Older Adult Group Project:

Improving Care Transition

🙠 🙢
Maricruz Chavez-Tinoco, Gabrielle Haugen, Hailey Kivinski,
Olga Romero, & Mariah Vasquez-Gilvin
November 16th, 2022

1
Case Study Overview

🙡 Sue Flynn, 70-year-old Caucasian

transgender female admitted to a local
Tucson ER for nonspecific CP and trouble
breathing. Sue has NKDA and is full code.

🙡 PMHx of HTN, CAD, anxiety, depression,

GERD.

🙡 Upon arrival Sue was anxious. She was

clutching 2 pill bottles (Nitroglycerin SL
and Lorazepam) that did not belong to
her. Friend provided her with these pills to
“help her calm down.”

🙡 EKG shows sinus rhythm, labs negative

(Vandervelden, n.d.)
for elevated troponins.
🙡 Assessment: pt alert, anxious, tearful 2
Case Study Overview Continued

🙡 Sue recently had a divorce from her

husband of 35 years after coming out as a
transgender female. She lives alone in a
second-floor, 2-bedroom apartment and has
supportive children.

🙡 According to Sue’s son, many friends have

turned their back on her.

🙡 Pt experiencing high stress and anxiety

levels. Recently dx with depression by PCP.

🙡 ASQ is positive (Pt answered yes to

questions 1 & 3).

🙡 Patient expressing anxiety r/t discharge.

(Vandervelden, n.d.)
🙡 Plan: discharge to home if NST
3
is negative.
What is Concerning about Case

🙡 Areas of concern

o The patient is showing risk factors for suicide and the plan
is to discharge her if her nuclear stress test is negative.

o Major change in support system

o Poor health literacy

4
 Boost Model 8P’s

Problems w Meds Psychological

🙡 The patient is taking 🙡 Sudden life changes have
medication that is not occurred to the patient’s social
prescribed. life.

🙡 Actions 🙡 Actions
o Medication education o Resources for
o Follow-up phone call psychological care and
LGBT+ support
o Involvement of support
system

(Eloi, 2021; Kelly et al., 2017) 5

 Boost Model 8P’s
Principal DX
🙡 The patient present to the ER
with non-specific chest pain,
difficulty breathing, and anxiety.
The admitting dx is myocardial
infarction rule out.
🙡 Actions
o Referral to a cardiologist and
psychiatrist/counselor
o Education on medication
regimen
o Education on symptom
recognition and when to seek
medical help (MedlinePlus, 2020)
Physical Limitations
🙡 There is no information regarding
the pt’s physical limitations in the
chart. Depression and anxiety
can have physical effects.
🙡 Actions
o Assess the patient’s mobility,
ability to complete ADLs, and
nutrition status
o Consultations with PT/OT,
nutritionist if needed
o Follow-up with PCP regarding
depression and anxiety
management (Villines, 2018) 6
 Boost Model 8P’s
Poor Health Literacy
🙡 The patient is presenting with CP
and is taking pills that are not
prescribed to her. She is also
experiencing high levels of anxiety
which may be hindering her ability
to comprehend discharge
information.
🙡 Actions
o Educate the patient on the
symptoms of an MI
o Education on medication
regimen and importance of only
taking medication as prescribed
(Yen & Leisure, 2019; Hall et al., 2019)
Patient Support
🙡 Patient has supportive children
but had a recent loss of her
major support system within her
church and her community.
🙡 Actions
o Schedule a follow-up phone
call at 72 hours to assess
condition, adherence and
complications.
o Refer the patient to support
group meetings
7
 Boost Model 8P’s

Prior Hospitalization Palliative Care

🙡 There was no indication of 🙡 Sue has coronary artery disease
prior hospitalization, we which is a progressive, chronic
assume it was not assessed. illness that would benefit from
palliative care.
🙡 Actions
o Assess history of prior 🙡 Actions
hospitalization o Educate Sue on palliative
o Schedule follow up call care.
within 72 hours of o Assess Sue’s desire to
discharge. participate and needs.
o Refer Sue to Soulistic
Hospice for palliative care.
(Al-Mahrezi & Al-Mandhari, 2016; Sanchis-Gomar et al.,
2016; Vernon et al., 2022) 8
 What P’s were Concerning or Overlooked?

🙡 The three P’s that were most overlooked were psychological,

prior hospitalization, and physical limitations.

🙡 Reasons
o She answered yes on questions 1 and 3 on the ASQ
screening.

o We do not know if she had been previously admitted for

psychiatric concerns or her medical condition recently
because previous hospitalization was not assessed.

o Sue lives in 2nd story apartment, alone.

(National Institute of Mental Health, n.d; Padilla et al., 2018; Progovac et al, 2020) 9
 Reflection on Prior Rotations

🙡 We feel that at Banner South Campus, unit 4 North, the

microsystems of patient focus and interdependence need
improvement to provide safer transitions and discharges.

🙡 We have witnessed
o Elderly patients not being given the opportunity to ambulate
to the toilet upon request which leads to functional decline.

o Nurses and technicians not clustering throughout the night

leading to sleep deprivation.

