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Experience with my mother over the past 3 years led me reflect on how we care for older adults. For those who do not have a nurse in the family to provide care coordination and oversight, how are the gaps in continuity of care and transitions in care addressed? Many specialized positions are emerging for nurses in care coordination. These positions tend to focus on the most complex patients and on selected transitions in care. There are pockets of excellence but nurses who provide direct care in inpatient and outpatient settings are the safety net for older adults like my mother. They need competencies in assessment of older adults and awareness of how illness may present differently in this population. They need to be aware of the entire continuum of care and provide care coordination for patients who are not receiving specialized care coordination services.
My very active mother is 79 years old and considers herself to be in pretty good health in spite of having atrial fibrillation, hypertension, borderline diabetes, severe back pain, cataracts, and Parkinson disease. She also has neuropathy in her feet and bilateral rotator cuff injuries that limit her range of motion. She lives in a rural area and must travel at least 30 minutes for general health care and an hour or more for specialty care. She reports that some weeks she has a hard time getting anything done except going to physician appointments. She sees an internal medicine physician, a podiatrist, orthopedic surgeon, ophthalmologist, chiropractor, and neurologist on a regular basis and periodically sees a cardiologist. In her experience, they do not communicate with each other about her care but they expect her to select the right things to do for her health from their varied advice. Sometimes their advice conflicts and then she selects the option she likes the best. Occasionally she asks advice from her nurse-daughter about what to do.
In January 2011, Mom took my Dad to be admitted to long-term care, after providing total care to him at home for 9 years. She underwent a total knee replacement later that month, which was followed by replacement of the second knee in November. With the first surgery, she was discharged from the urban hospital on the third postoperative day and admitted to a rehabilitation hospital in the same city. She spent a week there having physical therapy twice daily and occupational therapy once a day. We found the communications and handoffs to be less than ideal. Although she has never been on any medication for diabetes, she received sliding scale insulin when her blood sugar went slightly above 100. This bottomed out her blood sugar to the 40's, which required treatment, causing her to feel shaky and sick to her stomach when her next therapy session occurred. During our 3 to 4 phone conversations each day, I told her she could refuse the insulin. She is from a generation that often does not question those in authority, so she was reluctant to do that until her hypoglycemia reaction occurred on 3 consecutive days.
While in the facility, she learned how to do her laundry without harm to her knee. However, it appears it did not occur to anyone there that she might need to have help figuring out how to prepare meals and get them to the table while using a walker. As a result, she lost 15 pounds from her already thin frame in the 6 weeks after surgery. This was at a time when she needed energy to do physical therapy 3 times per week and daily exercises at home. She also had to arrange transportation to her therapy and other appointments because as long as she was taking pain medications she was told not to drive.
After her second surgery, there was a (somewhat) better plan of care in place. On the third postoperative day, the rehabilitation hospital had no beds, so she was admitted to a swing bed in the skilled care area of the long-term care facility where Dad was a resident. She spent 7 days there receiving therapy twice a day. The disadvantage to this arrangement was that she felt she had to go and check on Dad every day when she should have been focusing on her own recovery. I arranged to spend 2 weeks with her following her discharge so I could provide transportation to therapy and other appointments. I also made sure she had adequate nutrition so that she did not lose more weight during recovery. My brother stayed with her during the third week postsurgery. The therapy center arranged for their van to transport her for the next few weeks, and by the time she was 6 weeks postsurgery, she was able to drive on her own again.
Mom later had to have an arthroscopic surgery to remove scar tissue from the first knee. We were able to plan much better for her postsurgery care at home after this procedure. In about 3 weeks, she was back to her normal activities.
I live nearly 800 miles from Mom, but I am the one who provides the translation of varied instructions and prescriptions she receives. She has been known to stop taking medications after she looks up the side effects because she does not want to experience those. Because she is on Medicare, each year her primary care physician tries to put her on generic digoxin rather than brand name Lanoxin. Her heart "flutters" and she feels sick to her stomach after just 1 to 2 doses of generic digoxin, so we have had to find other sources of the brand name drug since her out of pocket payment would be $692 for a 3-month supply of the brand name medication. Periodically when I visit, I review all of her medications and attend physician appointments with her. I review the purpose of each medication and reinforce the importance of those that she needs to continue taking. On several occasions, I have found multiple prescriptions in differing doses of the same medications. So far, she has not had an adverse drug event.
