Advancing Geriatric Competencies
Case Study: Transitional Care
M. Catherine Wollman DNP, GNP-BC
Assistant Professor and Coordinator
Adult and Geriatric NP Program
Neumann University, Aston, PA
From the Hartford Institute for Geriatric Nursing
Web Based Case Studies
Introduction
• Modeled after the Geriatrics and the Advanced
Practice Curriculum: A Series of Web-Based
Interactive Case Studies currently found on the
Hartford Institute for Geriatric Nursing clinical
website ConsultGeriRN.org
(www.ConsultGeriRN.org/ ap_case_studies
• User-friendly way for faculty to include necessary
content
• Evolving cases which are interactive, tutorial in
format, and intended for use by students
Additional Case Studies
• Geropsychiatry
– Evaluation and Management of Memory Impairment for
the NP by Elena Schjavland, MS, APRN CNRN and Gwyn M.
Vernon, MSN, CRNP
– Evaluating Acute Confusion: A CNS Perspective by
Caroline Stephens, PhD, APRN, BC
• Co-morbidities
– Dizziness & Falls by Rosemarie Brager, PhD, CRNP
• Medication Management
– Medications and Adverse Outcomes in Older Adults by
DeAnne Zwicker, DrNP, APRN,BC
• Transitional Care
– Transitional Care for the Adult-Gerontology CNS by M.
Brian Bixby, MSN, CRNP and Mary D. Naylor, PhD, RN
– Transitional Care for the NP by M. Catherine Wollman
MSN, GNP-BC
• Urinary Incontinence
– Management of Urinary Incontinence for AdultGerontology APRNs: A Case Study by Marie Mangino,
MSN, CRNP, BC-G and Christine Bradway, PhD, RN, CRNP
Copyright and Permissions
"All materials are jointly copyrighted by the American Association of
Colleges of Nursing (AACN) and The Hartford Institute for Geriatric
Nursing, College of Nursing, New York University or are used with
permission from the original source. Permission is hereby granted to
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of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric
Nursing, College of Nursing, New York University are cited as the source.
They may not be used for ANY commercial or other purpose."
Available at www.hartfordign.org
E-mail notification of usage to: hartford.ign@nyu.edu
Acknowledgements
This module was prepared in collaboration with the
New Courtland Center for Transitions and Health at
the University of Pennsylvania School of Nursing,
Mary D. Naylor, PhD, RN, FAAN, Director
Learner Outcomes
At the completion of this case study, the
student should be able to:
•
•
•
Identify patients at high risk for poor outcomes at
the time of a transition
Define challenges and complex issues of
transitional care
Assume accountability for controllable and
anticipated issues surrounding transitions.
Recommended Reading
Coleman, E. A., Smith, J. D., Frank, J. C., Min, S.-J., Parry, C., &
Kramer, A. M. (2004). Preparing patients and caregivers to
participate in care delivered across settings: the care
transitions intervention. Journal of the American Geriatrics
Society, 52, 1817-1825.
Coleman, E. A., & Boult, C. (2003). Improving the quality of
transitional care for persons with complex care needs. Journal
of the American Geriatrics Society, 51, 556-557.
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009).
Rehospitalizations among patients in the Medicare fee-forservice program. The New England Journal Of Medicine, 360,
1418-1428.
Kripalani, S., Jackson, A. T., Schnipper, J. L., & Coleman, E. A.
(2007). Promoting effective transitions of care at hospital
discharge: a review of key issues for hospitalists. Journal of
Hospital Medicine, 2, 314-323.
Naylor, M. D. (2006). Transitional care: a critical dimension of
the home healthcare quality agenda. Journal for Healthcare
Quality: Promoting Excellence in Healthcare, 28(1), 48-54.
Additional websites
• The teach-back method
http://www.nchealthliteracy.org/toolkit/tool5.pdf
• The Care Transitions Program
http://www.caretransitions.org/
• The Transitional Care Model
http://www.transitionalcare.info/
Opening statement about patient
• Mrs. Teresa C. is an 82 year old Caucasian female who lives
independently in her one story home. She lives with Sam, her
84 year old husband who is identified as having cognitive
issues.
• Pt is 5' 2” and 145 lbs. She sees her PCP twice a year as well
as her cardiologist and orthopedic surgeon
• Daughter, Ann, lives nearby with her husband and three
teenagers. She has expressed concern about her parents
living alone. Ann or her husband visit daily and assist with
shopping, housekeeping and home maintenance. Two
additional children live out of state. Mr. and Mrs. C. insist
they are doing fine.
