Continuum of Care, Long-Term Care, Transitions, and Family Caregiving (Lecture Review)

Continuum of Care

• The continuum of care is all the care a person receives across their lifespan, delivered in different settings and in many forms.

• Definitions vary by source; Eliopoulos identifies three types:

  • Supportive and preventive services: typically provided in the community.

  • Partial and intermittent services: provided in both community and institutional settings.

  • Complete and continuous care: usually provided in institutions.

• In practice, these categories overlap as a person’s needs evolve along a trajectory from independence to high dependence.

• For nurses, understanding the continuum is important because most patients spend far more time outside the hospital than in it, and care needs extend beyond the acute episode.

• Key implication: hospital-focused nursing can miss broader patient needs; awareness of continuum supports better referrals and long-term outcomes.

• Transitions of care (moving from one setting to another) are critical risk points: information can be lost and errors can occur, leading to adverse events.

Why the continuum matters for nurses

• Most patients’ lives extend beyond the hospital; hospital stays are often short relative to overall care needs.

• In acute care, there is a risk of overemphasizing illness treatment while neglecting broader needs (social, functional, financial, etc.).

• Transitions of care are associated with higher risk of adverse events; understanding continuum informs smoother transitions and fewer errors.

• Transitions will be covered in a later slide, but the concept is introduced here due to frequent relevance in exams and practice.

Population context and community focus

• A common myth: most older adults live in nursing homes. Reality: the vast majority live in the community.

• Question posed to students: what percentage of older adults reside in the community vs institutions?

• Correct answer: $97.5\%$ live outside of institutions; only a small fraction live in nursing homes. This underscores the importance of community-based services.

• Community resources examples (where to look for services):

  • Eldercare resource sites like eldercare.acl.gov; enter ZIP code (e.g., 72034 in Conway) to pull up local services.

  • Federal and state links to services help with housing, nutrition, legal aid, etc.

• The bottom line: most care occurs in the community, so nurses should be familiar with community-based supports.

Supportive and preventive services (community-focused)

• Goals: maintain independence and allow older adults to stay in their homes as long as possible; cost savings vs institutionalization.

• Service categories and examples mentioned in the lecture:

  • Financial services

  • VA benefits, Social Security Administration.

  • Private options like reverse annuity mortgages (RAM) promoted by Tom Selleck; RAM involves extracting home equity over time.

  • Banks as sources of financing.

  • Employment services

  • State services (e.g., Arkansas Department of Workforce Services) for training and job openings; nutrition programs.

  • Nutrition and food assistance

  • SNAP (Supplemental Nutrition Assistance Program) previously called Food Stamps.

  • Eligibility: income-based; asset limits apply for households with older members; example given: assets must be below $4{,}500$ to access SNAP benefits for an older member.

  • Benefits issued via debit card; can be used at groceries and farmers’ markets.

  • Housing

  • Conway Housing Authority and similar programs provide government-subsidized housing for older adults or disabled; income limits apply.

  • Health care

  • General access to health services and bridging between community and clinical care; specifics depend on local systems.

  • Social supports and activities

  • Churches, senior centers, libraries, theaters, universities; volunteering is beneficial (lower depression, slower cognitive decline, lower mortality).

  • Education

  • Free classes for older adults (e.g., at BCA for those over 62); colleges and independent living facilities offer educational opportunities.

  • Counseling

  • Counseling services may be private or through churches and social service agencies; cost is often out-of-pocket; Medicare coverage for counseling varies.

  • Fraud prevention

  • Elder financial fraud is common; refer to Better Business Bureau or consumer protection agencies for assistance.

  • Legal and tax services

  • IRS services; pro bono legal services via law schools; link to free legal services in the resource site.

  • Transportation

  • Local senior transportation programs (e.g., Conway area: Bauker County Council on Aging) for appointments and shopping; often subsidized; increasingly includes rideshare options.

  • Personal emergency response systems (PERS)

  • Systems include Life Alert-type devices (necklace/bracelet); respond to falls or emergencies at home.

  • Types: in-home (landline or cellular), mobile (GPS-enabled), wearable devices; typical monthly cost: 20$-50/month.

  • Other supports

  • Smoking cessation classes; support groups (e.g., Alcoholics Anonymous).

• Emphasis: many of these services are preventive and supportive, not medical, and may be modestly funded or out-of-pocket; many require eligibility and/or assets limits.

Case study: Martha (82-year-old widow living alone)

• Scenario: Martha is an 82-year-old widow living alone, financially burdened, anxious, and isolated; fixed income; worried about expenses and staying at home; increased loneliness.

• Question: Which services are most appropriate for this situation? Most important? Practical prioritization?

• Suggested services based on the lecture:

  • Counseling for loneliness and anxiety (psychosocial needs).

  • Emergency response system (PERS) for safety at home.

  • Financial counseling to manage fixed income and expenses.

  • Social/participation supports to reduce isolation (senior centers, volunteers, social activities).

