SAFETY ALERT

Medication​ discrepancies​ are​ the​ most​ prevalent​ adverse​

event​following​hospital​discharge​and​the​most​challenging​

component​ of​ a​ successful​ hospital-to-home​ transition.​

Nurses‘​attention​to​an​accurate​prehospital​medication​list,​

medication​ reconciliation​ during​ hospitalization​ and​ at​ dis- charge,​ identification​ of​ high-risk​ medications,​ and​ patient​

and​ family​ education​ about​ medications​ is​ required​ to​​

enhance​safety.

play an important role in the development of interventions aimed at reducing rehospitalization” (p. 32). In addition to roles as care managers and transition coaches, nurses play a key role in many of the elements of successful transi- tional care models, such as medication management, family caregiver education, comprehensive discharge plan- ning, and adequate and timely communication between providers and sites of service (Box 3-7).

Further research is needed to evaluate what transitional care models are most effective in various settings and for which group of patients. Particularly important is research on transitions from nursing home to hospital, racial and cultural disparities in transitional care, and ways to im- prove family caregiver preparation and involvement during transitions. The Family Caregiver Alliance provides a hos- pital discharge planning guide for families and caregivers (www.caregiver.org). Other transitional care resources can be found at http://interact2.net/care.html, http://www.

caretransitions.org/, and www.ahrq.gov/qual/pips.

The CMS and The Joint Commission (TJC) have also increased efforts to promote better outcomes, patient safety, and effective care by requiring hospitals to collect data on the core measures and other quality indicators. The CMS posts 30-day, all cause, risk-adjusted readmission rates on its website for heart failure, acute myocardial infarction, and pneumonia. Participating hospitals are classified as better than U.S. national rate; no different than U.S. national rate;

or worse than U.S. national rate (see www.hospitalcompare.

gov). Medicare is also implementing initiatives to reduce

the amount of improper payments to providers as a result of medically unnecessary care (Hines et al., 2010).

A major goal of the Patient Protection and Affordable Care Act (PPACA) is improving care coordination and out- comes for individuals with multiple comorbid conditions who require high-cost care. The health care reform law cre- ates several programs based on promising models that in- clude the following: the Medicare Community-Based Care Transitions Program; the Medicare Independence at Home demonstration; bonus payments for Medicare Advantage plans with care management programs; Medical (Health) Home models in Medicare and Medicaid; and Community Health Teams to support the Medical (Health) Homes.

Many of these new initiatives include nurse practitioners and offer opportunities for new roles for registered nurses with preparation in care of older adults as well. The American Nurses Association provides information on key provisions related to nursing in health care reform (http://www.

nursingworld.org/MainMenuCategories/Policy-Advocacy/

HealthSystemReform).

Relocation

For many older adults, relocation is a major stressor and often a crisis for the older person and his or her family.

Relocation to a long-term care facility is identified as one of the most stressful and one that many older people fear.

With each move, if the adaptation is to be satisfying, one must begin to claim personal space by somehow placing

•​ Utilize​interdisciplinary​teams​guided​by​evidence-based​

protocols

•​ Comprehensive​geriatric​assessments

•​ Performance​measures​and​evaluation

•​ Use​information​systems​such​as​electronic​medical​​

records​that​span​traditional​settings

•​ Target​high-risk​patients

•​ Improve​communication​between​patients,​family​​

caregivers,​and​providers

•​ Improve​communication​between​sending​and​receiving​

clinicians

•​ Well-designed​and​structured​patient​transfer​records

•​ Simplify​posthospital​medication​regimen;​identifying​

high-risk​medications

•​ Reconcile​patients’​prehospitalization​and​​

posthospitalization​medication​lists

•​ Improve​patient/family​knowledge​of​medications​prior​

to​discharge

•​ Educational​materials​adapted​for​language​and​health​

literacy

•​ Schedule​follow-up​care​appointments​prior​to​​

discharge

•​ Discuss​warning​signs​that​require​reporting​and​medi- cal​evaluation

•​ Follow​up​discharge​with​home​visits/telephone​calls

•​ Care​coordination​by​advanced​nurse​practitioners

•​ Assessment​of​informal​support

•​ Involvement,​education,​and​support​of​family​caregivers

•​ Knowledge​of​community​resources​and​appropriate​​

referrals​to​resources​and​financial​assistance

•​ Enhance​discussions​of​palliative​and​end-of-life​care​

and​communication​of​advance​directives BOX

3-7

Suggested Elements of Transitional Care Models

one’s stamp of individuality on the new surroundings.