Subjective data
1. HTN for 20 years
–
furosemide 20 mg. daily, lisinoipril 10 mg. daily, and carvedilol 10
mg. daily
2. CHF for 2 years
–
–
furosemide, lisinopril and carvedilol
weighs herself infrequently but weight only varies by 1-2 lbs.
3. DM type II for 12 years
–
–
glipizide 5 mg daily
overweight
4. Chronic kidney disease, Stage 3
5. Hyperlipidemia
–
simvistatin 20 mg daily
6. Incontinence
–
tolteradine 2 mg ER
7. Macular degeneration
– Still driving car
8. Peripheral neuropathy and lower extremity weakness
– Fell twice in last two months
9. Chronic pain due to OA in hips; s/p bilateral knee
replacements
– acetominophene 650; Takes 5-6 tabs q day
10. Preventive health care
–
–
–
–
ASA 81 mg. daily
MVI daily; Calcium with Vitamin D
Doesn’t monitor blood glucose
No recent podiatry or ophthalmology care
Question #1
• What biopsychosocial factors place Mrs. C. at
high risk for poor health care outcomes? Press
submit after entering your answer.
Answer Question #1
• Over age 80
• Multiple chronic conditions
• High risk chronic conditions i.e. CHF, DM, chronic
pain
• Multiple providers
• Complex medication regimen
• History of falls
Question #2
• What other subjective information would be
essential to know, especially if Mrs. C were to
be hospitalized? Provide rationale for your
answer. Press submit after entering your
answer.
Answer #2
•
Mental status, ADL and IADL function, use of assistive
devices, sensory status, pain level
– Rationale: Baseline function is essential knowledge to determine
accurate, safe and effective plan of care.
•
Affect
– Rationale: Depression associated with chronic disease decreases
quality of life and significantly increases health service use and costs.1
•
Adherence to medications, OTC use or substance use
– Rationale: Adverse drug reactions increase with numbers of
medications2
1
Decker, S., Schappert, S., & Sisk, J. (2009) Use of medical care for chronic conditions. Health
Affairs, 28(1), 26-35.
2 Rogers, S., Wilson, D., Wan, S. Griffin, Mark; Rai, G., & Farrell, J. (2009) Medication-related
admissions in older people. Drugs & Aging, 26, 951-961.
Answer #2 (Cont’d)
•
•
•
•
Perceived level of health, previous ER or hospitalization use
– Rationale: Perceived state of health and previous health care use are
predictive for readmission1
Level of caregiver burden, use of community resources,source of health
insurance
– Rationale: Data is essential to support an effective discharge plan
Satisfaction with providers, health care follow up
– Rationale: Providers must support evidence-based geriatric plan in
partnership with patient
Advance directive
– Rationale: Multiple chronic diseases, age, and frailty suggest need for
advance planning. Patient values and goals must be considered.
1Soler,
R., Juvinyà, C., Noguer, C., Poch, C., Brugada, M., & Del Mar, G. (2010). Continuity of care and
monitoring pain after discharge: patient perspective. Journal of Advanced Nursing, 66, 40-8.
Additional subjective data
• Mrs. C.’s MMSE is 28/30. She has a high school education.
• She smiles appropriately but appears anxious.
• Feels her health is fair to poor. More tired recently.
Sometimes overwhelmed with husband’s behavior. He is
often belligerent and awake multiple times at night.
• She has an unsteady gait and uses a walker outside the home.
She holds onto railings and walls within her home.
• Has mild to moderate pain (3/10) in hips or lower legs at all
times. She has severe pain (7 or 8/10) if she stands over 15
minutes. Uses two Tylenol ES every day at least three
times/day.
• Very careful about taking her medications as prescribed.
• Uses Senna and Colace OTC. Complains of frequent
constipation. No drinking or smoking.
• Appetite is fair. Uses Meals on Wheels for lunch and dinner
during the week. Daughter brings meals on weekends.
Doesn’t follow special diet.
• Still drives during the day but very difficult to get to physician
offices because she can’t leave her husband alone. “Only
drives in the neighborhood.”
• Sees PCP and cardiologist every 6 months. She likes them and
feels they are attentive to her health care needs.
