Chapter 28:Using Current System Models

to Guide Care

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.

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

Acute Care Models and Programs (cont’d)

• 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.

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

Transitional Care Models and Programs (cont’d)

• 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

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

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 one’s own home and

community safely, independently, and comfortably, regardless of age, income, or ability level

Community Care Models and Programs (cont’d)

• Assisted living– assistance and monitoring of older residential

adults who can’t 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

Community Care Models and Programs (cont’d)

• 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

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

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