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• W184429534 abstract "Care transitions can heighten anxiety and aggressive behavior in older adults with dementia but careful communication between providers can mean a good transition, and prevent re-admissions.The Institute of Medicine report, Retooling for an Aging America (2008), criticized our present healthcare system as being fragmented and lacking incentives for effective collaboration between providers. Several models for enhancing the quality of care during discharge from the hospital appear to be effective, even in the management of chronically ill older adults.But these models have not been tested in older adults who experience severe cognitive and psychiatric disturbances (Epstein-Lubow and Fulton, 2012; Tew, 2005). By 2030, one-fifth of the U.S. population will be age 65 or older, and the prevalence of dementia in this group is estimated to be as high as 12 percent to 14 percent (Plassman et al., 2007).Older adults with dementia represent a particularly challenging segment of our population. Many require custodial care as their disease progresses. They exhibit such behavioral problems as persistent motor or verbal agitation, intrusiveness, wandering (or repeated attempts to flee), resisting personal care-even unprovoked physical aggression (Chow et al., 2012).For this population, stabilizing their behaviors in the hospital setting is only half the battle. In our experience, transition back to the community can often trigger a recurrence of disruptive behaviors because of the patient's distress over relocation. Patients who appeared stable decompensate temporarily following transfer back to the community. This creates frustration among caregivers who were informed the patient was doing better. Critical for these patients is enhanced communication during transitions and support for caregivers awaiting patients' transfer to home.This article reviews a transitional care intervention that was designed and implemented in a geropsychiatric hospital caring for behaviorally disturbed demented adults. In this program, a transitional care nurse provides enhanced bi-directional communication, nursing home outreach, training, and post-discharge followup for area facilities receiving patients from the forty-two-bed geriatrics unit at Pittsburgh's Western Psychiatric Institute and Clinic. The program was initially supported by a grant from the Practice Change Fellows Program (www. practicechangefellows.org), and has been fully funded by our hospital for the past two years.Case Study: How a Poor Transition Can Create MistrustA strong but moderately demented nursing home resident, age 80, does not understand she needs assistance with basic hygiene and incontinence care. She is afraid and angered when staffattempt to assist her. This eventually results in an episode of aggression.Nursing home management, concerned about safety, sends her to an emergency room for evaluation, and she is admitted to a hospital unit. In the hospital, higher staffing ratios allow for experimentation with behavioral management strategies; a medical work-up reveals an occult infection; a toileting schedule reduces the need for incontinence care; and verbal reassurance prevents the patient from becoming panicked when she is disoriented.Within a week, the woman is less distraught and suitable for discharge. The hospital's discharge planner communicates this to the nursing home admissions department. Hospital notes are faxed to the nursing home confirming improvement, and the patient is accepted for return. Minimal communication between care providers occurs. On the transfer day, a stack of paperwork is forwarded from the nursing home admissions department to the clinical nursing unit.The patient arrives at the nursing home distraught from the ambulance ride. She is frightened, and appears ready to aggressively protect herself. Medication with anti-anxiety drugs prior to the transfer was not helpful. Within the first few days of her arrival, she seems as distraught as she was the day she left. …" @default.
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• W184429534 date "2012-12-01" @default.
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• W184429534 title "Care Transitions and the Dementia Patient: A Model Intervention Builds Communication, Trust-And Better Care" @default.
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