• No advance directive in place.
• Hearing and vision impaired. No recent ophthalmology care.
• Medicare and AARP supplemental insurance
• To ER 6 months ago with hypoglycemic episode.
Acute Care Event
• Mrs. C. calls her daughter to complain of severe shortness of
breath and her daughter calls 911.
• She is seen in the ER and rules in for a NSTEMI with
exacerbation of HF. Following stabilization, she has a cardiac
catheterization and is transferred to ICU.
• The acute care NP in the ICU obtains a brief history from her
daughter and reviews the results of her BNP, ABGs, serum
chemistries, LFTs, chest x-ray, EKG, echocardiogram and
cardiac catheterization.
• The cardiologist recommends a two vessel bypass as opposed
to PTCA because of her diabetes. Mrs. C. refuses surgery and
wants to go home as soon as possible because she is worried
about her husband.
• The acute care NP has done a complete H and P and is aware
of all co-morbidities, prescription and OTC medications.
• She has talked to Mrs. C. and her daughter, Anne at length
and is aware of the functional status and stressors in Mrs. C.’s
life, especially related to her caregiving responsibilities.
• The NP orders removal of foley catheter on day 2, maintains
careful diuresis, administration of oxygen, intense glucose
management, and medications based on evidence-based
protocols for MI and HF.
Question #3
• What interventions are essential to begin in
ICU in order to prepare Mrs. C. for her
eventual transition to home? Provide
rationale for your answers. Press submit after
entering your answer.
Answer #3
• Assess for delirium with use of the confusion assessment
method (CAM).
– Rationale: Up to 60 % of older adults experience a delirium prior to or
during a hospitalization but the diagnosis is missed frequently.
Delirium is associated with poor outcomes such as prolonged
hospitalization, functional decline, increased use of chemical and
physical restraints. Patient’s decision making needs to be validated.
• Discuss end-of-life treatment wishes related to terminal and
palliative care
– Rationale: Clear documentation of patient preferences and goals will
direct ongoing patient care and verify use of appropriate resources.
Answer #3 (Cont’d)
• PT and OT referrals to begin early ambulation and evaluation
of safety and function.
– Rationale: to prevent deconditioning, prevent falls, and identify
appropriate assistive devices early
• Nutritional consult to evaluate diet related to DM and CHF
and make recommendations.
– Rationale: Early intervention to allow for several educational sessions
• Social work consult to evaluate for community support and
referrals.
– Rationale: Patient is caregiver for spouse. Additional assessment and
identification of resources are essential to determine ability to live
safely in their home.
Answer #3 (Cont’d)
• Pharmacy consult to evaluate adequacy and safety of
medication plan.
– Prevent inappropriate medication use and simplify complicated
medication regimen
• Communicate with PCP to review details of hospitalization
and pending results of tests or referrals.
– If EMR is unavailable, telephone, or fax communication will be
essential to update PCP, support follow up appointments, and
improve safety.
• Participate with interdisciplinary team to establish ongoing
discharge plan.
– Rationale: Discharge planner needs updated information in order to
determine appropriate plan at the time of transition.
Answer #3 (Cont’d)
• Use teach-back method to educate patient and daughter
about new diagnosis and medications. Ask patients (or their
caregivers) to verbally “teach back” information they’ve
received about proposed treatments, services, and
procedures
– Rationale: Health care practitioners have an ethical responsibility to
promote shared decision making and to work with patients and their
caregivers to negotiate treatment plans that respect the patient’s
values, preferences, and goals for care. Communicating and teaching
effectively will support self care abilities.
Question #4
• Mrs. C. is transferred to the intermediate
stepdown unit on day 3. What are the priority
interventions for a successful transition from
ICU to the stepdown unit? Provide rationale
for your answers. Press submit after entering
your answer.
Answer #4
• Aim for daytime transfer
– Rationale: Transfer of information will have improved accuracy when
staffing is at its maximum.
• Written documentation from ICU reflects functional,
cognitive, and affective problems at baseline and at the time
of transfer.
– Rationale: Medical diagnoses alone do not represent comprehensive
picture of patient status and prognosis.
• Accurate medication list to reflect previous medications taken
at home, new medications, and medications taken previously
that are to be discontinued.
– Rationale: Patient teaching requires reinforcement of essential
changes and patient statement of understanding.
