Three Models of Care Transitions
BOOST CTI TCM
Better Outcomes for Older
Adults *A patient centered 4-week *Nurse acts as main Care mgr
thru Safe Transition intervention program
(Reduce readmissions) designed to improve quality *She consults w/pt in hospital
of care and contain costs for and at home within 24 hours
*Reduce 30-day hospital patients with complex care of d/c
readmission rates for older needs as they transition
adults across care settings *Accompanies pt to post d/c
& f/u visits and provides
* Improve patient satisfaction weekly home visits also
ongoing phone support for an
*Identify high-risk patient s average of 2 months
to prevent adverse events
*Improve communication
between providers & patients
*Better prepare the patient
and family for discharge
Palliative Care Life threatening debilitating diseases and
have quality of life but active treatment
Hospice Family involved. Life expectancy 6 mos or
less
*Better Care
3 Triple Aim Goals * Better health outcomes
*Lower costs
A person directly and deliberately causes the
Active Euthanasia patient’s death
Ex: Morphine or phenobarbital
They don’t directly take a person’s life; they
Passive Euthanasia allow them to die
Ex: Withholding meds or feedings, removing
O2
*Susceptible to head & cold.
Atrophy of Sweat Glands *Lack of glands allows you to overheat easily
*Decrease wound healing
Quality of Life Autonomy and Independence
Orthopneic position Upright to prevent SOB
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, *Can cause death
*Increase Falls
*Injure self
Restraints *Mortality rates increase with restraints
*Bed rails
*Mitts
*Seatbelts in wheelchairs
Gustatory Deficit Lack of appetite & sense of smell
Degeneration & attrition on the intervertebral
Senile Kyphosis disks particularly of their Anterior portions, in
the physiological kyphotic THORACIC
segments
Wear and tear theory Cells wear out and cannot function with aging
Isometric exercise Pushing on the wall
Isotonic exercise Resistance bands
Malabsorption disorder caused by lack of
Short gut syndrome functional small intestine. Primary symptom
is diarrhea, which can cause dehydration,
malnutrition and weight loss
Endocrine Decrease in BMR (Basal Metabolic Rate)
Permanent decrease in mental capacity Dementia
*Invite
*Arrange environment
Satir’s Basic Principles for Communication *Maximize Understanding
*Maximize Communication
*Follow Through
*Sleep Disorders
*Problems w/bathing or feeding
SPICES *Incontinence
*Confusion
*Evidence of Falls
*Skin Breakdown
*Potentially inappropriate medications in
older adults
*Potentially inappropriate medications to
avoid in older adults with certain conditions;
Beers Criteria
*Medications to be used with considerable
caution in older adults
*Medication combinations that may lead to
harmful interactions
*A list of medications that should be avoided
or dosed differently for those with poor renal
function.
Cachexia Pt loses A LOT of body weight & muscle
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