Cost impact of the transitional care model for hospitalized cognitively impaired older adults

Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model’s nine core components. We also discuss measuring the TCM’s core components and the overall impact of this evidence-based care management approach.

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A Game a Day Keeps Cognitive Decline Away? A Systematic Review and Meta-Analysis of Commercially-Available Brain Training Programs in Healthy and Cognitively Impaired Older Adults

Neuropsychology Review ◽

10.1007/s11065-021-09515-2 ◽

2021 ◽

Author(s):

Lan Nguyen ◽

Karen Murphy ◽

Glenda Andrews

Keyword(s):

Systematic Review ◽

Older Adults ◽

Cognitive Decline ◽

Training Programs ◽

Meta Analysis ◽

Cognitively Impaired ◽

Brain Training

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Impact of Pain and Discomfort on the Lives of Cognitively Impaired Older Adults and Their Informal Caregivers

Innovation in Aging ◽

10.1093/geroni/igaa057.2848 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 786-787

Author(s):

Hyunjin Noh

Keyword(s):

Older Adults ◽

Cognitively Impaired ◽

Community Settings ◽

Adult Age ◽

Face To Face ◽

Disease Trajectory ◽

Care Recipients ◽

Home Based ◽

The Impact ◽

Future Program

Abstract This qualitative study explored the impact of pain and discomfort on the lives of cognitively impaired older adults and their caregivers from the caregiver perspective. Forty-three individuals of age 19+, who identified themselves as primary caregiver to a chronically or seriously ill older adult (age 50+) with cognitive impairment, such as Alzheimer’s Disease and Related Dementia, were recruited at various community settings. Individual, face-to-face interviews were conducted to ask participants how they thought their care-recipient’s pain and discomfort affected the care-recipient’s and the caregiver’s life respectively. Inductive, thematic analysis of interview transcripts revealed several key themes: compromised mobility, limited social interaction or activities, and depressive symptoms in both care-recipients and caregivers; aggravated cognitive decline in care-recipients; and poorer physical health in caregivers. Participants wanted more information on the disease trajectory and available services, particularly home-based therapies and social activities for care-recipients, which provides future program/practice implications.

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Educational intervention to improve palliative care knowledge among informal caregivers of cognitively impaired older adults

Palliative & Supportive Care ◽

10.1017/s1478951520001200 ◽

2020 ◽

pp. 1-9

Author(s):

Hyunjin Noh ◽

Lewis H. Lee ◽

Chorong Won

Keyword(s):

Older Adults ◽

Palliative Care ◽

Cognitive Impairment ◽

Educational Intervention ◽

Test Scores ◽

Informal Caregivers ◽

Cognitively Impaired ◽

Significant Difference ◽

Post Test ◽

Seriously Ill

Abstract Objective Lack of palliative care knowledge among caregivers may pose an access barrier for cognitively impaired older adults, who may benefit from the specialized care. Therefore, this study aims to examine the effectiveness of an educational intervention in improving palliative care knowledge among informal caregivers of cognitively impaired older adults. Method Using a one-group, pre- and post-test intervention design, this study implemented an individual, face-to-face educational intervention with an informational brochure for 43 informal caregivers of chronically or seriously ill older adults (50+) with cognitive impairment, recruited from communities in West Alabama. Their level of knowledge about palliative care was assessed by the Palliative Care Knowledge Scale (PaCKS). The pre- and post-test scores were compared by the Wilcoxon signed-ranks test, and the racial subgroup (Whites vs. Blacks) comparison was made by the Mann–Whitney U test. Results There was a statistically significant difference between the pre- and post-test scores (z = 5.38, p < 0.001), indicating a statistically significant effect of the educational intervention in improving palliative care knowledge among participants. There was a significant difference (U = 143, p < 0.05) between Whites and Blacks in the pre-test, which, however, disappeared in the post-test (U = 173.50, p > 0.05), suggesting that the amount of increased PaCKS scores were significantly greater for Blacks (Mdn = 9.50) than for Whites (Mdn = 4.00, U = 130.50, p < 0.05). Significance of results This study demonstrated that a one-time educational intervention can improve the level of palliative care knowledge among informal caregivers of chronically or seriously ill older adults with cognitive impairment, particularly among Black caregivers. Therefore, further educational efforts can be made to promote palliative care knowledge and reduce racial disparities in palliative care knowledge and its use.

