The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Academic-Practice Partnership for Caregiver Training and Support: The Duke Elder Family/Caregiver Training (DEFT) Center.

BACKGROUND After a hospital stay, many older adults rely on their caregivers for assistance at home. Empirical evidence demonstrates that caregiver support programs in hospital-to-home transitions are associated with favorable caregiver and patient outcomes. We tested the feasibility of implementing the Duke Elder Family/Caregiver Training (DEFT) program in an academic medical center.METHODS: We recruited adult caregivers of homebound patients who were aged 55 years or older from Duke University Hospital in Durham, North Carolina. Caregivers attended a face-to-face caregiver training and received two telephone checks after hospital discharge with DEFT services ending at 14 days of hospital discharge. We used a one-item survey to measure overall DEFT satisfaction. We also monitored 30-day readmissions of patients whose caregivers completed the DEFT program.RESULTS: The DEFT Center received 104 consult orders in six months. Of these, 61 agreed to participate but nine caregivers were unable to schedule the DEFT training and three decided to eventually withdraw from participation. Forty-nine caregivers received the DEFT training, 12 of whom were ineligible to continue because of change in patients' disposition plan. Of the remaining 37 caregivers, 15 completed the full program and reported high satisfaction; one patient was readmitted within 30 days of discharge.LIMITATIONS: The DEFT implementation was based on academic-medical partnership and relied on electronic medical records for consult and documentation. Replicability and generalizability of findings are limited to settings with similar capabilities and resources.CONCLUSION: The implementation of a caregiver training and support program in an academic medical center was feasible and was associated with favorable preliminary outcomes.

Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility.

BACKGROUND: Individuals discharged from the hospital to skilled nursing facilities (SNFs) experience high rates of unplanned hospital readmission, indicating opportunity for improvement in transitional care. LOCAL PROBLEM: Local physicians providing care in SNFs were not associated with the discharging hospital health care system. As a result, substantive real-time communication between hospital and SNF physicians was not occurring. METHODS: A multidisciplinary team developed and monitored implementation of the Health Optimization Program for Elders (HOPE) to improve patient transitions from acute hospital stay to SNFs. INTERVENTIONS: The HOPE used a nurse practitioner (NP) to identify geriatric syndromes, set patient/caregiver expectations, assess rehabilitation potential, clarify goals of care, and communicate information directly to SNF providers. RESULTS: The intervention was feasible, addressed unmet needs and errors in the SNF transition process, and was associated with lower 30-day readmission rates compared with concurrent patients not enrolled in the HOPE. CONCLUSIONS: An NP-led hospital to SNF transitional care program is a promising means of improving hospital to SNF transitions.

Bach to the Basics: Implementation and Impact of a Postoperative, Inpatient Personalized Music Program for Older Adults.

PURPOSE: Music as an intervention to mitigate pain and anxiety has been well studied in the perioperative period. We present a quality improvement (QI) report describing implementation and evaluation of a postoperative, inpatient personalized music program for older adults undergoing elective surgeries. DESIGN: We embedded this program in an existing interdisciplinary perioperative care program, with an outpatient and an inpatient component, at an academic institution. METHODS: We describe our initial QI steps, highlight critical lessons learned from this behavioral intervention, and discuss high yield areas to focus on future implementation efforts. FINDINGS: Rapid cycle improvement was an effective method to monitor QI measures. Participants in our program perceived improved mood and pain control, were satisfied with their experience, and had lower rates of incident delirium. CONCLUSIONS: This program offers perioperative teams, especially frontline nursing staff, an inexpensive, patient-centered tool to optimize postoperative pain and anxiety. We believe that it can be easily replicated at a variety of hospital systems.

Academic-Practice Partnership to Strengthen Nursing Care of Older Adults.

A long-standing academic-practice partnership was leveraged to facilitate student learning opportunities pertaining to care provision for older adults living with multiple chronic conditions and complex medical problems. Students from a gerontological nursing course in an accelerated baccalaureate nursing program were partnered with gerontology-educated population health nurses in primary care settings. Students observed how population health nurses integrated the Institute for Healthcare Improvement Age-Friendly 4Ms framework into clinical practice as they performed behavioral, psychosocial, and biometric health risks assessments for older adults during their Medicare annual wellness visit. The population health nurses served as role models for professional delivery of age-friendly care including preventative health and wellness care. Student confidence and perception of their understanding of age-friendly and gerontological nursing care improved. Post clinical experience debrief sessions and clinical reflection assignments demonstrated students' admiration of the expansive role and person-centered approach that population health nurses undertake to ensure comprehensive assessment and wellness promotion. Students appreciated the fluidity of population health nurses' conversation regarding the things that matter most to older adults with complex medical conditions.

The Duke-NICHE program: an academic-practice collaboration to enhance geriatric nursing care.

The Duke-Nurses Improving Care of Healthsystem Elders (NICHE) is an example of an academic-practice partnership between a university-based school of nursing and a health system that aims to improve care of older adults by simultaneously enhancing the expertise of frontline nursing staff, accelerating the implementation of evidence-based care approaches, and generating scientific knowledge at the point of care. This article describes the processes used to develop the partnership, and reports initial outcomes and lessons learned. Although challenging to develop and sustain, academic-health system partnerships hold potential to improve care through both improved implementation of evidence and stimulating new research at the point of care.

Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults.

Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.

Integrating Mental Health Concepts in the Care of Adults With Chronic Illnesses: A Curricular Enhancement.

BACKGROUND: In the United States, inadequate attention has been given to the mental health needs of chronically ill adults, and the attempts to integrate mental health in primary care have fallen short. METHOD: This article describes the beginning efforts of the faculty at Duke University School of Nursing to integrate mental health concepts into its adult-gerontological nurse practitioner and family nurse practitioner curricula. RESULTS: Competency and course content mapping activities revealed opportunities for mental health enhancement. Five mental health concepts were identified for module development: spectrum of emotions, validation skills, self-management, resilience, and diversity. Mental health modules will be integrated in the nurse practitioner Physical Assessment and Diagnostic Reasoning course, as well as in various clinical courses. CONCLUSION: Challenges and lessons learned, including efforts to foster active interprofessional learning among medical, physician assistant, and nurse practitioner students, are described.