I have shared this personal story to illustrate the challenges facing our geriatric population. My mother is not unique, except that she has a family member with a health care background helping her wend her way through the system. Most elders do not have a personal nurse looking out for them.
The number of persons older than 65 years is increasing each year. Baby Boomers (born 1946-1964) began to turn 65 in 2011. Older adults, in fact, are among the fastest growing age groups, and 20% of the population in the United States will be older than 65 years by 2020.1,2 It is projected that by 2050, the United States will be home to a million plus centenarians.1,2 In 2011, the Centers for Disease Control and Prevention life expectancy tables displayed the following life expectancies:3
Birth = 78.7 years
Age 65 = 84.1 years
Age 75 = 87.1 years
Older adults tend to have more chronic illnesses. It is projected that 60% of the population older than 65 years will have more than 1 chronic condition by 2030. Chronic diseases that become more common with age include diabetes mellitus, arthritis, congestive heart failure, and dementia. Medicare spends more than 8 of every 10 dollars on chronic illness care.4 In addition, older adults are susceptible to trauma caused by falling. According to the US Preventive Services Task Force (USPSTF), 30% to 40% of community-dwelling older adults fall each year and 5% to 10% of them experience a fracture, laceration, or head injury.5 Most of these falls occur at home. Falls are the leading cause of death due to unintentional injury. Persons who have experienced a fall often have a greater fear of falling and become more sedentary, which can lead to further impaired functioning and more likelihood of experiencing another fall.
Polypharmacy is another common issue for older patients. In the United States, the elderly (older than 65 years) comprise approximately 15% of the population but use 25% to 30% of all prescriptions and 40% of over-the-counter medications.6,7 The risk of adverse drug reactions increases by 16% if the person is taking 5 medications and continues to increase with each additional medication.6,7 The issue is exacerbated when patients have multiple chronic conditions and see multiple health care providers. They may also have prescriptions filled at multiple pharmacies. Combining these factors with changes of aging that affect absorption, distribution, metabolism, and excretion of medications make older patients much more likely to experience adverse drug events. Chronic illness, potential trauma from falls, issues of polypharmacy are just 3 of the challenges faced by aging adults. One of the promises of a transformed health care system is coordinated continuity of care, with Accountable Care Organizations decreasing system fragmentation and Case Managers working to smooth transition between health care silos. This projected future for our patients is exciting but has not yet transformed care in America. In the meantime, we have a growing population of older patients who, like my mother, deserve quality of coordinated care especially formulated for their needs. Nurses cannot wait for the "transformation." We have historically worked to make our patients health and lives better. It is our duty and privilege to intervene whenever we can to become the best possible nurses for our elders.
Registered nurses see older adults in many different practice settings and are in positions to positively impact their health care and how they experience that care. Emerging specialized roles for registered nurses that focus on coordination of care include nurse coordinator, nurse navigator, nurse facilitator, care manager, nurse expeditor, transition coach, health coach, and discharge advocate. Regardless of title, nurses who encounter older adults in their practice should develop their competencies for this patient population. According to the Hartford Institute for Geriatric Nursing, the competencies include the following:
2. Physiological and Psychological Age Changes
4. Skin Integrity
5. Functional Status
* Overall Function
* Urinary Incontinence
* Falls and Injuries
7. Elder Abuse
8. Discharge Planning8
Illnesses may present differently in older adults, so it is important to assess them effectively. For example, in a younger person, a urinary tract infection may present with frequency, burning, bladder spasms, blood in the urine, and fever. In an older person, the changes of aging may mask those symptoms so the first indication may be confusion or a fall. If the assessment is not pursued, the infection may be missed until it becomes severe or even life threatening.9
Continuity of Care is an intuitive concept that should help persons' transition smoothly as they receive health care, yet it eludes many persons experiencing our health care system today. They tend to experience the system in fragments as they go back and forth between primary care and specialty physicians, hospital to rehabilitation to home, etc.
Effective assessment is a critical foundation for the plan of care for older patients. Nurses need to know the physiological and cognitive changes that commonly occur with aging. Fortunately, there are many excellent resources available to help increase and maintain competencies regarding older adults.
