Education and Consultation Needs of Social Workers in Practice with Rural Older Adults.

The aging population and shortage of primary care physicians lead to increasing gaps in access to rural geriatric healthcare. Of concern is the lack of access to geriatric expertise, leading to adverse effects on rural older adults' health outcomes and quality of life. The Geriatric Rural Extension of Expertise through Telegeriatric Services (also known as GREETS) project surveyed rural physical and behavioral healthcare practitioners to identify gaps in geriatric competencies in the rural workforce. Using the Qualtrics platform, a survey was distributed to professional membership lists throughout the State of Michigan. A total of 106 responses were completed, of which 50 were from respondents who identified their profession as a social worker. As would be expected based on social workers' scope of practice and the settings in which they provide services, social worker respondents noted a higher need than the other practitioner respondents for education related to (a) managing chronic pain, (b) managing care of patients with multiple chronic conditions, (c) having serious illness conversations, (d) diagnosing dementia, and (e) discussing advance care planning. Having identified these needs provides a basis for identifying and implementing training and resources for social work and other disciplines involved in geriatric care and services.

Eliciting nurses' perspectives to improve health information exchange between hospital and home health care.

Despite patient safety initiatives to improve care transitions, prior research largely neglects to elicit feedback from home health nurses regarding health information exchange. The goal of this quality improvement study was to identify opportunities to facilitate information transfer during hospital-to-home-health-care transitions for older adults with heart failure. We conducted focus groups with 19 nurses employed by a single healthcare system using two commercially available electronic health record (EHR) vendors. We analyzed interview transcripts following an immersion/crystallization approach to identify themes. Average participants were females in their mid-fifties with 15 years of home health experience. Nurses reported challenges with hospital-to-home-health-care information exchange, specifically: 1) poor medication management, 2) ineffective communication, 3) technology issues, and 4) patient factors. Nurses identified several opportunities for improvement, including discordant EHR-generated medication lists, which may be amenable to technological solutions. Local quality improvement efforts should incorporate nurses' suggestions and leverage existing best practices.

Health Information Exchange of Medication Lists: Hospital Discharge to Home Healthcare.

Nurses report significant gaps in communication among patients discharged from the hospital with home healthcare (HHC) services. The aim of this pilot study was to quantify the contents of HHC admission packets used to guide nurses' first home visit after hospital discharge. We evaluated 20 randomly selected charts of older adults admitted to HHC after a hospitalization for heart failure. Admission packets contained nearly 50 pages of material, which frequently included duplicate documents printed from the hospital-based electronic health record (EHR). Despite the plethora of documents, most packets omitted key information, such as patients' cognitive and functional status, and even discharge summaries, which would be relevant and actionable for HHC nurses. Moreover, admission packets contained multiple, often discordant, EHR-generated medication lists, which makes reconciliation challenging for nurses and puts vulnerable patients at risk for adverse drug events. Overall, there is an urgent need to improve health information exchange between hospitals and HHC agencies, which will simultaneously promote nurse efficiency and patient safety.

Incremental geriatric assessment.

Older adults value (1) independence and the ability to make their own decisions, (2) mobility (the ability to travel outside or simply inside the home), (3) family and friends and the time spent with those persons who are important to them, (4) ethnicity, religion, and spirituality, and (5) home, wherever that might be. The importance of recognizing each person's individuality cannot be overemphasized. The method of incremental assessment presented in this article and summarized in Box 9 is intended to provide the office-based clinician with sufficient information to make decisions regarding the preventive, therapeutic, rehabilitative, and supportive goals of care. IADL and nutritional triggers are used to identify early signs of dysfunction in the home environment. The strengths and weaknesses of cognitive, physical, psychosocial, and spiritual aspects of function are examined in an incremental manner. Health care providers determine whether there is a match between the person's functional capabilities, the available support network, and the home environment. The approach prompts appropriate use of services needed by older adults who are either at risk for becoming, or already are, chronically ill, disabled, and functionally dependent. Use of validated assessment tools provides structure for the assessment process, helps assure consistency, and provides a mechanism for periodic re-evaluation. The assessment approaches also foster a common language for the health care team and consist of measurable parameters that can be used to monitor outcomes. The clinician should be flexible and realize that the assessment or the tools may need to be modified depending on the circumstances.