Answer #4 (Cont’d)
• In person visit on day of transfer by acute care NP or
designated staff.
– Rationale: Verbal transfer of critical information in addition to written
plan will prevent errors at the time of transition.
Additional Subjective Data
• Mrs. C. is ready for discharge from the stepdown unit on day
five.
• Additional diagnoses include CAD, CKD Stage 3, depression,
diabetic neuropathy, chronic pain from OA, chronic
constipation, decreased hearing and gait disturbance.
• Continued meds for Mrs. C. include ASA, simvistatin, MVI,
glypizide and cardevilol with the same dosages as previously.
Lisinopril is increased to 20 mg daily and furosemide is
increased to 40 mg.
• New meds included oxycodone 15 mg twice/day,
acetaminophen 325 mg. po prn for pain; calcium with vitamin
D, Miralax 1 capful daily, and duloxetine 30 mg daily
• Discontinued medications included tolterodine which hasn’t
been effective.
• Still refuses surgery but will continue to think about the
option.
• Has copy of advance directive and will discuss further with
PCP at follow up appointment.
1Swagerty,
D., & Brickley, R. (2005). American Medical Directors Association and American Society of
Consultant pharmacists joint position statement on the Beers list of potentially inappropriate medications in older
adults. Journal of the American Medical Directors Association, 6 (1),80-6 .
• Pain is 0/10 at rest and 3/10 with ambulation with addition of
oxycodone.
• Didn’t want to take more medication but agreed to take
oxycodone and duloxetine to treat probable depression and
pain.
• Working with the social worker to find Adult Day Care for her
husband, Sam. Children will assist with cost.
• Still very tired but happy to be working with PT to improve
strength.
• Denies chest pain, shortness of breath, dizziness, palpitations.
Additional objective data
• Lab results prior to discharge include:
–
–
–
–
–
Glucose (fasting): 120mg/dl (normal range: 65–109 mg/dl)
Creatinine: 1.8 mg/dl (normal range: 0.5–1.4 mg/dl)
Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)\]
Lipid panel
• Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
• HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
• LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
• Triglycerides: 130 mg/dl (normal: <150 mg/dl)
– A1C: 7.6% (normal: 4–6%)
– Hb 11.8 Hct 36
– Cardiac enzymes, liver function, TSH, albumin, UA and additional
chemistries WNL
• PE findings:
– Weight: 138 lb; height: 5′2″; body mass index (BMI): 26kg/m2
– Blood pressure: lying, right arm 134/76 mmHg; sitting, right arm
130/72 mmHg
– Heart: rate reg 78, no murmurs or gallops
– Eyes: corrective lenses, PEERLA. Additional assessment deferred to
ophthalmology
– Thyroid: non-palpable
– Lungs: clear to auscultation, resp rate 20
– Vascular: no carotid bruits; femoral, popliteal, and dorsalis pedis
pulses 2+ bilaterally
– Neurological: diminished vibratory sense to the forefoot, absent ankle
reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the
ankle
– Able to walk 50 feet with rolling walker
Assessment/Plan Prior to Discharge
1.
2.
3.
4.
5.
Hypertension controlled with lisinopril and carvedilol
HF – continue lasix, lisinopril and carvedilol and follow up
with cardiology
Type 2 diabetes - continue present medication (A1C
acceptable at 7.6%)1 Review teaching from dietician. Follow
up with ophthalmologist.
CKD stage 3 –hypertension and glucose under control;
caution with any new drugs
Hyperlipidemia controlled with simvistatin
1California
Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders
with Diabetes. (2003) Journal of the American Geriatric Society S1: S265-S280
6.
Incontinence – discontinue tolteradine and observe
symptoms
7. Macular degeneration – follow up with ophthalmology for
low vision assessment and to determine if she is safe to
drive
8. Peripheral neuropathy – started Cymbalta; follow up with
podiatrist
9. Chronic pain –started oxycodone twice/day and tylenol prn
10. Self-care management/lifestyle deficits
–
–
–
Limited exercise, no SMBG program
Limited understanding of diabetes, CAD and HF
Continue ASA , MVI and Calcium with Vitamin D
11. CAD - continue present meds and follow up with
cardiology
12. Depression – started Cymbalta
13. Constipation – started Miralax
14. Caregiver burden – referral to Social Work
Question # 5
• What are the additional and essential
components of the discharge plan in order to
achieve successful transition to home? Press
submit after entering your answer.