(Aurora et al., 2018; Tasheva et al., 2020) 10

Conclusion

● Importance of assessing and evaluating pt’s risk for

adverse events after discharge

● Patient cases are complex, thus requiring individual

screening of the 8Ps for a safe care transition

● Each of the 8Ps is important and can impact a patient’s

outcomes following hospital discharge

11
References

🙡 Adams, N., Hitomi, M., & Moody, C. (2017). Varied reports of adult transgender suicidality: Synthesizing and describing the
peer-reviewed and gray literature. Transgender health, 2(1), 60–75.
https://doi-org.ezproxy1.library.arizona.edu/10.1089/trgh.2016.0036
🙡 Alante. (n.d.). Palliative care. Alante Health. https://alantehealth.com/palliative-care
🙡 Arora, V. M., & Stewart, N. (2017). Sleep in hospitalized older adults. Journal of Clinical Sleep Medicine, 13(1), 127-135.
http://doi.org/10.1016/j.jsmc.2017.09.012
🙡 Al-Mahrezi, A. & Al-Mandhari, Z. (2016). Palliative care: Time for action. Oman Medical Journal, 31(2), 161-163.
http://doi.org/10.5001/omj.2016.32
🙡 Care transitions: Clinical topics. Society of Hospital Medicine. (n.d.).
https://www.hospitalmedicine.org/clinical-topics/care-transition/
🙡 Centers for Disease Control and Prevention. (2022). Health literacy research: Medications. Retrieved November 15, 2022,
from https://www.cdc.gov/healthliteracy/researchevaluate/medications.html
🙡 Eloi H. (2021). Implementing teach-back during patient discharge education. Nursing forum, 56(3), 766-771.
https://doi.org/10.1111/nuf.12585
🙡 Hall, W. J., Ruiz Rosado, B., & Chapman, M. V. (2019). Findings from a feasibility study of an adapted cognitive behavioral
therapy group intervention to reduce depression among LGBTQ (lesbian, gay, bisexual, transgender, or queer) young people.
Journal of Clinical Medicine, 8(7), 949.
🙡 Kelly, M. E., Duff, H., Kelly, S., McHugh Power, J. E., Brennan, S., Lawlor, B. A., & Loughrey, D. G. (2017). The impact of
social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A
systematic review. Systematic reviews, 6(1), 259. https://doi.org/10.1186/s13643-017-0632-2
🙡 MedlinePlus. (2020). Heart attack - discharge. National Library of Medicine.
https://medlineplus.gov/ency/patientinstructions/000090.htm.

12
References

🙡 National Institute on Mental Health. (n.d.). ASQ screening tool. U.S. Department of Human Services.
https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/asq-screening-tool
🙡 Padilla Colón, C. J., Molina-Vicenty, I. L., Frontera-Rodríguez, M., García-Ferré, A., Rivera, B. P., Cintrón-Vélez, G., & Frontera-
Rodríguez, S. (2018). Muscle and bone mass loss in the elderly population: Advances in diagnosis and treatment. The Journal of
Biomedicine, 3, 40-49. http://doi.org/10.7150/jbm.23390.
🙡 Progovac, A. M., Mullin, B. O., Dunham, E., Reisner, S. L. McDowell, W., Roman, M. J. S., Dunn, M., Telingator, C., Lu, F. Q.,
Breslow, A. S., Forstein, M., & Cook, B. L. (2020). Disparities in suicidality by gender identity among medicare beneficiaries.
American Journal of Preventive Medicine, 58(6), 789-798. http://doi.org/10.1016/j.amepre.2020.01.004
🙡 Sanchis-Gomar, F., Perez-Quilis, C., Leischik, R., & Lucia, A. (2016). Epidemiology of coronary heart disease and acute coronary
syndrome. Annals of Translational Medicine, 4(13), 256. http://doi.org/10.21037/atm.2016.06.33
🙡 Tasheva, P., Vollenweider, P., & Kraege, V. (2020). Association between physical activity levels in the hospital setting and hospital-
acquired functional decline in elderly patients. JAMA Network, 3(1). http://doi.org/10.1001/jamanetworkopen.2019.20185
🙡 United Way of Tucson and Southern Arizona. LGBTQIA + resources. (2022). https://unitedwaytucson.org/lgbtqia-resources/
🙡 Vandervelden. (n.d). Portrait of an elderly transgender lady wearing a colorful dress. [Photograph]. Getty Images.
https://www.gettyimages.co.uk/detail/photo/transgender-lady-in-her-late-60s-royalty-free-image/1402910348?adppopup=true
🙡 Vernon, D., Brown, J., Griffiths, E., Nevill, A. M., & Pinkney, M. (2019). Reducing readmission rates through a discharge follow-
up service. Future Healthcare Journal, 6(2). http://doi.org/10.7861/futurehosp.6-2-114
🙡 Villines, Z. (2018, July 9). How does depression affect the body? MedicalNewsToday.
https://www.medicalnewstoday.com/articles/322395.
🙡 Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., & Johnson, S. (2018). Associations between loneliness and perceived social support
and outcomes of mental health problems: A systematic review. BMC psychiatry, 18(1), 156.
https://doi.org/10.1186/s12888-018-1736-5
🙡 Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes.
Federal practitioner : for the health care professionals of the VA, DoD, and PHS, 36(6), 284–289.

13