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Journal of Clinical Psychiatry, 67 10 , OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector. Find Out More Benefit for Members Members have access to current topic More Letter to the Editor Thank you for giving us the opportunity to respond to the letter to the editor written by Lisa Palucci. We are pleased to see her interest in older adults with multimorbidity and advancing models of care and care coordination for this growing population group. Continue Reading View all Letters Naylor, PhD, RN, FAAN Abstract 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.
DOI: Vol20No03Man01 Key words: Transitional care, transitions, older adults, multiple chronic conditions, family caregivers, care experience, health outcomes, hospitalizations, resource use, care management, evidence-based practice Findings from multiple studies reinforce the poorly managed healthcare needs of older adults Staffing Uses APRNs who assume primary responsibility for care management throughout episodes of acute illness.
Engaging Patients and Caregivers Engages older adults in design and implementation of the plan of care aligned with their preferences, values and goals. Collaborating Promotes consensus on plan of care between older adults and members of the care team. Promoting Continuity Prevents breakdowns in care from hospital to home by having same clinician involved across these sites.
Fostering Coordination Promotes communication and connections between healthcare and community-based practitioners. Screening Identifying and targeting the specific population of older adults at risk for poor outcomes is the first essential component of the TCM. Staffing APRNs also maintain responsibility for day-to-day delivery of transitional care services, including oversight of other transitional care team members.
Maintaining Relationships A key feature of the TCM is establishing and maintaining trusting relationships with patients and family caregivers. Assessing and Managing Risks and Symptoms During initial meetings with patients, APRNs conduct comprehensive assessments of the unique symptoms experienced by each older adult e. Depending on patient medical history, other domains assessed also may include: fall risk Shumway-Cook et al. Collaborating Use of health information technology Promoting Continuity Between in-person visits, APRNs contact patients by phone and they are available by telephone seven days a week.