• Teaching point: test questions often ask to identify the most important or first steps; plan should address safety, finances, and social integration.

Partial and intermittent care services (community and institutional options)

• Definition: services for individuals with partial self-care limitations or intermittent therapeutic demand; provided in community or some institutional settings.

• Examples and notes:

  • Assistance with chores and custodial care at home

  • Cost considerations are a major barrier; Medicare and most insurers do not cover custodial care.

  • Home-care agencies (e.g., Visiting Angels) provide services typically with a minimum four-hour requirement; e.g., $31/hour; cost accumulates quickly (e.g., several hundred dollars per month).

  • Home-delivered meals (Meals on Wheels)

  • Senior center delivery; Falk County aging group; volunteers deliver meals and provide brief social contact.

  • Home monitoring

  • Involves at-home medical monitoring (e.g., EKG devices, blood pressure, etc.).

  • Home health care

  • Medicare-paid skilled nursing or rehabilitative services; requires a skilled need; must be ordered by a provider; patient must be homebound (not regularly traveling to a doctor); typically ends when skilled need ends; can include custodial care during the episode.

  • Duration is often limited (the lecturer notes that home health care episodes are generally short, e.g., 3–4 weeks depending on skilled need and payer rules).

  • Foster care and group homes

  • Community-based group living, sometimes tied to VA programs; may provide shared support.

  • Adult day health services

  • Day programs that provide social and some medical care; intended to provide caregiver respite; cost is usually out-of-pocket and may be a barrier; availability varies by location.

  • Day treatment and day hospital

  • Similar to adult day health but include a medical component; can involve on-site visits with physicians or therapists.

  • Assisted living

  • Settings where people who can live independently can receive varying levels of assistance; not federally regulated; state-by-state regulation; cost tends to be high (roughly $3{,}100$–$4{,}100$ per month, or $38{,}000$–$50{,}000$ per year).

  • Safety concerns: less regulation can lead to mismatches between needs and placement (e.g., someone who wanders or requires more supervision may not be suited to assisted living).

  • Respite care

  • Informal respite (family or friends); home-care-based respite; in-facility respite in nursing homes; Medicare typically does not pay for respite care unless the person is on hospice; some state programs offer respite funding (e.g., Alzheimer's Arkansas Association; first-come-first-served program; up to $1{,}000$ per year).

  • Case management vs care management

  • Care management: long-term relationship; follows a person across episodes; often involves nurses; coordination across transitions.

  • Case management: episodic; one problem-focused interaction; may end after the issue is addressed.

  • PACE (Program of All-Inclusive Care for the Elderly)

  • Multidisciplinary team delivers an integrated care plan; often income-related; eligibility typically tied to Medicaid.

  • Hospice

  • Medicare coverage becomes available when the patient is within an estimated six months of dying; hospice provides extensive supports including 24/7 nursing, equipment, and a high level of care; if illness extends beyond six months, coverage can be renewed with medical justification when appropriate.

• Key takeaway: there are many options to tailor care to needs, but access, cost, and regulatory differences influence what is feasible for a given person.

Complete and continuous care (nursing homes and hospitals)

• Definition: the highest level of structured, ongoing care for those with substantial needs; includes hospitals and long-term care facilities (nursing homes).

• Historical context (brief):

  • Before the 20th century, almshouses and limited elder care existed; the Social Security Act and the Hill-Burton Hospital Survey spurred expansion; Medicare and Medicaid in the 1960s massively increased nursing home usage.

  • Omnibus Budget Reconciliation Act (OBRA) of 1987 tightened federal regulation to address abuses; current systems are highly regulated with extensive documentation and compliance requirements.

• Regulatory landscape and implications:

  • Nursing homes are among the most regulated care settings; strong standards across resident rights, safety, transfers/admissions, and care quality.

  • The Minimum Data Set (MDS) is a key standardized assessment done on admission and with changes in condition; it is used for compliance and care planning; MDS staff (including MDS nurses) focus on this documentation.

  • Resident rights and the role of the state ombudsman are central to protections in nursing homes; ombudsman programs help resolve issues raised by residents or families.

• Demographics in nursing homes:

  • A relatively small percentage of the older adult population lives in nursing homes at any given time (roughly 5% or less).

  • The age distribution includes a substantial number of residents 85+; many residents are functionally dependent to qualify for LTC funding.

• Cost considerations and payer sources:

  • Private pay or spend-down on assets is common; Medicaid often pays for long-term care after assets are exhausted.

  • Medicare covers only short stays in nursing homes (approximately up to 60–100 days under certain rehab conditions) and does not cover long-term custodial stays.

• Nursing home operations and staffing issues:

  • High staffing turnover can be common; minimum staffing requirements and CNA certification are central; regimentation and quality of life concerns persist, though culture-change efforts seek to make settings more home-like.

• The culture-change movement in long-term care:

  • Eden Alternative: emphasizes bringing more home-like elements into care settings (pets, plants, less institutional design) and faced regulatory friction.

