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Ensuring Better Care Transitions for Frail Geriatric Patients

April 1, 2021
April 1, 2021

This is the first of two blog posts based on a recent webinar discussing the new learning module created by HealthStream and the Duke School of Nursing and School of Medicine about how to optimize inter-professional frail elder care. This post is based on remarks by Dr. Eleanor McConnell, Director of the Centers for Excellence in Geriatric Nursing Education and lead faculty for the gerontology specialties in the MSN program at Duke.

Every year, millions of seniors are readmitted to hospitals within 30 days of discharge, and nearly three quarters of those readmissions are potentially avoidable. These hospitalization rates can be reduced, but only if staff engage in very specific activities to target the patients at greatest risk.

New Learning Module

My colleague Dr. Mitchell Heflin and I partnered with HealthStream and about 20 Duke Health faculty members to examine challenges related to providing services for the frail elder population. Based on our findings, HealthStream developed a unique online inter-professional learning program. Successful completion will earn a participant five CE units and an inter-professional frail elder care certificate awarded by Duke Health.  

In the module, participants get to know a patient via video. To get the flavor of our teaching approach, let’s look at the following case study to determine how we can significantly improve the transition of care from the acute care setting to home.

Case Study

Meet Mr. Taylor. He has pulmonary disease with the usual comorbidities seen in an 81-year old. He lives with his wife of many years who has some mild memory loss. At the beginning of the video, we see a picture of a very vital-looking Mr. Taylor. However, when he begins detailing his current circumstances, he tells us his life has changed dramatically in the last few months.

He tells us the past six months have been difficult. He's had multiple hospitalizations to try to manage the flares of his COPD and heart failure, but things seem to be getting worse rather than better. He tells us he’s so exhausted, he wonders if he'll ever feel good again.

The video takes the learner through interactions among the various caregivers, showing barriers to candid and honest communication. Staff and family appear to be most concerned with “happy talk” about Mr. Taylor’s discharge to home, with little candor about the reality of his situation. In the heat of the moment, when everyone is so happy to hear Mr. Taylor is finally better and ready to go home, no one wants to say, “Wait a minute! What about...?”

Speak up

In Mr. Taylor’s case, there is no systematic care plan to meet his needs, no attention to providing clear communication in the next setting of care, and not enough attention to medication management. Because his caregivers did not speak up, he was readmitted 14 days later with progressively worsening shortness of breath. Sadly, this scenario occurs in nearly one in four heart failure patients discharged from the hospital.

The Impact of Frailty

One way to interrupt this cycle of re-hospitalization would be to consider Mr. Taylor’s frailty, in addition to his diagnoses of heart failure and lung disease, when making transition of care decisions. Does he tire easily? Can he climb a flight of stairs? Is he able to walk a block? Does he have more than five chronic illnesses? Has he lost more than 5% of his body weight? Based on the answers to these questions, Mr. Taylor is considered frail.

The module explains how recognizing frailty early in the hospitalization allows clinicians to address the root causes of falls, disabilities, or complications and how to better plan for post-hospital care. Had they considered his frailty, staff could have provided additional insights and directives to optimize his next phase of care and prevent re-hospitalization.

Optimizing Care

The case study walks learners through various actions to optimize Mr. Taylor’s care. During the transition process, a point person on the care team is identified who can set up a team meeting with the family to discuss their issues and concerns. Everyone is encouraged to speak openly and truthfully about the patient’s condition at the time of transition. The video calls out very specific approaches a nurse could take to voice concerns about a potential discharge.

We also thought carefully about each role: the prescriber, the CNA, the RN, the PT, and others. We parceled out the information they all needed to share, as well as the unique knowledge, roles and responsibilities of each.

For example, all roles need to understand what delirium looks like and when to alert the provider or prescriber. All should understand how they must think a bit differently about patient safety. As an individual, the prescriber must think about how medication might be an underlying cause and take specific actions to reverse this. The physical or occupational therapist may need to complete an assessment of the patient's home environment and whether there is sufficient family and social support.

Each team member plays both a specific and a shared role. When the team carries out its roles successfully they can prevent unnecessary readmissions.

Access the full Webinar here.