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. 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