Hartford Institute for Geriatric Nursing in collaboration with the American Journal of Nursing offers "Try This" and "How to Try This" assessment tools on a variety of topics pertaining to older adults.9 They include excellent demonstration videos, as well as print versions of the assessment tools. There are more than 25 assessment topics available on the Web site (http://nursingcenter.com) including such topics as pain assessment, sexuality, caregiver strain, and fall risk. The videos are accessible for no charge, and copies of the assessment tools may be obtained for a charge of $7.95.
New NICHE (Nurses Improving Care for Healthsystem Elders) has developed and tested several models to address the needs of older adults. The Geriatric Resource Nurse model prepares staff nurses to serve as geriatric experts on their units. They are trained by geriatric advanced practice nurses with a focus on geriatric syndromes such as falls and confusion. This model has been implemented in multiple types of units and has led to systematic and documentable improvement in care of the older adults.10
Moreover, NICHE has developed the ACE (Acute Care of the Elderly) Medical-Surgical Unit model. One of the goals of this type of unit is to prevent functional declines in older adult patients. ACE units typically include environments that have been adapted with enhanced lighting, flooring that decreases glare, communal areas for meals and activities, clocks and calendars in every room, staff that has expertise in geriatrics, and a dedicated interdisciplinary team. If available, families are incorporated into the care and planning for the patient. The geriatric advanced practice nurse practitioner and the geriatric medical director collaborate to provide clinical leadership and ongoing staff development.11
Many ACE concepts can be implemented even without a separate unit. For example, any facility can choose to make changes in the physical environment to address age-related changes and increase patient safety. They can also provide geriatric training for nurses and other staff who work with older adults.12
The Hartford Foundation and NICHE have jointly developed Evidence-Based Geriatric Nursing Protocols for Best Practice. These protocols have been tested in more than 300 hospitals and include evidence from community, primary, and long-term care. The fourth edition of the protocols was published in 2013. The protocols address common clinical conditions and issues in older adult patients. They are an excellent resource for anyone who works with older adult patients.13 Whether nurse leaders and hospital systems choose to become certified in geriatric care, or establish elder units, good models include evidence-based practices for all of our patient populations. In addition, registered nurses have a duty to coordinate care for all patients who receive their care. Currently, this coordination may only extend to the "silo" of health care, where the nurse practices until she/he has transferred care to another clinician within the continuum of care. However, it is an ethereal responsibility of our profession to ensure and to plan for an appropriate transfer, after careful assessment of what our patients will need after they leave our direct care. The geriatric population especially needs this attention to their care plan during and after hand off of care.
Patient-centered care coordination is a core professional standard and competency for all nursing practice.14,15 In addition, the American Association of Colleges of Nursing16 lists the ability to evaluate and optimize available health care resources as an essential competency for the baccalaureate-prepared nurse. The American Nurses Association (ANA) code of ethics guides nursing's responsiveness to changing health care systems and the context in which health care is provided, further supporting the care coordination role of the nurse.17 The ANA advocates for the vital role of nurses in the design and implementation of care coordination systems. The care coordination process is one part of professional practice through which nurses at every level influence patient care.15,18
The first American Nurses Association Professional Issues Panel focused on development of the Framework for Measuring Nurses' Contributions to Care Coordination.19 More than 300 nursing experts in care coordination participated in the work during 2013. The Framework, approved by the ANA Board of Directors in 2013, includes 3 elements: guiding principles, structural components, and measurement context. It will be widely disseminated, followed by publication of Care Coordination: The Game Changer, edited by Geri Lamb in early 2014. Nurses will need to familiarize themselves with these new resources to be as prepared as possible to integrate care coordination into their direct care roles.
Goals of Coordination of Care include maintaining continuity of care, collaboration and partnership with patients, fostering patient understanding, patient self-management of health issues, preventing decline/readmission, medication reconciliation and management, connecting to community resources, "translation" of information between physicians and others to patients and families, facilitating appointments for follow-up with primary care and specialists, addressing barriers, and facilitating patient accountability. All of these activities will improve the care of elders, throughout the continuum of care. While all, or many consumers will benefit from Case Management (or RN care coordination), older adults' lives will be especially better with this attention to their needs.20
There are already many excellent resources available to aid in increasing a nurse's knowledge base about changes of aging, common chronic conditions, assessment of older patients, effective evidence-based interventions, and care coordination. These can assist in developing the proficiencies needed to care for geriatric consumers of health care. Nurses are often in a position to make a difference for their older adult patients by planning for care in the continuum. Whenever and wherever nurses care for elders, they can work with patients to determine what elders need to maintain the quality of their lives in spite of physical limitations. Direct care nurses providing coordination of care and integration of services in the settings where she received care would have been invaluable in the care of my Mom. In the new era of accountable care, nurses need to take this broader view rather than an episodic or fragmented view of the patient experience in the health care system.