  • Pioneer Network and the greenhouse project: focus on creating cottage-like living spaces, flexible staffing, and resident autonomy.

  • Core themes: home-like environment, consistent staffing, nurturing relationships, staff education, empowering residents and families.

• Assisted living vs nursing homes (regulatory and safety considerations):

  • Assisted living is not federally regulated and varies by state; typically higher cost and less oversight on safety issues; potential for safety hazards when proper matching of needs is not done.

• Key nursing home concepts to know for exams:

  • Resident rights; the Nursing Home Ombudsman; MDS assessments; regulatory frameworks; common costs; and the balance between regulation and innovation in care models.

• Maslow-like framework for nursing home goals (as used in the lecture):

  • Bottom to top: Hygiene (physical/medical needs) → Holism (mind, body, spirit connected within community inside/outside) → Prevention of avoidable decline; Exercise of individual rights; Peak potential (biopsychosocial, spiritual functioning, peaceful dying, purpose, growth).

  • Traditional nursing homes focused mainly on hygiene; culture-change aims to reach holism and peak potential.

Culture-change movements and innovations in LTC

• Eden Alternative: movement toward more humane, home-like approaches, often clashing with rigid regulations before regulators adapted.

• Pioneer Network: focus on reorganizing physical space to resemble home life (e.g., cottages, smaller, more intimate settings).

• Greenhouse project: co-located, home-like cottages with dedicated CNAs; prevents long corridors and creates a more intimate living environment.

• Overall goal: shift from an institutional model to a more person-centered, relationship-based model.

Family caregiving (personal, demographic, and policy context)

• Personal relevance: caregiving is often done by family members; many students/faculty have personal caregiving experiences.

• Demographic trends (United States):

  • The older adult population is growing; the younger population is shrinking, increasing need for caregiving.

  • The workforce is mobile and more dispersed; families are geographically separated; definitions of family are evolving.

  • Most older adults want to stay at home; caregiving demands are rising as people age.

• Current caregiving landscape (statistics):

  • $53{,}000{,}000$ Americans provide unpaid care to an adult with health/functional needs.

  • Of caregivers, $61\%$ are women; $39\%$ are men; many caregivers work full- or part-time while providing care.

  • $26\%$ report difficulty coordinating care; $21\%$ report their own health as fair or poor.

  • $60\%$ of caregivers work while caregiving; $28\%$ care for a child or grandchild under 18.

  • Median household income for caregivers is about $54{,}000$.

  • The term "sandwich caregivers" describes those caring for children and aging parents simultaneously.

• Caregiver burden

  • Defined as stresses and negative consequences associated with providing care; a multidimensional biopsychosocial response to an imbalance between demands and resources.

  • Caregivers with higher burden have higher risks of anxiety, depression, poorer health, lower resilience, and even higher mortality risk (e.g., up to $63\%$ higher mortality rates for high burden).

• Factors increasing caregiver burden:

  • Female gender and spousal caregiving; living with a person with dementia; financial insecurity; stress from additional life events; poor caregiver health; family mental health history; poor relationship quality.

  • Low self-esteem in the caregiver; care recipient with high behavioral and psychological symptoms; coping strategies that are emotional rather than strategic.

• Caregiver burden assessment

  • The Caregiver Burden Inventory (CBI) by Nomek and Guest (1989) breaks burden into five dimensions: time dependence, developmental burden, physical burden, social burden, and emotional burden.

  • The inventory supports targeted interventions by identifying which burden types are most salient for a given caregiver.

  • Informal questions are useful to screen mental health, social support, and coping ability.

• Coping and family dynamics

  • Family dysfunction magnifies caregiver burden and can hinder care planning.

  • Nurses often help families work through decisions, provide options and information, and support decision-making processes.

• Interventions to support caregivers

  • Education about the medical condition and care tasks.

  • Building coping skills and resilience; coaching for caregiver skills.

  • Guidance on family decision making; facilitating input from all involved relatives; managing anger and resentment.

  • Encouraging use of community services and planning for long-term care needs.

  • Practical caregiving skills (turning, transfers, hygiene, incontinence care).

  • Health maintenance for caregiver and care recipient; promoting self-care, scheduling health checks, and counseling if needed.

  • Legal and financial planning (powers of attorney, advance directives, asset protection, etc.).

  • TLC framework for caregivers: Train (care techniques and medication use), Leave (respite and breaks), See care for themselves (health maintenance and support).

• Long-distance caregiving

  • Roughly $15\%$ of caregivers are long-distance; coordination can be more challenging; local geriatric care management services (e.g., "place for mom" type resources) can assist.

  • Nurses can guide family decisions remotely and encourage self-care for long-distance caregivers.

• Abuse of older adults

  • About $1\text{ in }10$ older adults experience some form of abuse; highest risk group: disabled women ≥75 living with relatives.

  • Forms include neglect, financial exploitation, physical, sexual, verbal/emotional abuse, and abandonment.