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Enhancing Our Understanding of Transitional Care Programs

Innovation in Aging ◽

10.1093/geroni/igaa057.448 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 136-137

Author(s):

Katherine McGilton ◽

Shirin Vellani ◽

Alexandra Krassikova ◽

Alexia Cumal ◽

Sheryl Robertson ◽

...

Keyword(s):

Older Adults ◽

Transitional Care ◽

Discharge Planning ◽

Grey Literature ◽

Occupational Therapists ◽

Community Dwelling ◽

Bibliographic Databases ◽

Multidisciplinary Teams ◽

Term Care ◽

Hospitalized Older Adults

Abstract Many hospitalized older adults experience delayed discharge. Transitional care programs (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community. There are knowledge gaps related to the processes and outcomes of TCPs. We conducted a scoping review following Arksey & O’Malley’s framework to identify the: 1) characteristics of older patients served by TCPs, 2) services provided within TCPs, and 3) outcomes used to evaluate TCPs. We searched bibliographic databases and grey literature. We included papers and reports involving community-dwelling older adults aged ≥ 65 years and examined the processes and/or outcomes of TCPs. The search retrieved 4828 references; 38 studies and 2 reports met the inclusion criteria. Most studies were conducted in Europe (n=19) and America (n=13). Patients admitted to TCPs were 59-86 years old, had 2-10 chronic conditions, 26-74% lived alone, the majority were functionally dependent and had mild cognitive impairment. Most TCPs were staffed by nurses, physiotherapists, occupational therapists, social workers and physicians, and support staff. The TCPs provided 5 major types of services: assessment, care planning, treatment, evaluation/care monitoring and discharge planning. The outcomes most frequently assessed were discharge destination, mortality, hospital readmission, length of stay, cost and functional status. TCPs that reported significant improvement in older adults’ functions (which was the main goal of the TCPs) included multiple services delivered by multidisciplinary teams. There is a wide variation in the operationalization of TCPs within and between countries.

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Transitional care of older adults in skilled nursing facilities: A systematic review

Geriatric Nursing ◽

10.1016/j.gerinurse.2016.04.012 ◽

2016 ◽

Vol 37 (4) ◽

pp. 296-301 ◽

Cited By ~ 14

Author(s):

Mark Toles ◽

Cathleen Colón-Emeric ◽

Josephine Asafu-Adjei ◽

Elizabeth Moreton ◽

Laura C. Hanson

Keyword(s):

Systematic Review ◽

Older Adults ◽

Transitional Care ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Skilled Nursing

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Factors Associated With Informational Support in Transitional Care for Older Adults With Chronic Diseases: A Cross-Sectional Study

Clinical Nursing Research ◽

10.1177/10547738211051881 ◽

2021 ◽

pp. 105477382110518

Author(s):

Gui-Ling Geng ◽

Wen-Wen Yang ◽

Xiao-Liu Shi ◽

Jia-Ning Hua ◽

Min Cui ◽

...

Keyword(s):

Older Adults ◽

Chronic Diseases ◽

Transitional Care ◽

Descriptive Analysis ◽

Cross Sectional Study ◽

Informational Support ◽

Cross Sectional ◽

Care Survey ◽

Strobe Statement ◽

Care Study

To evaluate the current situation and associated factors of informational support for older adults with chronic diseases in transitional care. Study was conducted in five hospitals of five different cities in Jiangsu Province, China. A random cluster sample of 800 older adults with chronic diseases responded to the informational support questionnaire of transitional care survey. Descriptive analysis, t-tests, variance analysis, and stepwise multiple linear regression were used to analyze data. The STROBE statement for observational studies was applied. Total score of ISQTC for older adults with chronic diseases was (44.05 ± 17.21). Marital status, educational level, past occupation, close friends, medical insurance, complications, and exercise habits were significantly correlated with informational support. The level of informational support in transitional care for older adults with chronic diseases was low. Clinical staff should periodically and primarily assess their informational support, help find information resources for those who have low initial informational support, and identify which information they preferred to carry out accurate transitional care.

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