Answer # 5
• Referral to home care for skilled nursing, PT and social work.
Include follow up contact with home care nurse or NP to
identify priorities.
(Note: Patient will be home bound for a period of time so is eligible for services.)
• Teach back method with patient and caregiver again to review
all of elements of plan of care.
• Written documentation of medications with highlighted
changes.
• Written documentation of signs, symptoms and red flags that
prompt a call to PCP or other designated clinician.
• Explicit written list of follow up studies, appointments, and
contact information if concerns arise.
Answer # 5 (Cont’d)
• Understanding of activity limitations and functional
expectations.
• Communication with PCP to update re: status at time of
discharge and additional pending test results or referrals.
• Arrange home visit by NP if possible.
• Give patient a copy of her own personal health record
including:
–
–
–
–
–
–
Medical history with all active problems
Contact information for all health care providers
Information about advance directives
Updated medication list
List of clinician appointments and tests
Record of recent hospitalizations with information related to
admission, discharge, and primary reason for hospitalization
– Recent test results
– Immunization record and other preventive health care information
Answer # 5 (Cont’d)
• Follow up with patient by telephone 2-3 days after discharge
to validate:
– Status of priority problems i.e. HF, DM, CAD, chronic pain.
Address disease specific issues e.g. weight, glucose readings
– How is she doing with medications? Side effects or problems?
Questions? Review discharge list of medications
– Were all of her questions answered at time of discharge?
– Have there been any difficulties arranging follow up
appointments with PCP, ophthalmologist ,or cardiologist?
– Ask “What questions do you have?”
Ongoing Challenges of Transitional Care
• Providers increasingly define their practice by
location.
• Patients with dramatically increased complexity of
care
• According to research published in the New England
Journal of Medicine, 20% of hospitalized patients on
Medicare were readmitted within 30 days after
discharge with a cost of $17.4 billion in 2004.1
1Jencks,
S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the
Medicare fee-for-service program. The New England Journal Of Medicine, 360, 1418-1428.
• High risk patients frequently transfer across sites of
care and transition from one level of health to
another.
• Patients lack confidence in their ability to effect the
plan of care.
• Reimbursement does not presently support payment
for transitional care interventions.
• Rehospitalizations create significant
quality of life and cost burden.
Priority Goal of Transitional Care
The nurse practitioner must assume
a lead role in supporting and
coordinating quality transitional
plans of care for high risk patients.
Additional Transitional Care Resources
Agency for Healthcare Research and Quality (AHRQ). (2010). Taking care of myself: A
guide for when I leave the hospital. Retrieved from
http://www.ahrq.gov/qual/goinghomeguide.pdf
American Geriatrics Society (AGS). (2007). Position Statement: Improving the quality
of transitional care for persons with complex care needs. Retrieved from
http://www.caretransitions.org/documents/Improving%20the%20quality%20%20JAGS.pdf
Care Transitions Quality Improvement Organization Support Center (QIOSC) (2010).
Retrieved from http://www.cfmc.org/caretransitions/
Guided Care. (2010). Care for the whole person, for those who need it most. Retrieved
from http://www.guidedcare.org/
Improving Chronic Illness Care (2010). The Chronic care model. Retrieved from
http://improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
Institute for Healthcare Improvement (2010). State action on avoidable
rehospitalizations (STAAR) initiative. Retrieved from
http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidableReh
ospitalizationsSTAAR.htm
Additional Transitional Care Resources
National Transitions of Care Coalition. (2010). Retrieved from www.ntocc.org
Naylor, M. (2009). The Transitional Care Model. Retrieved from
http://www.transitionalcare.info/index.html
New York State Department of Health. (2010). Suggested model for transitional care
planning. Retrieved from
http://www.health.state.ny.us/professionals/patients/discharge_planning/dischar
ge_transition.htm
Project RED (Re-Engineered Discharge). (2010). Retrieved from
http://www.bu.edu/fammed/projectred/
Robert Wood Johnson Foundation. (2008) Innovative care models. Retrieved from
http://www.innovativecaremodels.com/
Society of Hospital Medicine. (2008). Project Boost: Better outcomes for older adults
through safe transitions. Retrieved from
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/ht
ml_CC/project_boost_background.cfm
The Care Transitions Program. (2007). Improving quality and safety during care handoffs. Retrieved from http://www.caretransitions.org/