  • Signs can be subtle; reporting to adult protective services or a state adult protective agency may be required; formal assessment tools (e.g., an elder mistreatment assessment form) can aid in evaluation.

  • Caution: not all changes in aging or illness indicate abuse; clinicians should assess thoroughly and avoid mislabeling normal aging or caregiver stress as abuse.

• Positive aspects of caregiving

  • Despite challenges, caregiving can be moving, affirming, and deepen family bonds.

  • Caregivers report meaningful experiences and the opportunity to give back to someone they love; caregiving can bring personal growth and enhanced family relationships.

• Systemic considerations

  • Family caregiver burden is a major public health issue with implications for health systems, workforce, and patient outcomes.

  • Support programs, respite, counseling, and caregiver education are essential to sustaining families and maintaining patient well-being.

Practical case questions and test-oriented learning

• Expect questions that require applying continuum-of-care concepts to real cases (e.g., identifying appropriate services at hospital discharge).

• Example test-style question (reflected in the transcript): two appropriate points on the continuum for Ms. Rodriguez at hospital discharge (from the case study) include home health services and a short-term skilled nursing facility stay for rehabilitation.

• Understanding care transitions reduces 30-day readmissions; discharge planning benefits from a consistent care manager following the patient home and ensuring post-discharge monitoring.

Intra-hospital risks in older adults and prevention (acute care focus)

• Hospitalization risks for older adults:

  • Approximately half of all hospitalizations involve older adults; the hospital can be a risky environment for older patients.

  • Prolonged hospital stays increase risk of functional and cognitive decline; about $30\%$ of older adults experience hospital-associated disability (worse at discharge).

  • Increased risk of institutionalization, prolonged disability, and death; disability can last up to 3 years.

• Common nosocomial infections in the elderly:

  • CAUTIs: catheter-associated urinary tract infections.

  • CLABSIs: central line-associated bloodstream infections.

• Major geriatric risks in hospitals (six key areas): delirium, falls, pressure injuries, dehydration, incontinence, constipation.

• Nursing actions to mitigate hospital risks:

  • Careful, baseline assessment and prompt attention to new/worsening conditions.

  • Promote early discharge when safe to do so; maximize independence; avoid over-assistance.

  • Medication vigilance to avoid adverse drug events; monitor for interactions and appropriate dosing.

  • Minimize unnecessary urinary catheterization; maintain aseptic technique for catheters/central lines to prevent infections.

  • Environment management to prevent delirium: orientation, comfort, and supportive surroundings.

  • Postoperative considerations: preoperative education; infection control; careful management of anesthesia effects in older adults; monitor for hypothermia and hypoxia; ensure adequate nutrition for wound healing.

• Surgical considerations for older adults:

  • Anesthesia can be more profound in older adults; risk of hypothermia; greater likelihood of post-op delirium in older patients; ensure oxygenation and temperature regulation.

  • Preoperative medication management: hold or adjust meds that could cause harm during fasting or surgery (e.g., glyburide in a patient who will not eat pre-op).

  • Preop planning includes reviewing labs (potassium, etc.) and obtaining informed consent with patient understanding; avoid coercion; ensure the patient’s capacity and understanding.

• Postoperative care: pulmonary hygiene (deep breathing exercises) to prevent atelectasis and pneumonia; monitor cardiovascular status; manage fluids and electrolytes; be mindful of age-related vulnerabilities and slower recovery from anesthesia.

• Dehydration and infection in older adults:

  • Infections may present with altered mental status rather than fever; temperature can be less reliable as a sign of infection in older adults.

  • Signs of dehydration include reduced intake/output, dry skin, dry mucous membranes, coated tongue, and confusion when electrolytes are off; treatment focuses on fluids and electrolyte balance.

• Post-discharge planning

  • Early assessment of post-discharge needs is critical to ensure safe transitions and reduce readmissions.

  • Discharge planning should include home safety, caregiver support, medication management, follow-up appointments, and community resource connections.

Key case follow-up: Miss Rodriguez (recap questions)

• Question: What are two points on the continuum of services that might be appropriate for Miss Rodriguez at hospital discharge?

  • Potential answers: Home health services for skilled or custodial needs; a short-term skilled nursing facility for rehabilitation or transition; discharge planning should include post-discharge monitoring and caregiver support.

• Question: Describe a potential problem or challenge as Miss Rodriguez moves from hospital to the next level of care.

  • Potential challenges include gaps in communication between hospital and post-acute care providers, medication reconciliation issues, and ensuring home safety and caregiver support after discharge.

Summary and exam-ready takeaways

• The continuum of care frames all settings where care occurs, from preventive to continuous institutional care.

• Nurses must understand community resources, transitions of care, and factors influencing referral decisions.

• Most older adults live in the community, so community-based services are central to long-term well-being and cost containment.

• Long-term care has evolved with regulation and culture-change movements aimed at more home-like, resident-centered care.

• Family caregiving is widespread, with significant burden affecting health and quality of life; multiple tools and programs exist to support caregivers.

