Hostname: page-component-cd9895bd7-gxg78 Total loading time: 0 Render date: 2024-12-26T07:20:17.308Z Has data issue: false hasContentIssue false
  • English
  • Français

Improving the seniors’ transition from hospital to the community: a case for intensive geriatric service workers

Published online by Cambridge University Press:  26 July 2016

Carrie A. McAiney ,
Loretta M. Hillier ,
Janice Paul ,
Jane McKinnon Wilson ,
Anna Tersigni Phelan ,
Fred Wagner  and
Sheli O'Connor
Carrie A. McAiney*
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada Seniors Mental Health Research and Evaluation, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th Street, Rm G102, Hamilton, Ontario, Canada
Loretta M. Hillier
Affiliation:
Specialized Geriatric Services, St. Joseph's Health Care London, London, Ontario, Canada Aging, Rehabilitation & Geriatric Care Research Centre of the Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada
Janice Paul
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Jane McKinnon Wilson
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Anna Tersigni Phelan
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Fred Wagner
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 67 King Street East, Kitchener, Ontario, Canada
Sheli O'Connor
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
*
Correspondence should be addressed to: Dr. Carrie A. McAiney, Department of Psychiatry & Behavioural Neurosciences, McMaster University; Seniors Mental Health Research and Evaluation, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th Street, Rm G102, Hamilton, Ontario, L8N 3K7, Canada. Phone: 905-522-1155 ext.36722. Email: mcaineyc@mcmaster.ca.
Get access

Abstract

Background:

Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.

Methods:

This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.

Results:

During the study period, 632 clients were served. Rates of goal achievement ranged from 25%–87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.

Conclusions:

The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.

