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Prep for Success Transitions Settings, Study Guides, Projects, Research of Nursing

Prep for Success Transitions Settings

Typology: Study Guides, Projects, Research

2023/2024

Available from 08/29/2024

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Prep for Success: Care Transitions/Settings/Reimbursement
Chapter 5:
Define Gerontology the study of aging and older adults
Name 2 goals (focus has shifted to…)
1. emphasis on healthy and successful aging
2. emphasis on promoting wellness and preventing disease for the increasing
numbers and diversity of older adults worldwide
Define Geriatrics- is a subspecialty of internal medicine or family practice that focuses
on the medical problems of older people.
Focus has shifted from medical problems of older people to an emphasis on goals of
care based on healthy life expectancy, which is the average number of years a person
can expect to live without significant illness or disability and what is important based on
a comprehensive assessment of the individual, with emphasis on quality-of-life issues
and what is important to the individual.
Types of Geriatric Nursing Health Promotion Interventions include (p.66)
1. screening programs ex. Glaucoma, diabetes, hypertension, hyperlipidemia,
osteoporosis, cognitive impairment, obstructive sleep apnea, and many kinds of
cancer
2. Risk reduction interventions ex immunizations, statins for primary prevention
of cardiovascular disease, assessments (falls, anxiety, depression, heart
disease, pressure ulcers, elder abuse and neglect), lifestyle factors (weight
management, optimal nutrition, adequate physical activity, sleep
3. Environmental modifications (reducing fall risk, improves hearing and vision
and prevents urinary incontinence)
4. Health education (teaching to engage in self-care, they address specific
conditions as well as overall health and functioning ex. Physical activity, nutrition,
dental care, avoiding smoking and secondhand smoke)
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Prep for Success: Care Transitions/Settings/Reimbursement Chapter 5: Define Gerontology the study of aging and older adults Name 2 goals (focus has shifted to…)

  1. emphasis on healthy and successful aging
  2. emphasis on promoting wellness and preventing disease for the increasing numbers and diversity of older adults worldwide Define Geriatrics- is a subspecialty of internal medicine or family practice that focuses on the medical problems of older people. Focus has shifted from medical problems of older people to an emphasis on goals of care based on healthy life expectancy, which is the average number of years a person can expect to live without significant illness or disability and what is important based on a comprehensive assessment of the individual, with emphasis on quality-of-life issues and what is important to the individual. Types of Geriatric Nursing Health Promotion Interventions include (p.66)
  3. screening programs ex. Glaucoma, diabetes, hypertension, hyperlipidemia, osteoporosis, cognitive impairment, obstructive sleep apnea, and many kinds of cancer
  4. Risk reduction interventions ex immunizations, statins for primary prevention of cardiovascular disease, assessments (falls, anxiety, depression, heart disease, pressure ulcers, elder abuse and neglect), lifestyle factors (weight management, optimal nutrition, adequate physical activity, sleep 3. Environmental modifications (reducing fall risk, improves hearing and vision and prevents urinary incontinence) 4. Health education (teaching to engage in self-care, they address specific conditions as well as overall health and functioning ex. Physical activity, nutrition, dental care, avoiding smoking and secondhand smoke)

Chapter 6: 4M’s of Age-friendly health systems:Matters (know and align care w/ each older adults specific health outcome goals and care ● Medication (medication that does not interfere with what matters to the patient), ● Mentation (prevent, identify, treat, and manage dementia, depression, and delirium across settings of care) ● Mobility (ensure that older adults move safely every day in order to maintain function and do what matters) QSEN: patient-centered care, teamwork and collaboration, safety, evidenced-based practice, quality improvement, and informatics Medicare and Medicaid deny payment for certain hospital -acquired conditions that arw deemed to be preventable including catheter-associated urinary tract infections, fall- related injuries, and pressure injury stage 3 and 4 Define TRANSITIONAL CARE (lecture & p. 81) set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Effective transitional care interventions result in the following positive outcomes related to quality, safety, and cost of care: reduced all-cause readmissions, decreased mortality, and reduced hospitalizations Example: medication discrepancies during discharge are a major quality and safety concern and a factor leading to readmission w/in 30 days, particularly for older adults ex. Poor communication, incomplete information, limited access to essential services, Inadequate education of older adults and their caregivers, absence of a point person to coordinate care Why is this important? Think about the $$$ too Decrease cost- reduced all-cause readmissions, decreased mortality, and reduced hospitalizations et al., Positive Outcomes when interventions are in place:

  1. Reduced all-cause readmissions
  1. self-reported depression, social isolation
  2. financial stress
  3. lack of choice in assuming the caregiving role Describe 5 POSITIVE functional consequences of CAREGIVING:
  4. sense of purpose or meaning in life, and this is more common among those who have a choice in taking on the role (AARP and National Alliance for Caregiving, 2020).
  5. Additional positive outcomes related to the experience of caregiving include feelings of personal satisfaction and gratification,
  6. experiences of social approval,
  7. increased patience and tolerance, and
  8. improved personal relationship with care recipient Describe 4 NURSING ROLES (only one about teaching!) in promoting caregiver WELLNESS:
  9. teaching caregivers about continued care
  10. simple-communication techniques such as providing positive feedback when teaching caregivers
  11. Nurses also can teach through role modeling when providing care in clinical settings
  12. Also, they can suggest referrals for caregiver resources, such as the ones identified in Online Learning Activity 1-3 in Chapter 1.
  13. They also can initiate referrals to resources (e.g., social workers, geriatric assessment programs) and assist caregivers in finding and using resources and initiate referrals to resources. Chapter 7: Relate the above to the Community Resources Box 7- National Eldercare Locator: Provides free information about many types of resources in any part of the United States according to the zip code Senior Information and Referral Service: Local programs, sometimes called an “Infoline,” that provide information about agencies to address specific needs Area Agency on Aging: Governmental agencies that provide a wide range of services, including referrals, case management, and nonmedical home care workers

