Chapter 28 Using Current System Models to Guide

Chapter 28: Using Current System Models to Guide Care

Learning Objectives • Explain geriatric care as a continuum. • Identify the types of models of care and services available to older adults, including acute care, transitional care, care coordination, community care, and nursing home care models. • Describe appropriate coordination of the components of the healthcare system to provide better services to meet the needs of the older adult at different points in time. • Understand the role of the nurse in new models of care.

Acute Care Models and Programs • Acute Geriatric Units (AGUs) – Care for older adults with acute medical conditions – More efficient and more functional benefit than conventional hospital care • Acute care of the elderly units (ACE) – interdisciplinary team with special expertise in geriatric care; environmental adaptations used to prevent functional decline in older adults in acute care setting

Acute Care Models and Programs (cont’d) • Geriatric resource nurse (GRN) – Trained by geriatric nurse specialist • Nurses Improving Care for the Hospitalized Elderly (NICHE): Hartford Institute Program – Mission to create better care environments for hospitalized older adults • Transforming Care at the Bedside (TCAB) – Research-based “how to” guide to improve quality of care; Robert Wood Johnson Foundation National Program.

Transitional Care Models and Programs • Care Transitions Intervention (CTI): Univ. of Colorado – assistance with self-management of medications – patient-centered medical record that is kept by the patient – timely follow-up with primary physician or specialists – a list of signs and symptoms that could indicate worsening of their condition

Transitional Care Models and Programs (cont’d) • Transitional Care Model (TCM) – Addresses needs of elders with chronic conditions after discharge from hospital • Money Follows the Person (MFP) – Helps states rebalance long-term care systems by transitioning eligible Medicaid recipients from long-term care institutions back to the community

Transitional Care Electronic Resources • National Transitions of Care Coalition (NTOCC): provides consumer tools and resources, healthcare provider tools, and best practice tips to enhance transitional care. • Next Step in Care: provides information and advice to help family caregivers. http: //www. nextstepincare. org • BOOSTing Care Transitions: Provides materials to help optimize the discharge process at any institution

Community Care Models and Programs • Adult daycare – Supervised daily care in a nonresidential facility for the elderly and disabled • Aging in place – Ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level

Community Care Models and Programs (cont’d) • Assisted living – assistance and monitoring of older residential adults who can’t live independently but don't need 24 -hour skilled nursing home care • Home care skilled services – Skilled nursing and/or therapy services in the home

Community Care Models and Programs (cont’d) • Intergenerational care – Several generations receive ongoing services or care in the same location • Program of All-Inclusive Care for the Elderly (PACE) – To help older adults remain in the community

Nursing Home Care Models • Culture change – More person-centered care in LTCFs • Eden Alternative model – Person-centered core • The Green House – Homelike environment • Pioneer Network – Holistic, individualized care for elderly and chronically ill

Summary • Many systems can be used to design care for older adults • These models can assist gerontological nurses to plan system or city-wide care • Aging in place • Maintaining quality of life in spite of health challenges