Keywords

seniorstransitional carecommunity careadherence
Type
Research Article
Information
International Psychogeriatrics , Volume 29 , Issue 1 , January 2017 , pp. 149 - 163
Copyright
Copyright © International Psychogeriatric Association 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Aminzadeh, F. and Dalziel, W. B. (2002). Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes and effectiveness of interventions. Annals of Emergency Medicine, 39, 238–247. doi:10.1067/mem.2002.121523.Google Scholar
Bayliss, E. A., Ellis, J. L. and Steiner, J. F. (2007). Barriers to self-management and quality of life outcomes in seniors with multimorbidities. Annals of Family Medicine, 5, 395–402. doi:10.1370/afm722.CrossRefGoogle ScholarPubMed
Canadian Institute for Health Information (2009). Patient Cost Estimator. Patient Cost Estimator. Retrieved from: http://www.cihi.ca/CIHI-ext-portal/internet/en/ApplicationNew/spending+and+health+workforce/spending/CIHI020209; last accessed 29 March 2015.Google Scholar
Canadian Institute for Health Information (2010). Seniors' use of Emergency Departments in Ontario 2004-2005 to 2008-2009. Retrieved from: https://secure.cihi.ca/free_products/seniors_ed_e.pdf; last accessed 25 March 2015.Google Scholar
Coleman, E. A., Parry, C., Chalmers, S. and Min, S. S. (2006). The care transitions intervention. Results of a randomized controlled trial. Archives of Internal Medicine, 166, 1822–1828. doi:10.1001/archinte.166.17.1822.Google Scholar
Coleman, E. A. et al. (2013). Understanding and execution of discharge instructions. American Journal of Medical Quality, 28, 383–391. doi:10.1177/1062860612472931.CrossRefGoogle ScholarPubMed
Covinsky, K. E., Kahana, E., Chin, M. H., Palmer, R., Fortinsky, R. H. and Landefeld, C. S. (1999). Depressive symptoms and 3-year mortality in older hospitalized medical patients. Annals of Internal Medicine, 130, 563–569. doi:10.7326/0003-4819-130-7-199904060-00004.CrossRefGoogle ScholarPubMed
Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118, 219–223. doi:10.7326/0003-4819-118-3-199302010-00011.Google Scholar
Cresswell, K. M., Fernandes, B. M. B. and Sheikh, A. (2007). Adverse drug events in the elderly. British Medical Bulletin, 83, 259–274. doi:10.1093/bmb/ldm016.Google Scholar
Gaugler, J. E., Kane, R. L., Kane, R. A. and Newcomer, R. (2005). Early community-based service utilization and its effect on institutionalization in dementia caregiving. Gerontologist, 45, 177–185. doi:10.1093/geront/45.2.177.CrossRefGoogle ScholarPubMed
Gellad, W. F., Grenard, J. L. and Marcum, Z. A. (2011). A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. American Journal of Geriatric Pharmacotherapy, 9, 11–23. doi:10.1016/j.amjopharm.2011.02.004.Google Scholar
George, M. (1997). Offering more than support? Nursing Standard, 19, 24–25.Google Scholar
Gill, T. M., Allore, H. G., Gahbauer, E. A. and Murphy, T. E. (2010). Change in disability after hospitalization or restricted activity in older persons. Journal of the American Medical Association, 304, 1919–1928. doi:10.1001/jama.2010.1568.Google Scholar
Greysen, S. R. et al. (2014). “Missing pieces”–functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. Journal of the American Geriatrics Society, 62, 1556–1561. doi: 10.1111/jgs.12928.Google Scholar
Grief, C. L. (2003). Patterns of ED use and perceptions of the elderly regarding thier emergency care: a synthesis of recent literature. Journal of Emergency Nursing, 9, 122–126. doi:10.1067/men.2003.65.Google Scholar
Happ, M. B., Naylor, M. D. and Roe-Prior, P. (1997). Factors contributing to rehospitalization of elderly patients with heart failure. Journal of Cardiovascular Nursing, 11, 75–84.Google Scholar
Haywood, K. et al. (2015). Patient and public engagement in health-related quality of life and patient-reported outcomes research: what is important and why should we care? Findings from the first ISOQOL patient engagement symposium. Quality of Life Research, 24, 1069–1076. doi:10.1007/s11136-014-0796-3.CrossRefGoogle ScholarPubMed
Heckman, G. A. (2011). Integrated care for the frail elderly. Healthcare Papers, 1, 62–68. doi:10.12927/hcpap.2011.22255.Google Scholar
Heckman, G. A., Hillier, L., Manderson, B., McKinnon-Wilson, J., Santi, S. M. and Stolee, P. (2013). Developing an integrated system of care for frail seniors. Healthcare Management Forum, 26, 200–208.Google Scholar
Hoenig, H. M. and Rubenstein, L. Z. (1991). Hospital-associated deconditioning and dysfunction (Editorial). Journal of the American Geriatrics Society, 39, 220–222.Google Scholar
Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. doi:10.1056/NEJMra052321.Google Scholar
Katz, M. G., Jacobson, T. A., Veledar, E. and Kripalani, S. (2007). Patient literacy and question-asking behavior during the medical encounter: a mixed-methods analysis. Journal of General Internal Medicine, 22, 782–786. doi: 10.1007/s11606-007-0184-6.CrossRefGoogle ScholarPubMed
Krueger, R. and Casey, M. A. (2000). Focus Groups. Thousand Oaks, CA: Sage.Google Scholar
Lincoln, Y. S. and Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage Publications.Google Scholar
McCauley, K. M., Bixby, B. and Naylor, M. D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9, 302–310. doi:10.1089/dis.2006.9.302.Google Scholar
Naylor, M. D. (2003). Transitional care of older adults. Annual Review of Nursing Research, 20, 127–147.Google Scholar
Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M. and Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: a randomized control trial. Journal of the American Geriatrics Society, 52, 684. doi:10.1111/j.1532-5415.2004.52202.x.CrossRefGoogle Scholar
Oddone, E. Z. et al. (1996). Classifying general medicine readmissions. Are they preventable? Journal of General Internal Medicine, 11, 597–607.Google Scholar
Patton, M. Q. (2002). Qualitative Evaluation and Research. Thousand Oaks, CA: Sage.Google Scholar
Pham, C. and Dickman, R. L. (2007). Minimized adverse drug events in older patients. American Family Physician, 76, 1837–1844.Google Scholar
Rockwood, K. et al. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173, 489–495. doi:10.1503/cmaj.050051.Google Scholar
Russell, C. L., Ruppar, T. M. and Matteson, M. (2011). Improving medication adherence: moving from intention and motivation to a personal systems approach. Nursing Clinics of North America, 46, 271–281. doi: 10.1016/j.cnur.2011.05.004.Google Scholar
Schulz, R. and Martire, L. M. (2004). Family caregiving of persons with dementia. Prevalence, health effects, and support strategies. American Journal of Geriatric Psychiatry, 12, 240–249. doi:10.1097/00019442-200405000-00002.Google Scholar
Shah, M. N., Rathouz, P. J. and Chin, M. H. (2001). Emergency department utilization by non-institutionalized elders. Academic Emergency Medicine, 8, 267–273. doi:10.1111/j.1553-2712.2001.tb01303.x.Google Scholar
Sharples, A., Gibson, S. and Galvin, K. (2002). 'Floating support': implications for interprofessional working. Journal of Interprofessional Care, 16, 311–322. doi:10.1080/1356182021000008247.Google Scholar
Weldring, T. and Smith, S. M. S. (2013). Patient-reported outcomes (PROs) and patient-related-reported outcome measures (PROMs). Health Services Insight, 6, 61–68.Google Scholar
Williams, A., Manias, E. and Walker, R. (2008). Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. Journal of Advanced Nursing, 63, 132–143. doi:10.1111/j.1365-2648.2008.04656.x.Google Scholar