Terry Fries-Maloy, MSW, LISW
Care Coordinator, Hickman & Lowder Co., L.P.A
P. Lal Arora, MD, FRCPC
Lorain Geriatrics, Mercy Regional Medical Center,
Carole Klingler, BSN, RN
Team Leader, Hospice of the Western Reserve
Close your eyes and imagine if you can… You are in your mid-eighties and living alone. It’s 3:00 a.m. and your full bladder awakens you. You slowly and carefully get out of bed and take a few steps toward the bathroom. Your foot catches on something and the next thing you know you are falling. Your right shoulder hits the edge of the nightstand and you hear and feel the crrraaaack of your left hip as you hit the floor. You try to get up. The pain is too great. Your shoulder hurts and your leg won’t move. You slowly drag yourself to the nightstand and pull on the cord until the phone drops at your side. You dial 9-1-1 and your unexpected journey into the world of transitional care begins…
The above scenario is not an uncommon one among our elderly. Accidents, sudden illness and the worsening of chronic conditions that cannot be managed at home often result in our elders being admitted to the hospital. Patients in older age groups occupy the majority of the beds in today’s hospitals. They are also the ones who are most often moved from one area of the hospital to another (such as from an intensive care unit to a medical floor), from the hospital to home (and back again) or from the hospital to a nursing home. They are also the least likely to understand all that is involved in such transitions.
In medical terms this series of movements has been defined as “Transitional Care” and has also been identified by the Institute of Medicine as one of the major sources of medical errors in today’s health care system. It is the responsibility of the medical team transferring the patient and the staff receiving the patient to ensure a smooth transition for the elder. The members of the medical team who are charged with ensuring good transitional care may include, in the pre-admission stage, the emergency medical staff on the ambulance and the personnel in the emergency room. Once the elder has been admitted, key persons responsible for providing quality transitional care are the social worker, the nursing staff, therapists and the physicians caring for the patient. Families can also be helpful in coordinating care during such transitions.
There are practical ways that families, and even the elders themselves, can help to reduce the stress of relocation even in advance of a hospitalization or move to a long-term care facility. An in-office, pre-crisis discussion with the elder’s physician about anticipated health care needs, the treatment options available and the wants and needs of the elder can help enhance communication with all parties and help to avoid crisis-based decision making.
The completion and distribution of copies of a Health Care Power of Attorney document and a Living Will, if desired, will help guide the medical personnel, as well as the family, if the elder is not able to state his or her own wishes regarding medical treatment. Copies of these documents should be given to and discussed with family members or other significant persons, the primary care physician and clergy, if desired, so that the elder’s wishes regarding care can be upheld. Too many people complete these directives, put them in a private place and, when the crisis occurs, others may not even know that they exist or have no idea where they are stored.
Keeping a list of current medications, doses and administration times on hand can be a lifesaver if an emergency arises. A wise idea is a “grab and go” bag that contains information about medications, including over-the-counter drugs, a list of health conditions (current diagnoses and past surgeries and treatments), copies of one’s Health Care Power of Attorney, Living Will, emergency contact information – be sure it is updated periodically – and insurance and personal identification information. Personal items such as a nightgown and robe, toiletries, pen and paper and a list of family and friends’ addresses and phone numbers are also vital additions to a “grab and go” bag. If an unexpected or emergency trip to the hospital becomes necessary, just grab it and go.
Another vital area of pre-planning involves legal and financial foresight. More than half of all Americans die without a will and even more do not plan ahead for their health care and long-term care costs. While simple estate planning may cost several hundred dollars, dying without such planning will certainly cost one’s estate thousands of dollars. Seeking the advice of an elder law attorney, in advance of a crisis, may protect an individual’s assets and provide the comfort of knowing that the elder’s wishes regarding finances and property will be respected.
When an elder’s situation is complex, when there is no family or family is far away, or when family members do not have the time or expertise to advocate for their elder, the hiring of an elder care coordinator is an option for some individuals and families. The care coordinator offers an independent, professional perspective of the elder’s situation, makes recommendations designed to sustain or improve the quality of the elder’s life and offers advocacy, guidance and support to the elder and family through all of the transitional phases.
If an elder is admitted to the hospital it is vital that the elder and family keep the lines of communication open with one another, with their physician and with the treatment staff at the hospital including nurses and, when involved, therapists. A key contact, and one which should be made very early in the hospital stay, is the hospital social worker or discharge planner. Today’s hospitals, often guided by Medicare and other insurance company guidelines, begin planning for the patient’s discharge almost from the point of admission. The hospital social worker can help to explain the insurance coverage and, in a proactive fashion, begin to link the elder with the appropriate community resources to ease the discharge transition.
Another area of concern during transitions, especially discharge from a hospital or nursing home, is errors with prescription medications. In nursing terms “medication reconciliation” is defined, according to the Wisconsin Hospital Association, as “a formal process of identifying the most complete and accurate list of medications a patient is taking and using that list to provide correct medications for the patient anywhere within the health care system.” Medication reconciliation also involves the patient clearly understanding the reasons for the difference in what he or she was taking before entering a facility compared with what is being prescribed at the time of discharge. Every effort needs to be made to avoid duplication (e.g. Prilosec and Nexium), or omission of an important medication. Similarly, it is nursing‟s responsibility to determine, with help from the physician, that every medication prescribed has an appropriate supporting diagnosis.
If the elder is being discharged home and with an order from the physician for home health care, a nurse can provide medical assessment of the individual at home, review medications and apprise the physician of any significant concerns or changes in medical conditions. With guidance from the physician, home health nurses are able to provide timely interventions at home. If necessary, they can seek additional services such as social work, nurse’s aides, therapists and palliative care or hospice services. Palliative care extends the principles of hospice care to a broader population of patients who are not ready for hospice or do not choose it, but could benefit from pain and symptom management. Health care professionals who specialize in palliative care work closely with staff and volunteers to address all the symptoms with the aim of promoting comfort and dignity. At any point in the disease process, the palliative care program may be used in conjunction with other therapies. These services, if considered appropriate, are usually covered by one‟s insurance, including Medicare.
It is sometimes necessary to transfer an elder patient from the hospital to a nursing home. These stays are usually short term, ranging from a few days to a few weeks. An elder’s health insurance will often pay for such stays if it is determined that special services, called “skilled care,” are needed to promote recovery and regain function. These services may include physical, occupational or speech therapy or intravenous (IV) medications for a short time. Again, there is staff available at each hospital to determine the appropriateness of such a transfer and ensure that all insurance benefits are utilized to the benefit of the patient. Medication reconciliation must again be done by the nursing staff discharging the patient and verified by the nurses receiving the patient.
While planning for the transfer of an elder, one must also keep in mind that transferring to yet another facility, one offering an even higher level of care, may become necessary within a short period of time due to the possibility of continued loss of function. When there is the potential for the elder to further decline, even with ongoing interventions, consideration should be given in advance to other possible care options. When transferring a person to a facility, one must be certain that appropriate physician and specialty services are also available to meet the elder’s needs.
Frequent changes in the living environment over a short period of time can be challenging for anyone, but transitions are especially difficult for an elder and those with significant cognitive decline, such as Alzheimer’s disease, or impaired physical function. Planning ahead, staying organized, identifying the key supports during each transition and communicating routinely with “the team” will help to ensure greater ease of transition and less trauma to the elder when the need for a move becomes necessary.