide education using simple language and not
medical jargon, assess level of health literacy, use teach back
● Relevance: lack of medication knowledge (time, dosage,
indication), unknown level of compliance
Patient Support
Widowed, no living relatives, lives alone
● Nurse Actions: follow up call at 48-72 hours, link the patient to
public services for home health aides, consult case management
or social worker
● Relevance: questionable ability to take care of self, defensive
when memory and driving ability are questioned
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(Bedlin & Phillips, 2022), (Findley, 2015), (Manjunath et al., 2021)
 Boost Model 8P’s
Prior Hospitalization Palliative Care

Prior hospitalization
●No accounts of past hospitalization included in patients past medical history
or exam synopsis
Nurse Actions - research the patient's chart to determine prior
hospitalizations, ask the patient about past hospitalizations
Relevance - ensures a strong understanding of the patient's medical history
is understood by the care team, helps shape the plan of care moving forward

Palliative care
●Limited ROM in left hip with chronic pain, difficulty walking with cane,
incontinent of urine, medication incompetency
Nurse Actions - PT consult, connect patient with a local home-health nurse
(Aventas Homecare)
Relevance - ensures the patient is comfortable, safety, and ADL help
(SM et al., 2022) 7
What P’s were Concerning or Overlooked?

Problems with Medications

● Listing the incorrect dosage when compared to the dose
on the bottle
● Having the wrong medication or mixtures of medications in
the bottles
○ May lead to the patient unintentionally harming himself

Psychological
● Trouble walking (fall risk)
● Progressive decline and inability to care for self
○ Patient would be unsafe living alone

(Alzheimer's Society, 2022), (Cross et al., 2016) 8

Reflection on Prior Rotations

We feel that the Diamond 5 unit at Banner - University Medical

Center needs to improve the microsystems of staff focus and
process improvement to provide safe transition for future
discharges because we observed:
- Rushed discharges due to inadequate staffing
- Lack of interdisciplinary communication about discharge
planning
- Decreased acknowledgment of the barriers to at-home care

(Eastern Michigan University, 2019) 9

 References

Alzheimer’s Society. (2022). What happens when a person with dementia is discharged from hospital?

Alzheimer’s society: united against dementia.

https://www.alzheimers.org.uk/get-support/help-dementia-care/hospital-discharge

Bedlin, H., & Phillips, M. (2022, June 15). 3 Reasons You Should Support Home Care for Older Adults.

The National Council on Aging. Retrieved November 12, 2022, from https://ncoa.org/article/3-

reasons-you-should-support-home-care-for-older-adults

City of Tucson. (2014, March 11). Fall prevention.

Fall Prevention | Official website of the City of Tucson (tucsonaz.gov)

Cross, A. J., Elliott, R. A., & George, J. (2016). Interventions for improving medication-taking ability

and adherence in older adults prescribed multiple medicatio ns. Cochrane Database of Systematic
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 References

Eastern Michigan University. (2019, October 10). Learn how nurse staffing affects patient safety

and satisfaction. EMU Online.

https://online.emich.edu/degrees/healthcare/rn-to-bsn/nurse-staffing-affects-patient-safety-sati

sfaction/

Findley, A. (2015). Low Health Literacy and Older Adults: Meanings, Problems, and

Recommendations for Social Work. Social Work in Health Care, 54(1), 65-81.

https://doi.org/10.1080/00981389.2014.966882

Havrilla , & Johnston. (2022, June 29). Dementia care: Keeping loved ones safe and happy at

home. Dementia Care: Keeping Loved Ones Safe and Happy at Home | Johns Hopkins

Medicine., from 11
 References

Kripalani, S., Jackson, A. T., Schnipper, J.L., and Coleman, E.A. (2007). Promoting effective

transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of

Hospital Medicine, 2(5), 314-323. https://doi.org/10.1002/jhm.228

Malone , L. (2021, January 12). Five tips for addressing polypharmacy in older adults. Duke

Health Referring Physicians., from

https://physicians.dukehealth.org/articles/five-tips-addressing-polypharmacy-older-adults

Manjunath, J., Manoj, N., & Alchalabi, T. (2021). Interventions against Social Isolation of Older

Adults: A Systematic Review of Existing Literature and Interventions. Geriatrics (Basel),

6(3). https://doi.org/10.3390/geriatrics6030082

Placita In Home Care (2022, October 13). Home care services: Placita in home care.
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 References

Society of Hospital Medicine (2013). Project boost implementation guide. In Coffey, C.,

Greenwald, J., Budnitz, T., & Williams, M.V. (Eds.), Project boost implementation guide to

improve care transitions (2nd ed.). Society of Hospital Medicine.

https://www.hospitalmedicine.org/clinical-topics/care-transitions/

The National Council of Aging. (2021, January 01). Get the facts on healthy aging.

Get the Facts on Healthy Aging (ncoa.org).

Western Governors University. (2022, June 9). What is a nurse case manager?

What Is A Nurse Case Manager? (wgu.edu)

SM, M., Karl, Diana, L, L., & O.r. (2020, August 20). Aventas Homecare. 5 Reviews - Tucson

Senior Care. Retrieved November 13, 2022, from

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