As noted above, cognitive impairment significantly impacts — and complicates — discharge planning and assessment of transitional needs and heightens risk for all-cause risk for readmission and is often overlooked or unknown. This tool along with those recommended earlier is available from the John A. As with any tool, the Mini-Cog represents a point in time and indicates current status and not a diagnosis.
It does, however, direct the clinical team towards a needed work-up. Any suspected or documented cognitive impairment with or without the above screening criteria should independently trigger post-discharge intervention to assure appropriate information transfer and follow-up after discharge to home or other care setting. It is imperative that either a well-informed caregiver be actively involved during the discharge process or a referral for visiting nurse services is made with preference for both being involved.
Implementing evidence-based practice
The TCM protocol schedule is very straightforward. There are a few minimal expectations but no rigid guidelines. The APNs are not held to productivity standards, but rather are given the time to address the complex needs of this most at high risk group and to address their needs ameliorable to intervention and long-term patient benefit. While day rehospitalization rates need to be radically addressed we also look to make changes that affect the long-term outcomes of not only the primary diagnosis but also of co-morbid conditions. The APNs are instructed to use their clinical judgment to determine the frequency number and intensity length of patient and caregiver visits and telephone contacts.
The minimal expectations are that a patient will be visited at the hospital within 24 hours of study enrollment; daily throughout the hospitalization; within 24 hours of discharge to home; at least weekly during the first month; and at least semi-monthly through the duration of the intervention. The APNs are strongly encouraged to attend the first discharge physician follow-up appointment if a transition in provider hospital-to-home is occurring. In addition to in-person visits the APNs monitor their patients via telephone.
Background and Significance
The APNs are available via telephone daily Monday-Friday and on an on-call basis on weekends to answer physician, patient, and caregiver questions. APNs initiate telephone contact with a patient during any week that a patient is not visited at home. Patients are visited in the acute inpatient setting within 24 hours of enrollment in the TCM program. Ideally they will have also been enrolled within hours of admission.
This assessment continues , completed, and amended after discharge to reflect hospital and home findings. Goals inform the emerging plan of care. The APN collaborates with provider and other members of the health care team to streamline the plan of care. Home visits should begin within 24 hours of discharge from the hospital.
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This is a critical time to assess understanding and patient implementation of the plan of care. Any delay in visiting is clearly documented and outcomes tracked.
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After the initial visit, a minimum of one home visit per week is made during the first month. Bimonthly visits continue until discharge from the program. Telephone contact is made with the patient, as needed, and in each week an in-person visit is not scheduled. An explicit, personalized plan for emergency care is developed during hospitalization and the initial visit. This plan addresses what to do during those hours when the APN is unavailable; it also lays the groundwork for longer term understanding of symptoms, early identification, and intervention.
It is informative for the APN to accompany the patient on their first post-discharge visit with their provider.
During the visit, the APN helps the patient and caregiver s to achieve their visit goals by coaching the patient to develop a list of questions and triage it prior to the visit so the most important issues are addressed. The APN will also provide the patient with copies of their hospital discharge and any tests for their providers review.
Per the standard definition, transitional care is time limited and from the initial assessment the APN should be continually assessing discharge readiness and ability for self-management.
Probable reasons for readmissions should be discussed and plans to monitor each set of symptoms are discussed with the patient. Needed referrals for social services, specialist care, or other services should be initiated early in the follow-up period. The APN assures continuity of care through communication with the provider s who will continue to follow the patient.
Discharge summaries and letters are written to each provider and a specific discharge plan created for the patient with a revised action plan included and personal health record. The APN will facilitate access to palliative care or hospice services, assisted living, or chronic case management, as needed, and within their scope of practice. The APN remains available to the patient for questions after discharge but does not re-open thecare episode.
Current barriers to widespread adoption of the TCM include the organization of current systems of care, regulatory barriers, lack of quality and financial incentives, and culture of care issues. The CCTP demonstration program offers a unique opportunity for the Penn team and health care systems to redefine care through adopting and adapting the TCM widely.
As noted before, the RCTs greatly informed our understanding of interventions needed to improve the transitions of older adults from hospital to home or other settings and importantly has informed our partnerships with health systems, insurers, and other key stakeholders in conducting ongoing translational efforts Naylor, Bowles, et al.
TL was enrolled in the TCM program during his acute episode of care. He was followed by the advanced practice nurse APN for 85 days. The visits were front loaded with greater than six occurring in the first 30 days post-discharge. Telephone calls to the patient served as reminders and status checks during the follow-up period. TL is a 78 year-old African-American male with a primary diagnosis of heart failure. TL was admitted to the acute care facility via the emergency room after arriving at an unrelated routine follow-up appointment acutely short of breath after walking three city blocks at a moderate pace in winter temperatures — a normal walking distance in his usual state of health.
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He reported being in his usual state of health until approximately one month prior. Since that time he has noted an increased weight gain and decreased exercise tolerance which he attributed to decreased workload at home and lack of activity due to seasonal change. Evidence Informed Nursing with Older People takes a unique case-study approach, with individual chapters presenting nursing practice-based case studies on some of the most common areas of care faced by nurses working around the world with older people.
Each case study illustrates the connections between practice, theory, evidence and values. User-friendly and accessible, this textbook includes key points, reflection activities, test points, and perspectives from older people throughout. Key features. Undetected location. NO YES. Evidence Informed Nursing with Older People.
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