Because the older adult is particularly likely to move or be moved, the subject of relocation is significant. Nurses in hospitals, the community, and long-term care institutions frequently care for elders experiencing relocation.

The first issue to address in any move is whether it is necessary and whether it will provide the least restrictive lifestyle appropriate for the individual. Questions that must be asked to assess the impact on the individual after a move are presented in Box 3-8. Nurses’ concerns are with assessing the impact of relocation and determining meth- ods to mitigate any negative reactions.

Relocation stress syndrome is a nursing diagnosis de- scribing the confusion resulting from a move to a new environment. Characteristics of relocation stress syndrome include anxiety, insecurity, altered mental status, depres- sion, insecurity, loss of control, and physical problems. An abrupt and poorly prepared transfer actually increases ill- ness and disorientation. Research suggests that individuals are better able to meet the challenges of relocation if they have a sense of control over the circumstances and the confidence to carry out the needed activities associated with a move.

To avoid some of the effects of relocation stress syn- drome, the individual must have some control over the environment, preparation regarding the new situation, and maintenance of familiar situations to the greatest degree possible. Nurses must carefully assess and monitor older people for relocation stress syndrome effects. Working with families to help them plan relocations, understanding the effects of relocation, and implementing effective ap- proaches are also necessary. It is important that some

familiar and some treasured items accompany the transfer.

Too often, elders arrive at long-term care institutions via ambulance stretcher from the hospital with nothing but a hospital gown. Everything familiar and necessary in their lives remains at the home they have left when they became ill.

Even more distressing is when families or responsible parties sell the home to finance long-term care stays with- out the input of the elder. It is no wonder so many resi- dents with dementia in nursing homes wander the hall- ways looking for home and for something familiar and comforting. Family members will need considerable sup- port when an elder is moved into an institution. No matter what the circumstances, the family invariably feels that they have in some way failed the elder (see Chapter 24).

A summary of relocation stress syndrome and nursing actions to prevent relocation stress during transition to long-term care are presented in Box 3-9.

Implications for Gerontological Nursing and Healthy Aging

Nurses in all practice settings play a key role in improving care for older people across the continuum. New roles for nursing are emerging in the era of health care reform and heightened attention to improved patient outcomes. Most nurses work in only one setting and are not familiar with the requirements of other settings or the needs of patients in those settings. As a result, there are often significant misunderstandings and criticisms of care in the different settings across the continuum. As Barbara Resnick pointed out: “We can stop the finger pointing and start working

•​ Are​significant​persons​as​accessible​in​the​new​location​

as​they​were​before​the​move?

•​ Is​the​individual​developing​new​and​reciprocal​relation- ships​in​the​new​setting?

•​ Is​the​individual​functioning​as​well,​better,​or​not​as​

well​in​the​new​location?​This​determination​cannot​be​

made​immediately,​but​this​assessment​must​be​done​

within​at​most​6​weeks​of​the​move.

•​ Was​the​individual​given​options​before​the​move?

•​ Was​the​individual​given​the​opportunity​to​assess​the​

new​environment​before​making​a​decision​to​move?

•​ Has​the​individual​been​able​to​move​important​items​of​

furniture​and​memorabilia​to​the​new​setting?

•​ Has​a​particular​individual​who​is​familiar​with​the​​

environment​been​available​to​assist​with​orientation?

•​ Was​the​decision​to​move​made​hastily​or​with​​

inadequate​information?

•​ Does​the​new​situation​provide​adequately​for​basic​

needs​(food,​shelter,​physical​maintenance)?

•​ Are​individual​idiosyncratic​needs​recognized,​and​is​

there​an​opportunity​to​actualize​them?

•​ Does​the​new​situation​decrease​the​possibility​of​​

privacy​and​autonomy?

•​ Is​the​new​living​situation​an​improvement​over​the​​

previous​situation,​similar​in​quality,​or​worse?

BOX

3-8

Assessment of Relocation

Relocation​stress​syndrome​is​a​physiological​and/or​psycho- social​disturbance​as​a​result​of​transfer​from​one​environ- ment​to​another.

