Chapter 28: Using Current System Models to Guide Care

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Chapter 28Using Current System Models to Guide
Care
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Learning Objectives

• Explain geriatric care as a continuum.
• Identify the types of models of care and services
  available to older adults, including acute care,
  transitional care, care coordination, community
  care, and nursing home care models.
• Describe appropriate coordination of the
  components of the healthcare system to provide
  better services to meet the needs of the older
  adult at different points in time.
• Understand the role of the nurse in new models of
  care.

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Acute Care Models and Programs

• Acute Geriatric Units (AGUs)
• Care for older adults with acute medical
  conditions
• More efficient and more functional benefit than
  conventional hospital care
• Acute care of the elderly units (ACE)
• interdisciplinary team with special expertise in
  geriatric care environmental adaptations used to
  prevent functional decline in older adults in
  acute care setting

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Acute Care Models and Programs (contd)

• Geriatric resource nurse (GRN)
• Trained by geriatric nurse specialist
• Nurses Improving Care for the Hospitalized
  Elderly (NICHE) Hartford Institute Program
• Mission to create better care environments for
  hospitalized older adults
• Transforming Care at the Bedside (TCAB)
• Research-based how to guide to improve quality
  of care Robert Wood Johnson Foundation National
  Program.

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Transitional Care Models and Programs

• Care Transitions Intervention (CTI) Univ. of
  Colorado
• assistance with self-management of medications
• patient-centered medical record that is kept by
  the patient
• timely follow-up with primary physician or
  specialists
• a list of signs and symptoms that could indicate
  worsening of their condition

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Transitional Care Models and Programs (contd)

• Transitional Care Model (TCM)
• Addresses needs of elders with chronic conditions
  after discharge from hospital
• Money Follows the Person (MFP)
• Helps states rebalance long-term care systems by
  transitioning eligible Medicaid recipients from
  long-term care institutions back to the community

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Transitional Care Electronic Resources

• National Transitions of Care Coalition (NTOCC)
  provides consumer tools and resources, healthcare
  provider tools, and best practice tips to enhance
  transitional care.
• Next Step in Care provides information and
  advice to help family caregivers.
  http//www.nextstepincare.org
• BOOSTing Care Transitions Provides materials to
  help optimize the discharge process at any
  institution

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Community Care Models and Programs

• Adult daycare
• Supervised daily care in a nonresidential
  facility for the elderly and disabled
• Aging in place
• Ability to live in ones own home and community
  safely, independently, and comfortably,
  regardless of age, income, or ability level

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Community Care Models and Programs (contd)

• Assisted living
• assistance and monitoring of older residential
  adults who cant live independently but don't
  need 24-hour skilled nursing home care
• Home care skilled services
• Skilled nursing and/or therapy services in the
  home

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Community Care Models and Programs (contd)

• Intergenerational care
• Several generations receive ongoing services or
  care in the same location
• Program of All-Inclusive Care for the Elderly
  (PACE)
• To help older adults remain in the community

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Nursing Home Care Models

• Culture change
• More person-centered care in LTCFs
• Eden Alternative model
• Person-centered core
• The Green House
• Homelike environment
• Pioneer Network
• Holistic, individualized care for elderly and
  chronically ill

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Summary

• Many systems can be used to design care for older
  adults
• These models can assist gerontological nurses to
  plan system or city-wide care
• Aging in place
• Maintaining quality of life in spite of health
  challenges