Transitions from acute care to the community for OAs Flashcards
Discharge planning
• According to the Effective Practice and Organization of Care, discharge planning is defined as an “individualized plan of discharge to facilitate the transfer of a patient from hospital to a post discharge setting”
Transitional care
• Transitional care is defined as “interventions to improve transition from one care provider to another“
Components of discharge planning and transitional care
- Several components are involved in the discharge planning and the transition of care.
- These can include communication and education to ensure that the patient and caregiver can properly manage medical problems and support and coordination services
- Span across the hospital community interface, that integrate multiple service providers
Specialized geriatric inpatient unit
- Units such as Geriatric Assessment and Treatment Units, Geriatric Rehabilitation Units, Acute Care of the Elderly (ACE) Units, and Geriatric Mental Health Units
- Focused on providing comprehensive geriatric assessment and treatment for older adults with complex conditions
Acute Care of the Elderly (ACE) Inpatient Unit at St. Michael’s Hospital
• The Purpose of the 8 bed unit is to provide coordinated, interprofessional geriatric inpatient assessment and treatment for older adults with acute medical issues.
The Goals for an ACE admission include:
- Assessment and enhancement of physical, cognitive and psychological functioning
- Provide evidence-based treatment of acute/chronic geriatric problems
- Facilitate the transition from hospital to community and prevent premature institutionalization
Admission criteria to the ACE unit
Person aged 65 years old or older who:
• Presents with acute, complex medical illness (eg. Pneumonia, UTI) and the presence of one or more geriatric syndromes:
- Recurrent Falls, poor mobility, and balance
- Unexplained or acute functional decline, or potential for functional decline.
- Cognitive impairment, dementia, delirium, or combination
- Polypharmacy
- Malnutrition and/or unintentional weight loss
- Elder Abuse
- Incontinence
• Has the potential to return to or close to pre-illness level of functioning
ACE unit exclusion criteria
- Requires intensive medical monitoring (ie. Telemetry) or surgery
- Resides in Long Term Care or requires long Term care as support system is exhausted
- Presents with severe/end-stage dementia or terminal disease
- Presents with primarily an active psychiatric diagnosis and/or behavioural issues not related to delirium
- Designated ALC (Alternate Level of Care)
Regional geriatri program
A network of organizations that support Specialized Geriatric Services (SGS) across Ontario with experienced practitioner teams, trained to manage the complexities of geriatric care.
Inpatient Geriatrics Consultation Team:
• If the patient has not been transferred under the care of the ACE team
• Team available to provide a comprehensive geriatric assessment and consultation to the attending physician/care team for patients admitted to non-geriatric units
Discharge destinations from acute care
1. Home • Patient’s home • Retirement Home • Long Term care facility • Supportive Housing • Shelter
- Rehabilitation Program
• Physiotherapist and Occupational Therapist to determine if patient is a candidate, once medically stable
• The goal of rehab is to progress patient’s function back to previous mobility/ cognitive baseline prior to admission - Other destinations:
• Referral to Retirement Home
• Rooming House
• Long Term Care Facility (Nursing Home)
Rehabilitation programs
• The Goal of Rehabilitation Programs to return home close to or back to functional Baseline
High-Intensity Stream Program
• Length of Stay would be within 2-3 weeks.
Slow-Intensity Stream Program
• Length of Stay is within 3-4 weeks.
Geriatric
• Patients over the age of 65
Medical
• Patients under the age of 65
Orthopedic
• Surgeries related to joint replacements/fractures
Amputee
• Amputation surgery candidates that have potential to transfer with and without prosthetic
Transitional Care Unit
• Patients waiting for Long Term Care Placements.
• Length of Stay will be dependent
on the next available LTC bed in their application.
Complex Continuing Care Unit
• Patients that require high nursing care
• Tracheostomies, Feeding Tubes and
Extensive Wounds, Mostly Bed-bound and require Hoyer Lifts
Retirement homes
- Retirement homes are privately owned. They rent private accommodation to seniors who can live with little or no help. They do not provide 24-hour nursing care.
- One can expect to live much more independently here than you would in a long-term care home or supportive housing.
- You do not need to provide proof that you are healthy and need little support and care. The retirement home may assess your needs to make sure that it can provide you with the right level support.
- The government does not fund retirement homes. You need to cover the full cost of your own housing and care. The cost of private room = $1500 to $6000 per month.
- You can often choose to opt in or out of meal plans and/or other services.
Long term care homes
- Facility where adults can access to 24-hour nursing and personal care
- There is more assistance one would receive than in a retirement home or supportive housing.
To live in a long-term care home, you must:
• be age 18 or older
• have a valid Ontario Health Insurance Program (OHIP) card
• have high nursing and personal care needs
• frequent assistance with activities of daily living
• have care needs which cannot be safely met in the community through publicly- funded community-based services and other care-giving support
• All personal and nursing care provided by long-term care homes in Ontario are funded by the government.
• You must pay for accommodation charges such as room and board
Criteria for rehabilitation
Inclusion:
• Patient must have either/both physical/cognitive goals to progress within 4 weeks max in program
• Based on age will determine which stream. Under 65 will be Medical and Over 65 will be Geriatric Rehab Program.
Exclusion:
• Patient comes from Long term care facility
• Does not want to participate daily in therapy sessions.
• Does not have carry-over due to cognitive impairments (Delirium/ Moderate-Severe Dementia)
Criteria for retirement home/long term care facilities (RH/LTC)
Inclusion:
• For RH, patient must have income to pay to stay. They should be mobile with aid and if require more assistance prepared to pay more
• For LTC, patient requires high level nursing care (bed-bound/feeding tube/catheter/severely cognitively impaired) and unable to manage in the the community
Exclusion:
• RH – not enough income, high nursing care
• LTC – lower nursing care needs
Social determinants of health
- Income and Social Status
• Lower income clients are higher risk of poor health, increased barriers to health care access - Employment and Working Conditions
• Full time vs. part-time/freelance vs. retired vs. unemployed - Education and Literacy
• Lower educated clients require assistance navigating health care system - Physical Environments
• Home vs. Facilities (Long Term Care /Retirement Home/ Boarding Home) vs. No Fixed Address/Shelters - Social Supports and Coping Skills
• Family, Community agencies, LHIN services vs. None - Healthy Behaviours
• Lack of understanding/education on long terms affects of risky and unhealthy behaviours - Access to Health Services
• Canadian Citizen vs. No OHIP (No Status, Refugee, Interim Federal Health - Culture /Race /Gender
• Language Barriers
• Family obligation/gender roles. Perceptions on caregiver roles, hospitalizations.