Defining Characteristics Major

Change​in​environment​or​location Anxiety

Apprehension Increased​confusion Depression Loneliness Minor

Verbalization​of​unwillingness​to​relocate Sleep​disturbance

Change​in​eating​habits Dependency

Gastrointestinal​disturbances Increased​verbalization​of​needs Insecurity

Lack​of​trust Restlessness Sad​affect

Unfavorable​comparison​of​posttransfer​and​pretransfer​staff Verbalization​of​being​concerned​or​upset​about​transfer Vigilance

Weight​change Withdrawal Related Factors

Past,​concurrent,​and​recent​losses Losses​involved​with​the​decision​to​move Feeling​of​powerlessness

Lack​of​adequate​support​system

Little​or​no​preparation​for​the​impending​move Moderate​to​high​degree​of​environmental​change History​and​types​of​previous​transfers

Impaired​psychosocial​health​status Decreased​physical​health​status Sample Diagnostic Statement

Relocation​stress​syndrome​related​to​admission​to​​

long-term​care​setting​as​evidenced​by​anxiety,​​

insecurity,​and​disorientation Expected Outcomes

​1.​ The​resident​will​socialize​with​family​members,​staff,​

and/or​other​residents.

​2.​ Preadmission​weight,​appetite,​and​sleep​patterns​will​

remain​stable.​If​previous​patterns​were​dysfunctional,​

more​appropriate​health​patterns​will​develop.

​3.​ The​resident​will​verbalize​feelings,​expectations,​and​

disappointments​openly​with​members​of​the​staff​and/

or​family.

​4.​ Inappropriate​behaviors​(e.g.,​“acting​out,”​refusing​to​

take​medicines)​will​not​occur.

Expected Short-Term Goals

​1.​ The​resident​will​become​independent​in​moving​to​​

and​from​areas​within​the​facility​during​the​next​​

3​months.

​2.​ The​resident​will​react​in​a​positive​manner​to​staff​​

effort​to​assist​in​adjusting​to​nursing​home​placement​

in​the​next​3​months.

​3.​ The​resident​will​express​his​or​her​thoughts​or​concerns​

about​placement​when​encouraged​to​do​so​during​​

individual​contacts​in​the​next​3​months.

​4.​ During​the​next​3​months,​the​resident​will​not​develop​

physical​or​psychosocial​disturbances​indicative​of​trans- location​syndrome​as​a​result​of​the​change​in​living​​

environment.

Expected Long-Term Goals

​1.​ The​resident​will​verbalize​acceptance​of​nursing​home​

placement​within​the​next​6​months.

​2.​ The​resident​will​indicate​acceptance​of​nursing​home​

placement​through​positive​body​language​within​the​

next​6​months.

Specific Nursing Interventions

​1.​ Identify​previous​coping​patterns​during​admission​​

assessment.​Clearly​document​these,​and​share​the​​

information​with​other​staff​members.

​2.​ Include​the​resident​in​assessing​problems​and​developing​

the​care​plan​on​admission.

​3.​ Adjust​for​limitations​in​sensory-perceptual​disturbances​

when​planning​care​for​residents.​Visual​disturbances​

necessitate​special​intervention​to​assist​residents​in​

finding​their​way​around.

​4.​ Staff​members​will​introduce​themselves​when​entering​

the​resident’s​room,​indicating​the​nature​of​their​​

relationship​with​the​resident.​Example:​“Hello,​Mr.​S.​

My​name​is​Nancy.​I’ll​be​your​nurse​attendant​today,​

helping​you​with​your​meals​and​your​bath.”

​5.​ Each​staff​member​providing​care​for​the​resident​should​

make​it​a​point​to​spend​at​least​5​minutes​each​day​

with​new​admissions​to​“just​visit.”

BOX

3-9

Relocation Stress Syndrome

together through the common transitions patients endure in our health care system. This will be a win-win situation for patients and providers alike” (2008, p. 154).

It is essential that educational programs prepare students for competent care of older adults in a variety of health care settings, including acute, long-term, home, and community- based care. Nurses in all settings need to increase awareness of the roles and responsibilities of nursing practice across the continuum and work collaboratively to improve care out- comes, particularly during times of transition. We can no longer work in our individual “silos” and not be concerned with what happens after the patient is out of our particular unit or institution. Nurses are well positioned “to create services and environments that embrace values that are at the core of this profession—patient/caregiver centered care, communication and collaboration, and continuity (Naylor, 2002, p. 140).

KEY CONCEPTS

• A familiar and comfortable environment allows an elder to function at his or her highest capacity.

