Chapter 25: Caring Across the

Continuum

Learning Objectives• State the potential risks factors in

transitioning across healthcare settings for older adults.

• Describe different evidence-based practice (EBP) care transition models used in different settings (acute/subacute care, long-term care, home care).

• Recognize the key roles and functions of the geriatric nurse in optimizing care across the continuum.

Learning Objectives (cont’d)

• Define terms utilized for care settings.

• Contrast and compare settings available for older adult living.

• Contrast settings of care in which nurses care for older adults.

Continuum of Care• Healthcare policy

– Patient Protection and Affordable Care Act

• Risk in care transitions– Key risk factors

• Inadequate client and family education• Poor communication between providers and clients• Poor coordination of care• Medication discrepancies• Lack of follow up• Health literacy issues• Lack of support systems• Cultural barriers

Continuum of Care (cont’d)

• Information exchange– Communication insures optimal exchange of

key patient information– Relationships between healthcare providers

that promote information exchange improve safety

• Transitional care models– Acute care– Home care– Long-term care

Continuum of Care (cont’d)

• Healthcare settings (Figure 25-1, P. 862)– Acute care hospital– Acute rehabilitation– Transitional/progressive care unit– Long-term acute care hospital– Home health care

Managing Long-Term Needs

• Long-term care facility (LTCF)– Provide care for older adults or anyone who has

lost ability for self-care due to illness, disability, or advanced dementia

• Alzheimer’s/memory care facilities– Dedicated units within LTCF for people with

mid- to late-state Alzheimer’s and other dementias

• Eden Alternative– Transform institutional approaches to care in a

community where “life is worth living”

Maintaining Independence: Living Options for Older Adults

• Adult day services– Helps older adults remain in their homes

• Assisted living facility– For older adults who can function on their own but

need some assistance with ADLs

• Coming Home Project: Affordable Assisted Living – Caring for rural America

• Green House concept– A home in the community

Maintaining Independence: Living Options for Older Adults (cont’d)

• Independent living– home ownership, apartment, retirement

communities, subsidized government housing

• Continuing care retirement community– Continuum of care from independent living to

skilled nursing care

• Foster care or group homes– Alternative to nursing home

• Naturally occurring retirement community

A Shift in Living Arrangements

• Elder cottage housing opportunity (ECHO)– Free-standing, mobile, modular-type homes that

can be transformed to be temporarily placed on a caregiver’s property to maintain safety for the older adult requiring assistance while allowing for privacy and independence

– Uses technology tailored to the specific needs of the individual, based on the resident’s and caregiver’s requirements

– Can remotely monitor the resident through sensors that alert caregivers.

– Smart Home Technology

End-of-Life Care Options

• Hospice care– Holistic, interdisciplinary care that helps the

dying person “live until they die.”– Pain management and comfort care– Settings

• Hospice facility• Nursing home unit• Home-care

Nursing Responsibility in Transitioning Care

• Nurses contribute to safety and continuity of care for their patients upon discharge or transfer to another care setting– Interagency transfer

• Detailed transfer form• Verbal report

– Discharge to home• Detailed discharge instructions to patient

and caregiver

Caring for the Caregiver

• Respite care– Provides much-needed time off for family

members who care for someone who is ill, injured, frail, debilitated, or demented.

– Can be provided in an adult day facility, in the home of the person being cared for, or in an assisted living or long-term care facility.

– Not covered by Medicare or Medicaid

Summary• Gerontological nurses care for older adults

in a variety of settings• Nurses need to fully comprehend settings

where care is implemented• Recognize and institute appropriate client-

and family-specific interventions to decrease potential risk factors

• Evidence-based practice