1. APPLICATION IN A CONTINUING CARE RETIREMENT COMMUNITY
The ACES Framework
APPLICATION IN A CONTINUING CARE RETIREMENT COMMUNITY

3. ACES Essential Nursing Actions
Assess Function and Expectations
Coordinate and Manage Care
Use Evolving Knowledge
Make Situational Decisions

4. Assess Function and Expectations
Ask the question……..
what is current function and how far is current function from baseline?
Many of the older adults we care for seek treatment for one complaint, but other matters complicate the picture. This is the overwhelming piece..where to start and many times the “other matters” are mental health issues which on their own are overwhelming. We teach students to prioritize and often the issue that brings an individual to treatment for is the priority issue but it is the mental health issue that makes the person less likely to optimize for example physical therapy after a CVA or a broken hip.
The other day I saw a patient in the rehab center…he was 54 years old and had a stroke that left him blind ..He was working as a computer analyst and every staff member said the same thing…how tragic..and it was
However if an 80 year old is living in assisted living and now broke a hip and is depressed and probably not able to return to assisted living health care professionals are much more accepting
The question…how far is the person physically from baseline may be an easier question…how far are they mentally is more difficult…I like to ask in increments…how was mom last week…six months ago…a year ago to get a sense of where the person is likely to return to…this is especially key when we look at cognitive issues

5. Functioning as a Predictor
Can’t separate the two…is a person not walking because they are now depressed and has been so psychomotor slowed that they are now deconditioned?
Is a person falling because they are forgetting their walker?
Is a person not able to complete a task in physical therapy because they can’t follow direction (cognitive problem) or they don’t care (mood problem) or they are frightened (anxeity) or they physically are unable?

6. Transitions Comprehensive Assessment
Core features of Transitional Care:
Comprehensive Assessment
Implementation of an evidenced based plan of transitional care.
Care the is initiated at hospital admission, but extends beyond discharge through home and telephone visits.
Mechanisms to gather and share information across settings of care
Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patient's potential needs at the time of admission and continues throughout the patient's stay. Ongoing consultation with the patient care team and reassessment of the patient's changing medical functional, social and cognitive capabilities assures that the comprehensive needs of the patient are addressed. Patients and families are apprised of the appropriate community resources available and encouraged to participate in all phases of the transitional care planning process. Referral mechanisms with community providers occur in a timely, systematic fashion in order for the patient to gain access to identified resources. The process concludes with the coordination and implementation of services and transition to the least restrictive level of care in keeping with the individual's wishes.
•Transitional Care Planning considers the patient's medical, physical, cognitive, economic and emotional strengths and abilities as well as their available support system
•Assessment of the patient's level of functioning prior to admission provides insight into resources available post discharge
•Ongoing collaboration between the patient, family and the interdisciplinary team provides an invaluable link, which facilitates the process of informed decision making
•Patients and families will receive verbal and written information of the range of services and available options available in the patient's community
•Patients and families will be given the opportunity to select the providers of services whenever possible
Involving patient and caregivers in planning and executing the plan of care.
Coordinated services during and following the hospitalization

7. (Quality and Safety in Nursing Education)
QSEN
(Quality and Safety in Nursing Education)
Patient-centered care
Evidence-based practice
Teamwork and collaboration
Safety
Quality improvement
Informatics

8. Quality of Life Considerations
What Risks is an individual willing to talk to get the Benefits they want…..What risks do you take?
What are the client’s Expectations?
How is a GOOD Quality of Life defined?
Are older Adults asked what they want?....are you?