• Acute care for older adults carries specific risks (delirium, infections, falls, dehydration); proactive assessment, prevention, and careful discharge planning are essential.

• Case-based learning (costs, services, and transitions) is crucial for exams and clinical decision-making; you should be able to identify appropriate services at discharge and anticipate potential transition problems.

Quick reference numbers and terms (LaTeX)

• Proportion living outside institutions: $97.5\%$

• Caregiver population: $53{,}000{,}000$

• Caregiver gender distribution: $61\%$ women, $39\%$ men

• Working caregivers: $60\%$ (of all caregivers)

• Caregiver education level: $36\%$ with a high school education or less

• Median caregiver household income: $54{,}000$

• Asset limit for SNAP for older member: $4{,}500$

• Assisted living monthly range: $3{,}100$ to $4{,}100$ per month; annual: $38{,}000$ to $50{,}000$

• Long-distance caregivers: $15\%$

• Proportion of hospitalizations involving older adults: approximately $50\%$

• Hospital-associated disability prevalence: $30\%$

• Cost and care terms:

  • MDS: Minimum Data Set

  • CAUTI: catheter-associated urinary tract infection

  • CLABSI: central line-associated bloodstream infection

  • PACE: Program of All-Inclusive Care for the Elderly

  • OBRA: Omnibus Budget Reconciliation Act

  • RAM: Reverse Annuity Mortgage

  • FMLA: Family and Medical Leave Act

Chapter 10: Continuum of Care, Service Selection, Transitions, and Nursing Roles

Describe the continuum of services available to older adults

• The continuum of care is all the care a person receives across their lifespan, delivered in different settings and in many forms.

• Definitions vary by source; Eliopoulos identifies three types:

  • Supportive and preventive services: typically provided in the community.

  • Partial and intermittent services: provided in both community and institutional settings.

  • Complete and continuous care: usually provided in institutions.

• In practice, these categories overlap as a person’s needs evolve along a trajectory from independence to high dependence.

• Most older adults live in the community; $97.5\%$ live outside of institutions.

Supportive and preventive services (community-focused)

• Goals: maintain independence and allow older adults to stay in their homes as long as possible; cost savings vs institutionalization.

• Service categories and examples:

  • Financial services (VA benefits, Social Security, reverse annuity mortgages (RAM), banks).

  • Employment services (State services for training and job openings).

  • Nutrition and food assistance (SNAP – income and asset-based, e.g., assets below $4{,}500$ for older members).

  • Housing (government-subsidized programs like Conway Housing Authority).

  • Health care (general access, bridging community and clinical care).

  • Social supports and activities (churches, senior centers, libraries, volunteering).

  • Education (free classes for older adults, college opportunities).

  • Counseling (private or via churches/social service agencies, Medicare coverage varies).

  • Fraud prevention (Better Business Bureau, consumer protection agencies).

  • Legal and tax services (IRS, pro bono legal services).

  • Transportation (local senior programs, rideshare options).

  • Personal emergency response systems (PERS): in-home, mobile, wearable devices (typical monthly cost: 20$-50/month).

  • Other supports (smoking cessation, support groups).

Partial and intermittent care services (community and institutional options)

• Definition: services for individuals with partial self-care limitations or intermittent therapeutic demand; provided in community or some institutional settings.

• Examples:

  • Assistance with chores and custodial care at home (major barrier: cost; Medicare/insurers typically don't cover custodial care; e.g., $31/hour, four-hour minimum for home-care agencies).</p></li><li><p>Home-delivered meals (Meals on Wheels).</p></li><li><p>Home monitoring (at-home medical monitoring).</p></li><li><p>Home health care (Medicare-paid skilled nursing/rehabilitative, requires skilled need, provider order, homebound status, limited duration).</p></li><li><p>Foster care and group homes.</p></li><li><p>Adult day health services (day programs for social/medical care, caregiver respite, usually out-of-pocket cost).</p></li><li><p>Day treatment and day hospital (similar to adult day health but include medical component).</p></li><li><p>Assisted living (varying levels of assistance, not federally regulated, state-regulated; cost: roughly$3{,}100$–$4{,}100$per month or$38{,}000$–$50{,}000$per year; safety concerns due to less regulation).</p></li><li><p>Respite care (informal, home-care, in-facility; Medicare typically doesn't pay unless on hospice, some state programs).</p></li><li><p>Case management vs care management (Care management: long-term, follows person across episodes, often nurses; Case management: episodic, problem-focused).</p></li><li><p>PACE (Program of All-Inclusive Care for the Elderly): multidisciplinary team, integrated care, often income/Medicaid-related.</p></li><li><p>Hospice: Medicare coverage when patient is within estimated six months of dying; provides extensive supports.</p></li></ul></li></ul><p>Complete and continuous care (nursing homes and hospitals)</p><ul><li><p>Definition: the highest level of structured, ongoing care for those with substantial needs; includes hospitals and long-term care facilities (nursing homes).</p></li><li><p>Historically (pre-20th century: almshouses; post-1960s: Medicare/Medicaid dramatically increased usage).</p></li></ul><h6 id="f2f7ad09-868e-4645-ad56-6a7c2e84c9db" data-toc-id="f2f7ad09-868e-4645-ad56-6a7c2e84c9db" collapsed="false" seolevelmigrated="true">Discuss factors that influence service selection for older adults</h6><ul><li><p>Cost considerations: a major barrier for many services (e.g., custodial home care, adult day health, assisted living).</p></li><li><p>Eligibility requirements: income-based and asset limits (e.g., SNAP, government-subsidized housing, PACE).</p></li><li><p>Regulatory differences: state-by-state regulation for services like assisted living, which can lead to mismatches between needs and placement.</p></li><li><p>Patient needs: evolving from independence to high dependence, requiring different levels of care and support.</p></li><li><p>Availability: varies by location for community resources.</p></li><li><p>Payer sources: private pay, spend-down on assets, Medicaid for long-term care, Medicare for short-term skilled needs (not long-term custodial).</p></li><li><p>Caregiver support: the presence or absence of family care could influence the selection of formal paid services.</p></li><li><p>Safety concerns: important in settings with less regulation, like assisted living.</p></li></ul><h6 id="11c8b64f-c6be-4942-b54d-eefdd01953ca" data-toc-id="11c8b64f-c6be-4942-b54d-eefdd01953ca" collapsed="false" seolevelmigrated="true">Discuss problems related to transitions across care settings</h6><ul><li><p>Transitions of care (moving from one setting to another) are critical risk points: information can be lost and errors can occur, leading to adverse events.</p></li><li><p>Transitions are associated with higher risk of adverse events; understanding continuum informs smoother transitions and fewer errors.</p></li><li><p>Potential challenges during transitions include gaps in communication between hospital and post-acute care providers, medication reconciliation issues, and ensuring home safety and caregiver support after discharge.</p></li><li><p>Understanding care transitions reduces 30-day readmissions; discharge planning benefits from a consistent care manager following the patient home and ensuring post-discharge monitoring.</p></li></ul><h6 id="1a41e795-2f6f-4be9-bd04-7d5320561c24" data-toc-id="1a41e795-2f6f-4be9-bd04-7d5320561c24" collapsed="false" seolevelmigrated="true">List functions of gerontological nurses</h6><ul><li><p>Understanding the continuum of care and how patient needs extend beyond acute episodes.</p></li><li><p>Familiarity with community-based supports and resources to aid patient referrals.</p></li><li><p>Informing smoother transitions and reducing errors across care settings.</p></li><li><p>Helping families work through decisions, providing options and information, and supporting decision-making processes.</p></li><li><p>Mitigating hospital risks through careful baseline assessment, prompt attention to new conditions, promoting early discharge, maximizing independence, medication vigilance, minimizing unnecessary catheterization, maintaining aseptic technique, and managing the environment to prevent delirium.</p></li><li><p>Guiding family decisions remotely and encouraging self-care for long-distance caregivers.</p></li><li><p>Reporting elder abuse to adult protective services or state agencies when signs are present.</p></li><li><p>Focusing on documentation such as Minimum Data Set (MDS) assessments in long-term care facilities.</p></li><li><p>Coordinating care across transitions as a care manager.</p></li><li><p>Proactive assessment, prevention, and careful discharge planning in acute care.