Advancing Geriatric CompetenciesCase Study: Transitional Care

M. Catherine Wollman DNP, GNP-BCAssistant Professor and Coordinator

Adult and Geriatric NP ProgramNeumann 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 Adult-

Gerontology APRNs: A Case Study by Marie Mangino, MSN, CRNP, BC-G and Christine Bradway, PhD, RN, CRNP

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Copyright and Permissions

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

Acknowledgements

Learner Outcomes

At the completion of this case study, thestudent 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 ReadingColeman, 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-for-service 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 data1. 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 35. Hyperlipidemia

– simvistatin 20 mg daily6. 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 day10. 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.

• 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.

Answer #2 (Cont’d)

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.

• 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.

Answer #3 (Cont’d)

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.

• 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.

Answer #4 (Cont’d)

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/m′ 2

– 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. Hypertension controlled with lisinopril and carvedilol2. HF – continue lasix, lisinopril and carvedilol and follow up

with cardiology3. Type 2 diabetes - continue present medication (A1C

acceptable at 7.6%)1 Review teaching from dietician. Follow up with ophthalmologist.

4. CKD stage 3 –hypertension and glucose under control; caution with any new drugs

5. 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 prn10. 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 Cymbalta13. Constipation – started Miralax14. 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.

• 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?”

Answer # 5 (Cont’d)

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 ResourcesAgency 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/STateActiononAvoidableRehospitalizationsSTAAR.htm

Additional Transitional Care ResourcesNational Transitions of Care Coalition. (2010). Retrieved from www.ntocc.orgNaylor, M. (2009). The Transitional Care Model. Retrieved from

http://www.transitionalcare.info/index.htmlNew York State Department of Health. (2010). Suggested model for transitional care

planning. Retrieved from http://www.health.state.ny.us/professionals/patients/discharge_planning/discharge_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/html_CC/project_boost_background.cfm

The Care Transitions Program. (2007). Improving quality and safety during care hand-offs. Retrieved from http://www.caretransitions.org/

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