Discharge and Care Transition Planning in Elder Mistreatment Cases

1
Discharge and Care Transition Planning in Elder
Mistreatment Cases

• Module 12Nursing Responses to Elder
  MistreatmentAn IAFN Education Course

2
Learning Objectives

• In this module, participants will learn to
• Identify priorities in discharge/care transition
  planning in elder mistreatment (EM) cases on
  patient safety, health and well being
• Discuss issues to consider and actions to take
  when planning for discharge/care transition with
  patients in EM cases

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Questions to Consider

• Who in your practice setting conducts
  discharge/care transition planning?
• What are procedures for discharge/care transition
  planning in your practice setting? Are there
  forms used for planning? Are procedures any
  different if the case involves actual or
  potential EM?
• What are key issues, challenges and questions
  that need to be addressed when planning for
  discharge/care transition in EM cases?

4
Checklist for Planning

• Using a standardized process to plan for
  discharge/care transition can help ensure a focus
  on patient safety, health and well being when
  formulating a plan, no matter what circumstances
  are involved

5
Checklist for Planning

• Involve the patient (and guardian/patients
  support system as appropriate to the case) in
  discharge/care transition planning

6
Checklist for Planning

• Work with other involved professionals as
  appropriate to streamline plans for follow-up
  care and services and maximize effectiveness of
  interventions

7
Checklist for Planning

• Make sure that the medical needs of patient have
  been met through discharge or care transition plan

8
Checklist for Planning

• Make sure that safety needs of patient have been
  met through discharge or care transition plan
• Home environment safe?
• If home is not an option, is alternate living
  environment safe?
• Long-term care facility safe?

9
Checklist for Planning

• If patient is living in the community, determine
  home assistance needed
• Does the patient have a non-abusive caregiver?
• Can that caregiver provide the assistance needed?
  

10
Checklist for Planning

• If the patient is living in a long-term care
  facility, what changes are needed in the plan of
  care to meet patient needs?

11
Checklist for Planning

• Take actions as indicated by answers to previous
  questions
• Educate patient
• Coordinate with other professionals
• Notify authorities as required by law
• Help patient develop a plan for safety
• Make sure patient has clothing and transportation
• Arrange for follow-up medical appointments
• Refer patient to services

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Checklist for Planning

• Provide patient with oral and written
  discharge/care transition instructions
• Document discharge/care transition instructions
  in the medical record
• Identify situations requiring nurse follow-up
  with patients

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Closing Assessment Module 12

• What one important thing did you learn in this
  module that you can apply in your practice
  setting?

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Closing Assessment Overall

• Explain whether or not your personal learning
  objectives for the course were met
• Identify the courses strengths and what could be
  improved