</p></li></ul><h5 id="aa041e9d-22ca-4a2b-9041-6ad7a8756d90" data-toc-id="aa041e9d-22ca-4a2b-9041-6ad7a8756d90" collapsed="false" seolevelmigrated="true">Chapter 33: Acute Care</h5><h6 id="4b510cca-4a54-4f8b-b564-5ce07d8467fc" data-toc-id="4b510cca-4a54-4f8b-b564-5ce07d8467fc" collapsed="false" seolevelmigrated="true">Identify risks faced by acutely ill older adults</h6><ul><li><p>Approximately half of all hospitalizations involve older adults; the hospital can be a risky environment.</p></li><li><p>Prolonged hospital stays increase risk of functional and cognitive decline; about$30\%$of older adults experience hospital-associated disability (worse at discharge), which can last up to 3 years.</p></li><li><p>Increased risk of institutionalization and death.</p></li><li><p>Common nosocomial infections: CAUTIs (catheter-associated urinary tract infections), CLABSIs (central line-associated bloodstream infections).</p></li><li><p>Major geriatric risks in hospitals (six key areas): delirium, falls, pressure injuries, dehydration, incontinence, constipation.</p></li></ul><h6 id="960c3646-70ed-4919-8644-ae523e208bb9" data-toc-id="960c3646-70ed-4919-8644-ae523e208bb9" collapsed="false" seolevelmigrated="true">Discuss common geriatric emergencies and related nursing actions</h6><ul><li><p>Geriatric risks like delirium, falls, and severe dehydration can lead to emergencies.</p></li><li><p><strong>Dehydration</strong>: Signs include reduced intake/output, dry skin, dry mucous membranes, coated tongue, confusion (when electrolytes are off). Treatment focuses on fluids and electrolyte balance.</p></li><li><p><strong>Infection</strong>: May present with altered mental status rather than fever; temperature can be less reliable as a sign. Nursing actions include prompt attention to new/worsening conditions and maintaining aseptic technique.</p></li><li><p><strong>General nursing actions for emergencies/risks</strong>:</p><ul><li><p>Careful, baseline assessment and prompt attention to new/worsening conditions.</p></li><li><p>Medication vigilance to avoid adverse drug events; monitor for interactions and appropriate dosing.</p></li><li><p>Environment management to prevent delirium: orientation, comfort, supportive surroundings.</p></li><li><p>Postoperative considerations: monitoring for hypothermia and hypoxia, ensuring adequate nutrition, pulmonary hygiene (deep breathing exercises), monitoring cardiovascular status, managing fluids and electrolytes.</p></li></ul></li></ul><h6 id="262bd93a-b59c-4b7e-aa65-9a97616922d2" data-toc-id="262bd93a-b59c-4b7e-aa65-9a97616922d2" collapsed="false" seolevelmigrated="true">Identify measures to reduce risk of infection in older adults</h6><ul><li><p>Minimize unnecessary urinary catheterization.</p></li><li><p>Maintain aseptic technique for catheters and central lines.</p></li><li><p>Practice rigorous infection control, especially in postoperative care.</p></li></ul><h6 id="c14dfe47-1fff-41f9-be19-373e9d2e8f72" data-toc-id="c14dfe47-1fff-41f9-be19-373e9d2e8f72" collapsed="false" seolevelmigrated="true">Discuss importance of early discharge planning for hospitalized older adults</h6><ul><li><p>Early assessment of post-discharge needs is critical to ensure safe transitions and reduce readmissions.</p></li><li><p>Promoting early discharge when safe to do so can reduce risks of functional/cognitive decline associated with prolonged hospital stays.</p></li><li><p>Discharge planning that ensures consistent care management post-discharge can help reduce 30-day readmissions.</p></li></ul><h6 id="b10df83b-5f50-483f-9f6f-84b63ea1037a" data-toc-id="b10df83b-5f50-483f-9f6f-84b63ea1037a" collapsed="false" seolevelmigrated="true">Describe factors influencing post discharge outcomes for older adults</h6><ul><li><p><strong>Comprehensive discharge planning</strong> should include:</p><ul><li><p>Home safety assessment.</p></li><li><p>Caregiver support and education.</p></li><li><p>Medication management and reconciliation.</p></li><li><p>Follow-up appointments scheduling and adherence.</p></li><li><p>Connections to community resources.</p></li></ul></li><li><p><strong>Communication</strong> between hospital and post-acute care providers.</p></li><li><p><strong>Medication reconciliation issues</strong> that can lead to errors.</p></li><li><p><strong>Home safety and caregiver support</strong> directly impact patient well-being and ability to remain at home.</p></li></ul><h5 id="826a5f12-8fbe-44e4-a8f2-ccc44c825d8d" data-toc-id="826a5f12-8fbe-44e4-a8f2-ccc44c825d8d" collapsed="false" seolevelmigrated="true">Chapter 34: Long Term Care</h5><h6 id="4fb25b84-1b44-4864-a415-393aecfea77a" data-toc-id="4fb25b84-1b44-4864-a415-393aecfea77a" collapsed="false" seolevelmigrated="true">Discuss problems resulting from the lack of a unique model for long-term care</h6><ul><li><p>Traditional nursing homes focused mainly on hygiene, often neglecting holistic and peak potential needs.</p></li><li><p>Regulatory friction occurred with culture-change movements (e.g., Eden Alternative) clashing with rigid existing regulations.</p></li><li><p>Assisted living (varying by state and not federally regulated) can lead to mismatches between needs and placement due to less oversight, creating potential for safety hazards.</p></li></ul><h6 id="56d62a46-8bbe-40fe-9e8a-930afa81ba0d" data-toc-id="56d62a46-8bbe-40fe-9e8a-930afa81ba0d" collapsed="false" seolevelmigrated="true">Identify categories of standards described in nursing home regulations</h6><ul><li><p>Nursing homes are among the most regulated care settings, with strong standards across:</p><ul><li><p>Resident rights.</p></li><li><p>Safety.</p></li><li><p>Transfers/admissions.