Senior Centers: Community-based centers providing services for older adults, such as meals, limited transportation, and social and educational programs Home-Delivered Meals: Programs that provide home delivery of hot meals to homebound people, sponsored by local senior centers, churches, or hospitals Companions and Friendly Visitors: Programs that offer services such as socially oriented home visits, assistance with errands, or accompaniment to appointments Telephone Reassurance: Service providers make scheduled telephone calls to older people to provide support and reminders Internet-Based Programs: Services for support, reminders, and socialization provided via social media apps and overseen by public or nonprofit organizations. Personal Emergency Response Systems: An emergency response system that involves the use of a “call button” (e.g., necklace or bracelet) to initiate a phone call to designated people when assistance is needed (e.g., if the person falls).. Energy Assistance Programs: State and local programs that offer financial assistance for utility bills for people with low incomes Home Weatherization and Home Repair Service: Contractors paid by government agencies to provide home repairs and maintenance (e.g., insulation, window caulking, and installation) for people with low incomes Describe the 2 focuses of a PARISH NURSE (faith community nursing) : (p. 91)

  1. On the intentional care of the spirit
  2. As well as on the promotion of whole-person health and the prevention or minimization of illness w/in the context of a faith community and the wider community
  3. Provide spiritual care in conjunction with various types of health services such as education, referrals, screenings, coaching. Counseling, and advocacy What is the primary goals of RESPITE Services? Respite care - refers to any service whose primary goal is to relieve caregivers periodically from the stress of their usual caregiving responsibilities ● In-home respite programs commonly use trained volunteers for some services and are administered through nonprofit organizations such as the Alzheimer’s association or faith-based programs
  4. Improved well-being for caregivers

Define PERSON-DIRECTED CARE (p.95 & lecture) Person-centered care (also called person-directed care or resident-centered care), defined as care that emphasizes personal choices and quality of life, is a core component of the culture change movement. Person-centered care focuses on promoting a sense of dignity and honoring individual preferences ● Culture change- describes a major movement toward implementing fundamental reform sin the ay that nursing home provide care. A major goal of culture change is to transform the philosophy and practice in nursing homes from an overemphasis on safety, uniformity, and medical care to a consumer -directed focus on health promotion, quality of life, and individualized care. Key components include:

  1. Choices about sleep and wake times
  2. Choices about mealtime and food selection
  3. Flexibility in time and frequency of bathing and showering
  4. Having consistent staff
  5. Being heard by organizational leaders How is person-directed care considered INTER-PROFESSIONAL? Delivery of person-centered care involves an interprofessional approach to not only developing, but also consistently implementing, a care plan based on a comprehensive assessment of the needs and preferences of the individual who is receiving care (i.e., the resident). In addition to strong nursing input, the care plan integrates assessments and interventions from team members such as social workers, rehabilitation therapists, primary care practitioners, mental health practitioners, dental care providers, and spiritual care providers MORE DETAIL ON REIMBURSEMENT ( lecture & text) MEDICARE also called TITLE 8 of the Social Security ACT “The FIX-IT HEALTH CARE model”

MEDICAID also known as Title 19 is combined Federal and State funding (tax$). The Wisconsin card has the word Medical Assistance Program on it. A person is allowed liquid assets of no > $2,000 (p.99). Does this amount include the person’s home? The home is generally exempt Can an older person give all their money to their kids and then go on Medicaid? No Medicaid still treats it as a gift even up to $18,000 and will be scrutinized; strict policies to prevent the transfer of assets from one family member to another for 5 years before applying for Medicaid, however the income and assets of a spouse are usually exempt from these restrictions Initially, Medicaid paid for mainly inpatient nursing home care, but since the early 1990’s, the focus shifted toward paying for community-based services for people who otherwise would need nursing home care. (but the cost of home-care must be lower than the cost of care in an institutional setting) LONG TERM COMMUNITY-BASED CARE. 2 examples in Wisconsin ( lecture & web links in Supplemental Resources) :

  1. IRIS (Include, Respect, I Self-Direct) 3 examples of that it covers: ● Adaptive technology ● Adult day care center ● Adult family home ● Education and training for yourself and your workers ● Counseling and therapeutic services ● Individual directed goods and services ● Daily living skills training ● Day services ● Home-delivered meals ● Home modifications (like ramps) ● Housing counseling and startup ● IRIS self-directed personal care

● Home delivered meals ● Home health ● Home modifications ● Housing counseling ● Mental health day treatment services (in all settings) ● Mental health services (except those provided by a physician or on an inpatient basis) ● Nursing home, including Intermediate Care Facility for Individuals with Intellectual Disabilities and Institution for Mental Disease (coverage is for people under age 21, or 65 and older) ● Nursing services (including respiratory care, intermittent, and private duty nursing) ● Occupational therapy (in all settings except for inpatient hospital) ● Personal care ● Personal emergency response system ● Physical therapy (in all settings except for inpatient hospital) ● Prevocational services ● Relocation services ● Residential services o Adult family home o Community-based residential facility o Residential care apartment complex ● Respite care ● Self-directed personal care ● Skilled nursing services, registered nurse/licensed practical nurse ● Specialized medical equipment and supplies ● Speech and language pathology services (in all settings except for inpatient hospital) ● Supported employment ● Supportive home care ● Training services for unpaid caregivers ● Vocational futures planning