• Nurses must be knowledgeable about the range of resi- dential options for older people so they can assist the elder and the family to make appropriate decisions.

• Nursing homes are an integral part of the long-term care system, providing both skilled (subacute) care and chronic, long-term, and palliative care. Projections are that this setting will provide increasing amounts of care to the growing numbers of older adults.

• Culture change in nursing homes is a growing move- ment to develop models of person-centered care and improve care outcomes and quality of life.

• Nurses play a key role in insuring optimal outcomes during transitions of care.

• Relocation has variable effects, depending on the indi- vidual’s personality, health, cognitive capacities, sense of control, opportunities for choice, self-esteem, and preferred lifestyle.

ACTIVITIES AND DISCUSSION QUESTIONS

1. Identify three objects in your living space that are important to you, and explain why these are significant.

Will you take these with you whenever you relocate?

2. Ask an older relative about the items or conditions in his or her home that make him or her feel secure and comfortable.

3. Discuss with this elder various moves he or she has made and how he or she felt about them.

4. How might the care needs of an older adult in assisted living, subacute care, and a nursing home differ? What is the role of the professional nurse in each of these settings?

5. Select three places listed in your phone book as retire- ment communities, and make inquiries regarding pos- sible placement of an older adult parent. What ques- tions did you ask? What is the cost? What are the provisions for health care? What types of activities and assistance are available? Which would you select for your grandmother and why?

6. In your experience in the acute care setting, what im- provements would you suggest to improve transitions to other care settings? Discuss any experience you or your friends or family may have had with transitions after hospital discharge.

​ 6.​ Allow​the​resident​as​many​opportunities​to​make​​

independent​choices​as​possible.

​ 7.​ Identify​previous​routines​for​activities​of​daily​living​

(ADLs).​Try​to​maintain​as​much​continuity​with​the​​

resident’s​previous​schedule​as​possible.​Example:​If​

Mr.​S.​has​taken​a​bath​before​bed​all​of​his​life,​adjust​

his​schedule​to​continue​that​practice.

​ 8.​ Familiarize​the​resident​with​unit​schedules.

​ 9.​ Encourage​family​participation​through​frequent​visits,​

phone​calls,​and​activity​sessions.​Be​sure​to​let​the​

family​know​schedules.

​10.​ Establish​familiar​landmarks​for​the​resident​when​​

leaving​his​or​her​room​so​that​he​or​she​can​recognize​​

areas​more​quickly.

​11.​ Encourage​family​members​to​bring​familiar​belongings​

from​home​for​the​resident’s​room​decorations.

​12.​ Provide​reorientation​cues​frequently.​Example:​“You​

are​in​the​dining​room.​Your​room​is​down​the​hall​three​

doors​just​past​the​window.”

​13.​ Encourage​the​resident​to​talk​about​expectations,​​

anger,​and/or​disappointments​and​the​recent​life​

changes​that​he​or​she​has​experienced.

​14.​ Review​the​patient’s​medication​list​with​the​physician​

to​verify​the​need​for​medications​that​might​promote​

disorientation.

​15.​ Provide​for​constructive​activities.​Initiate​activity​​

therapy​consultation.

BOX

3-9

Relocation Stress Syndrome—cont’d

7. If you were the director of nursing, what would your nursing home be like (design, staffing, quality of care, training)?

Inouye S, Baker DI, Leo-Summers L: The hospital elder life prog- ress: a model of care to prevent cognitive and functional de- cline in older hospitalized patients, J Am Geriatr Soc 48(12):1657–1706, 2000.

Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program, N Engl J Med 360(14):1418–1428, 2009.

Kanak MF, Titler M, Shever L, et al: The effect of hospitalization on multiple units, Appl Nurs Res 21(1):15–22, 2008.

Kleinpell R: Supporting independence in hospitalized elders in acute care, Crit Care Nurs Clin N Am 19:242–252, 2007.

Leading Age: Choosing a provider (2011). Available at http://www.

leadingage.org/Choosing_A_Provider.aspx.

Medicare.gov: What is Medicare? (2012). Available at http://www.

medicare.gov/navigation/medicare-basics/medicare-basics- overview.aspx.

Mezey M, Stierle L, Huba G, et al: Ensuring competence of specialty nurses in care of older adults, Geriatr Nurs 28(6S):

9–13, 2007.