</p></li><li><p>Care quality.</p></li></ul></li><li><p>The Omnibus Budget Reconciliation Act (OBRA) of 1987 tightened federal regulation to address abuses, requiring extensive documentation and compliance.</p></li><li><p>The Minimum Data Set (MDS) is a key standardized assessment used for compliance and care planning.</p></li></ul><h6 id="7b508593-39ae-43ca-9e7e-9509a9d0d888" data-toc-id="7b508593-39ae-43ca-9e7e-9509a9d0d888" collapsed="false" seolevelmigrated="true">List roles of nurses in long-term care facilities</h6><ul><li><p>Conducting and overseeing Minimum Data Set (MDS) assessments and documentation.</p></li><li><p>Ensuring compliance with federal and state regulations regarding resident rights, safety, and care quality.</p></li><li><p>Working with resident rights and state ombudsman programs to resolve issues.</p></li><li><p>Providing care management, maintaining long-term relationships, and coordinating care across episodes and transitions.</p></li><li><p>Implementing culture change initiatives to create more home-like, person-centered environments.</p></li><li><p>Addressing hygiene, holism, and healing needs of residents.</p></li></ul><h6 id="1fd61e3a-55ae-4444-8470-be92f55d0d73" data-toc-id="1fd61e3a-55ae-4444-8470-be92f55d0d73" collapsed="false" seolevelmigrated="true">Describe hygiene, holism, and healing needs of long-term care facility residents</h6><ul><li><p>A Maslow-like framework for nursing home goals suggests:</p><ul><li><p><strong>Hygiene (physical/medical needs)</strong>: focused on basic physical and medical care.</p></li><li><p><strong>Holism (mind, body, spirit connected within community inside/outside)</strong>: encompassing the whole person within their social and spiritual context.</p></li><li><p><strong>Prevention of avoidable decline</strong>.</p></li><li><p><strong>Exercise of individual rights</strong>.</p></li><li><p><strong>Peak potential (biopsychosocial, spiritual functioning, peaceful dying, purpose, growth)</strong>: aiming for a higher quality of life and purpose.</p></li></ul></li><li><p>Traditional nursing homes focused mainly on hygiene; culture-change aims to reach holism and peak potential.</p></li></ul><h5 id="3d48477e-bf4a-44aa-bb68-8c8d6525f403" data-toc-id="3d48477e-bf4a-44aa-bb68-8c8d6525f403" collapsed="false" seolevelmigrated="true">Chapter 34: Family</h5><h6 id="926c4305-4954-4fa1-9f82-be504a20327c" data-toc-id="926c4305-4954-4fa1-9f82-be504a20327c" collapsed="false" seolevelmigrated="true">List various structures and functions of families</h6><ul><li><p><strong>Structures</strong>: Evolving definitions of family, including traditional and non-traditional configurations, often geographically dispersed due to mobile workforce.</p></li><li><p><strong>Functions</strong>: Primarily providing unpaid care to an adult with health/functional needs, offering social and emotional support, and participating in decision-making for older adults.</p></li></ul><h6 id="83fea951-59de-451f-a33f-7bd757a86df4" data-toc-id="83fea951-59de-451f-a33f-7bd757a86df4" collapsed="false" seolevelmigrated="true">Discuss roles that family members can assume</h6><ul><li><p><strong>Primary caregiver</strong>: providing direct care activities.</p></li><li><p><strong>Coordinator of care</strong>: managing appointments, medications, and services.</p></li><li><p><strong>Advocate</strong>: ensuring the older adult's needs and rights are met.</p></li><li><p><strong>Emotional support provider</strong>: offering comfort and companionship.</p></li><li><p><strong>Financial manager</strong>: assisting with financial decisions and management.</p></li><li><p><strong>Decision-maker</strong>: often in conjunction with the older adult, for medical or living arrangements.</p></li></ul><h6 id="67a3af95-5f2a-4123-86c9-eca3bd632cee" data-toc-id="67a3af95-5f2a-4123-86c9-eca3bd632cee" collapsed="false" seolevelmigrated="true">Identify risks to caregivers and ways to reduce them</h6><ul><li><p><strong>Caregiver burden</strong>: Defined as stresses and negative consequences associated with providing care; a multidimensional biopsychosocial response to an imbalance between demands and resources.</p></li><li><p><strong>Risks of higher burden</strong>:</p><ul><li><p>Higher risks of anxiety, depression, poorer health, lower resilience, and even higher mortality risk (up to$63\%$higher mortality rates).</p></li><li><p>Difficulty coordinating care (26$54{,}000$).

  • Stress from additional life events.

  • Poor caregiver health; family mental health history.

  • Poor relationship quality with care recipient.

  • Low self-esteem in the caregiver.

  • Care recipient with high behavioral and psychological symptoms.

  • Coping strategies that are emotional rather than strategic.

• Ways to reduce risks (Interventions to support caregivers):

  • Education about the medical condition and care tasks.

  • Building coping skills and resilience; coaching for caregiver skills.

  • Guidance on family decision making; facilitating input from all involved relatives; managing anger and resentment.

  • Encouraging use of community services and planning for long-term care needs.

  • Practical caregiving skills (turning, transfers, hygiene, incontinence care).

  • Health maintenance for caregiver and care recipient; promoting self-care, scheduling health checks, counseling.

  • Legal and financial planning (powers of attorney, advance directives, asset protection).

  • TLC framework: Train (care techniques/medication), Leave (respite/breaks), See care for themselves (health maintenance/support).