We don't have to wait for those new roles to be developed and implemented. We can begin providing a better quality of nursing care for elders right now. Nurses in every segment of health care can improve the health and well-being of everyone's mother (and father), and every other older patient. When we learn more about and practice, holistic geriatric nursing, we will improve the lives of this very special population.
1. Healthy People 2020. Older adults. http://www.healthypeople.gov. Accessed November 24, 2013. [Context Link]
2. Healthcare intelligence network. Baby boomers' impact on healthcare: high demands, expectations met with a healthy dose of prevention. http://www.hin.com/library/babyboomersandhealthcare.pdf. Published 2006. Accessed November 23, 2013. [Context Link]
3. United States Life Tables, 2009. NVSR 62(7). http://www.cdc.gov/nchs/products/life_tables.htm Accessed November 24, 2013. [Context Link]
4. Centers for Medicare & Medicaid Services. Chronic conditions among medicare beneficiaries. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Re. Accessed November 24, 2013. [Context Link]
5. U.S. Preventive Services Task Force. Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(3):197-204. http://www.uspreventiveservicestaskforce.org/recommendations.htm. Accessed November 24, 2013. [Context Link]
6. American Geriatrics Society (AGS). AGS updated BEERS criteria for potentially inappropriate medication use in older adults. http://www.americangeriatrics.org/health_care_profssionals/clinical_practice/cli. Published 2012. Accessed October 12, 2013. [Context Link]
7. Dayer-Berenson L, Martinez Y, Pavolovich-Danis S. Polypharmacy in the elderly. http://ce.nurse.com/course/ce214-60/polypharmacy-in-the-elderly/. Accessed November 24, 2013. [Context Link]
8. Hartford Institute for Geriatric Nursing. Hospital competencies-competency: care of adult 65 years +. http://consultgerirn.org/resources/hspital_competencies/. Published 2006. Accessed October 12, 2013. [Context Link]
9. Hartford Institute for Geriatric Nursing. Try This: (R) Assessment Tool Series: General Practice Specialty Practice and Dementia Series. http://hartfordign.org/Resources/Try_This_Series. Accessed October 12, 2013. [Context Link]
10. Nurses Improving Care for Healthsystem Elders (NICHE) Web site. http://www.nicheprogram.org. Accessed November 23, 2013. [Context Link]
11. NICHE Encyclopedia. ACE model. http://www.nicheprogram.org/niche_encyclopedia-ace_units-ace_model. Published 2006. Accessed November 24, 2013. [Context Link]
12. Sanders ED. Older adult patients-Texas hospitals respond. Texas Nurs Voice. July, August, September 2012:6(3):5-6. [Context Link]
13. Hartford Institute for Geriatric Nursing. Geriatric nursing resources for care of older adults. http://consultgerirn.org. Published 2012. Accessed November 23, 2013. [Context Link]
14. American Nurses Association. Care coordination and registered nurses' essential role. http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Res. Published 2012. Accessed November 23, 2013. [Context Link]
15. Cipriano P. American Academy of Nursing on Policy. The imperative for patient-, family-, and population-centered interprofessional approaches to care coordination and transitional care: a policy brief by the American Academy of Nursing's Care Coordination Task Force. Nurs Outlook. 2012;60(5):330-333. [Context Link]
16. American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. 2008. http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf. Published October 20, 2008. Accessed December 9, 2013. [Context Link]
17. American Nurses Association. Code of ethics for nurses with interpretive statements. http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNu. Accessed December 26, 2013. [Context Link]
18. American Nurses Association. The value of nursing care coordination. http://www.nursingworld.org/carecoordinationwhitepaper/. Published 2012. Accessed November 23, 2013. [Context Link]
19. American Nurses Association. Framework for measuring nurses' contributions to care coordination. http://www.nursingworld.org/Framework-for-Measuring-Nurses-Contributions-to-Care. Published October 2013. December 26, 2013. [Context Link]
20. Cropley S, Sanders E. Care coordination and the essential role of the nurse. Creat Nurs. 2013;19(4):189-194. [Context Link]
older adult resources; care coordination
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