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Why Better Training for Frail Elder Care is Necessary (Part 2)

This blog post excerpts an article in the Q4 2015 issue of PX Advisor, our quarterly magazine designed to bring you thought leadership and best practices for improving the patient experience. We interviewed Mitchel T. Heflin MD, MHS Associate Professor of Medicine, Duke University School of Medicine; Eleanor McConnell PhD, RN, GCNS-BC Associate Professor, Duke University School of Nursing; and Loretta Matters MSN, RN, Associate Director, Center of Excellence for Geriatric Nursing Excellence, Duke University School of Nursing about the Duke Inter-Professional Frail Elder Care certificate program that HealthStream is helping to develop as part of our Living Labs initiative.

Tell us a little bit about the new certificate program—how does it work, what are the topic areas involved, care settings, etc.?

Changing this trajectory, or at least caring for people effectively across this period of time, requires not just attending to the “admitting diagnosis” but to the variety of factors that constitute high quality care for older adults. We have chosen five initial focus areas based on our assessment of the evidence and feedback from teams of professionals who care for frail elders. Increased expertise in these areas would prepare clinicians to impact frailty-related adverse outcomes among older adults across the care continuum. These topic areas include:

  • Delirium, an acute impairment in cognition, which is common among hospitalized elders, and can have far-reaching effects on safety and care outcomes
  • Poor nutrition, an important factor in the development of frailty and a barrier to recovery
  • High risk medications, increase the incidence of adverse events—recognition and removal can reduce complications and improve outcomes
  • Transitions of care, a set of robust evidence-based strategies, can improve care delivery between settings and reduce readmissions in high risk older adults
  • Goals of Care, established to help clinicians account for patient prognosis, priorities and preferences in medical decision making in late life.

Can you describe the differing ways in which frontline staff, prescribers, and allied staff are currently equipped to face these challenges? What new skills do they need?

Members of the care team often are trained to perform a set of tasks or duties that apply narrowly to their functions in caring for a person with a single disorder. Yet care for older adults requires understanding of how multiple diseases interact with each other, and with aging. Failing to understand these complexities can create gaps in care, leading to delayed diagnosis of problems, and setting the stage for transitions that are especially risky for the frail elder population. Failing to appreciate the importance of team care can likewise lead to delayed care or unresolved care needs. To address the care needs of older adults across the care spectrum, we have characterized the nature of the problems and desired staff performance from an interprofessional perspective.

What makes your program unique?

We have identified both core competencies that we expect of all healthcare staff, as well as role-specific competencies. For example, in the area of medications—ALL professionals should understand that geriatric syndromes such as malnutrition, falls, cognitive disturbance, and urinary incontinence may result from an adverse drug effect. Prescribers, however, need to have more in-depth knowledge of how to avoid high risk drugs and how to prescribe therapeutic alternatives. Likewise, medication reconciliation, which is already mandated by the Joint Commission, takes on added importance (and complexity) in elders who are also likely to be cared for by multiple providers.

In addition to role-specific differences in content, we have designed the modules to take into account both common and distinct implications for care in different care settings. For example, delirium onset is much more prevalent in the hospital than in other care settings. However, delirium can certainly be first observed in the clinic setting—either in the context of new-onset acute illness, or in the context of post-acute care. For this reason, it is important for ALL care settings to have the capacity to recognize and assess delirium, and to develop a setting appropriate response. However, opportunities in clinic and home care to observe behavioral indicators of delirium are much more limited than in hospital or residential LTC settings— so heightened awareness among staff is needed, along with setting-specific examples of what they might see and how they might engage family caregivers more effectively.

To make sure every member of the care team knows how to diagnose and handle situations, we are going to provide training in best practices that are supported by evidence. The content of the training will be provided at two levels: that which is applicable across the entire team and that which is customized by individual role, as appropriate.

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