National Adult Day Services Association, Ohio State University College of Social Work, MetLife Mature Market Institute:

The MetLife National Study of Adult Day Services: providing support to individuals and their family caregivers (2010). Avail- able at http://www.metlife.com/assets/cao/mmi/publications/

studies/2010/mmi-adult-day-services.pdf.

Naylor M: Transitional care of older adults. In Archbold P, Fitzpatrick J, Stewart B, editors: Annual review of nursing research. New York, 2002, Springer, pp. 127–147.

Naylor M, Keating S: Transitional care: moving patients from one care setting to another, Am J Nurs 108(9 Suppl):58, 2008.

Naylor M, Kurtzman E, Pauly M: Transitions of elders between long- term care and hospitals, Policy Polit Nurse Pract 10:187, 2009.

Omnibus Budget Reconciliation Act (OBRA) of 1987 (Public Law No. 100-203): Amendments 1990, 1991, 1992, 1993, and 1994, Rockville, MD, U.S. Department of Health and Human Services, Health Care Financing Administration.

Prudential Insurance Company of America: Prudential research report: long-term care cost study (2010). Available at http://

www.prudential.com/media/managed/LTCCostStudy.pdf.

Rahman A, Schnelle J: The nursing home culture change move- ment: recent past, present, and future directions for research, Gerontologist 48(2):142–148, 2008.

Resnick B: Hospitalization of older adults: are we doing a good job? Geriatr Nurs 29(3):153–154, 2008.

Robinson K, Reinhard S: Looking ahead in long-term care: the next 50 years, Nurs Clin North Am 44(2): 253–262, 2009.

Tilly J, Reed P, editors: Dementia care practice recommendations for assisted living residences and nursing homes, Washington, DC, 2008, Alzheimer’s Association.

White-Chu E, Graves W, Godfrey S, et al: Beyond the medical model: The culture change revolution in long-term care, J Am Med Direct Assoc 6:370, 2009.

REFERENCES

Alliance for Quality Nursing Home Care and the American Health Care Association: Annual quality report: a comprehen- sive report on the quality of care in America’s nursing homes and rehabilitation facilities (2011). Available at http://www.aqnhc.

org/www/file/AHCA_Alliance_2011_Quality_Report_v2.

Alzheimer’s Association: Dementia care practice: recommendations for as-pdf.

sisted living residences and nursing homes (2009). Available at http://

www.alz.org/national/documents/brochure_DCPRphases1n2.pdf.

AssistedLivingFacilities.org: Assisted living costs (2012). Available at http://www.assistedlivingfacilities.org/articles/assisted-living- costs.php.

Baker B: Old age in a new age: the promise of transformative nursing homes, Nashville, TN, 2007, Vanderbilt University Press.

Baker B, as cited in Haglund K: Closing keynote speaker found hope in changes benefiting residents and staff, Caring Ages 9(6):8, 2008.

Bixby M, Naylor M: The Transitional Care Model (TCM): hospital discharge screening criteria for high risk older adults (2009).

Available at http://consultgerirn.org/uploads/File/try this/try_

this_26.pdf.

Brawley E: What culture change is and why an aging nation cares, Aging Today 28:9–10, 2007.

Chalmers S, Coleman E: Transitional care. In Capezuti E, Swicker D, Mezey M, et al, editors: The encyclopedia of elder care, ed 2, New York, 2008, Springer.

Coleman EA, Parry C, Chalmers S, et al: The Care Transitions Intervention: results of a randomized controlled trial, Arch Intern Med 166(17):1822–1928, 2006.

Corbett C, Setter S, Daratha K, et al: Nurse identified hospital to home medication discrepancies: implications for improving transitional care, Geriatr Nurs 31:188, 2010.

Daniel K, Carson C, Ferrell S: Emerging technologies to enhance safety of older people in their homes, Geriatr Nurs 30(6): 384–389, 2009.

Gleckman H: The death of nursing homes (2009). Available at http://www.kaiserhealthnews.org/Columns/2009/

September/092809Gleckman.aspx.

Graham C, Ivey S, Neuhauser L: From hospital to home: assessing the transitional care needs of vulnerable seniors, Gerontologist 49:23, 2009.

Hain D, Tappen R, Diaz S, Ouslander J: Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implica- tions for nursing practice, J Gerontol Nurs 38(8):32–44, 2012.

Hines P, Yu K, Randall M: Preventing heart failure readmissions:

is your organization prepared? Nurs Econ 28:74, 2010.

Hooyman N, Kiyak A: Social gerontology. Boston, 2011, Pearson.