One in five hospitalized Medicare beneficiaries is readmitted within 30 days of discharge from an acute care setting at a cost of $2.6 billion annually; three quarters of these readmissions are potentially avoidable. HealthStream partnered with Duke Health to study ways to optimize the care of this important and growing population.
In a recent HealthStream webinar, Dr. Eleanor McConnell, director of the Duke Centers for Excellence in Geriatric Nursing Education, and Dr. Mitchell Heflin, associate professor of medicine at the Duke School of Medicine and senior fellow in the Center for the Study of Aging and Human Development, spoke to us about ways to improve healthcare for vulnerable seniors. They made the following recommendations for better care:
Identify Patient Frailty
An important step in determining the care plan for an older patient is to assess whether the patient is frail. According to Dr. McConnell, “Frailty increases the risk of falls and fractures, disability, hospitalization, complications after surgery, and even death. A caregiver can determine frailty by asking the person five simple questions, easily remembered using the simple mnemonic, F. R. A. I. L.” McConnell says if a person answers yes to three or more of these questions, he or she meets the definition of frailty:
Fatigue—Do you tire easily?
Resistance—Can you climb one flight of stairs?
Ambulation—Can you walk one block?
Illness—Do you have more than five chronic illnesses?
Loss of weight—Have you lost more than 5% body weight?
“Determining frailty early in a hospitalization helps clinicians address the root causes of falls, disabilities, or complications, and allows them to make better plans for post-hospital care,” says McConnell. “Frailty, in combination with other risk factors, increases an older patient’s vulnerability to a difficult transition of care and re-hospitalization.”
Focus on Care transitions
In addition to frailty, says McConnell, “Older patients are more vulnerable during transitions of care because they may have poor health literacy, decreased social support, functional impairment, and or medical problems, such as coexisting chronic medical problems.”
Study participants saw a need to increase the care team’s confidence about speaking up at the time of discharge regarding concerns they may have. The module seeks to improve team knowledge and provide caregivers with the tools they need to achieve a more effective transition of care.
Establish a Shared Framework for Caregiving Across Professional Disciplines
Inter-professional cooperation while caring for older adults is essential. “While care providers should rely on their experience and expertise, they should also operate within a shared framework that includes understanding the patient’s values and preferences… and setting realistic goals of care with the patient and family,” says Dr. Mitchell Heflin, associate professor of medicine at the Duke School of Medicine and senior fellow in the Center for the Study of Aging and Human Development.
“A few simple questions… can lead to a very important exchange, with the patient revealing important information about his or her concerns. If the CNA is empowered to speak up… this will inform decision-making about the patient’s transition of care. Listening to the patient helps the team develop a care plan that addresses the patient’s goals and preferences,” Heflin explains.
Emphasize Medication Management
When assessing a patient’s medication intake, says Heflin, “It’s important to compare the proposed medication plan to the medication plan the patient followed before admission and ask questions. Is the plan realistic? Can it be simplified? What are the risks of overdose if the patient resumes taking medicines they may still have at home? The team must communicate in a way that patients and their caregivers can understand.”
The patient and family members also need to understand the roles of the different people in the transition process, including the pharmacist and others involved in the next setting of care. “Both the patient and the family should be educated about how to take new medications, especially inhalers or injectables,” offers Heflin.
After educating the patient and family, a team member should ask them to explain how they will manage medications, using a teach-back method. McConnell suggests, “One way to determine whether a patient has understood medication guidance is to ask them to repeat the instructions to the caregiver.”
Assess Patients for Delirium
Patients who have delirium are at high risk for problems during transitions of care. “For these patients,” McConnell says, “it’s essential to create a familiar environment, address any sensory deficits, maintain daytime and nighttime routines, and promote good nutrition and hydration. The team should also be vigilant for any signs of pain and alert the next care setting about these factors.”
Heflin points out that the elderly are at high risk for malnutrition. “Over 80% of older adults in the acute care setting are malnourished. Poor nutrition can be caused by social isolation, depression, or cognitive impairment. For adults living at home, poor nutrition may result from a reduced appetite or a lack of transportation that limits access to healthy foods. Financial constraints can also be a factor,” says Heflin.
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