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The Resource Geriatrics Models of Care : Bringing 'Best Practice' to an Aging America

Geriatrics Models of Care : Bringing 'Best Practice' to an Aging America

Geriatrics Models of Care : Bringing 'Best Practice' to an Aging America
Geriatrics Models of Care
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Bringing 'Best Practice' to an Aging America
This book describes geriatrics practice models that are used to guide the care of older adults, allowing seniors to remain at home, prevent functional disability and preserve quality of life. The models include specific interventions which are performed by health care workers to address the needs of older persons and their caregivers. These models respect patient values, consider patient safety and appreciate psychosocial needs as well. Divided into six parts that discuss hospital-based models of care, transitions from hospital to home, outpatient-based models of care and emergency department models of care, this text addresses the needs of vulnerable patients and the community. Geriatric Models of Care is an excellent resource for health care leaders who must translate these programs to address the needs of the patients in their communities
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Geriatrics Models of Care : Bringing 'Best Practice' to an Aging America
Geriatrics Models of Care : Bringing 'Best Practice' to an Aging America
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  • Foreword -- References -- Preface: The Adoption of Geriatric Practice Models -- Reference -- Contents -- Contributors -- About the Editors -- Part I: Hospital Based Models of Care -- 1: Acute Care for Elders -- Introduction -- Hospitalization-Associated Disability -- Consequences of Hospitalization-Associated Disability -- Risk Factors for Hospitalization-Associated Disability -- Other Serious Complications in Older Adults Associated with Hospitalization -- Delirium -- Urinary Incontinence -- Falls -- Pressure Ulcers -- Malnutrition -- ACE Unit Care Model, Setting, and Patient Population -- ACE Unit Precursors -- Core Components of the ACE Model of Care -- Roles of ACE Unit Interdisciplinary Team Members -- What Does the ACE Model Mean for the Individual Patient Experience? -- ACE Geriatric Interdisciplinary Provider Training -- ACE Unit Setting and Patient Population -- ACE Unit Outcomes -- Process and Clinical Outcomes -- Health Care Utilization and Cost Outcomes -- Future for ACE -- Scaling-Up the ACE Model -- Future Direction of ACE Outcomes Research -- ACE and Health Care Reform -- ACE Unit Development: Getting Buy-In from Stakeholders -- Barriers to ACE Unit Development -- Leveraging ACE in the Current Health Care Environment -- Steps in ACE Unit Development -- Sustaining an ACE Unit -- Conclusion -- References -- 2: Hospital Elder Life Program (HELP) -- Overview -- Key Points -- Program Structure and Interventions -- Eligible Patients and Enrollment Process -- Enrollment Criteria for Hospital Elder Life Program -- Inclusion Criteria -- Exclusion Criteria -- Intervention Process -- The HELP Interdisciplinary Team -- Elder Life Nurse Specialist -- Key Responsibilities of the ELNS -- Elder Life Specialist -- Key Responsibilities of the ELS -- Geriatrician -- Key Responsibilities of the HELP Geriatrician -- Volunteers
  • Interdisciplinary Rounds -- Staff Overview -- Quality Assurance Procedures -- Quality Assurance to Improve Intervention Adherence -- Quality Assurance to Improve Staff Role Functioning -- Quality Assurance of Volunteer Performance -- Patient-Family Survey -- Ongoing Program Quality Improvement -- Strategies to Improve Adherence -- Guiding Principle -- General Strategies -- Volunteer-Related Strategies -- Help Outcomes -- Potential Outcomes to be Tracked at HELP Sites -- Process Measures -- Clinical Outcomes -- Evidence for Efficacy and Cost-Effectiveness -- Efficacy Studies -- Cost-Effectiveness Studies -- Challenges to Implementation -- Challenges in Starting a Program -- Challenges in Sustaining HELP -- Surviving in Difficult Economic Times -- Challenges for Surviving in Difficult Economic Times -- Learning from Closure of Operational Sites -- The HELP Dissemination Process -- Support for the HELP Dissemination Process -- Feasibility of Family Participation -- Integration of HELP with Other Geriatric Models of Care -- Summary -- References -- 3: The Acute Care for Elders Consult Program -- Acute Care for Elders: Background and Introduction -- The Dysfunctional Syndrome, the ACE Prehabilitation Model, and the ACE Interdisciplinary Team -- ACE Consult Team -- Challenges Faced by ACE Consult Programs -- ACE Consult Program: Evaluation Measures -- The Business Case for ACE Consult Programs -- The Future of Acute Care for Elders -- Medicare Rule Changes for Care Transitions, and How ACE Principles Can Minimize the Impact on Hospitals -- Conclusions -- References -- 4: Acute Care for Elders (ACE) Tracker and e-Geriatrician Telemedicine Programs -- Introduction to ACE -- ACE at Aurora Health Care -- The Structure of Aurora Health Care's Senior Service Line -- Leadership Support for Acute Care for Elders -- Education, Direction, and Communication
  • A Description of ACE Tracker -- ACE Tracker Validation -- How the ACE Tracker Is Used -- Role of the "e-Geriatrician" -- Measuring Outcomes -- Lessons Learned and Future Implications -- References -- 5: The NICHE Program to Prepare the Workforce to Address the Needs of Older Patients -- NICHE Program History -- Current NICHE Program -- Outline Placeholder -- Population -- Program Setting -- Conceptual Basis for NICHE -- The GRN -- Role of the Interdisciplinary Team -- Barriers to the Program -- NICHE Measurement -- How Have Organizations Used GIAP Data? -- What Have GIAP Results Demonstrated in NICHE Hospitals? -- Unit Level Data: Clinical and Staff-Related -- Additional Unit-Level Measures -- How Have Organizations Used Unit-Level Data? -- What Have Unit-Level Results Demonstrated in NICHE Hospitals? -- NICHE Program Evaluation -- NICHE Business Plan Development -- Scaling the Niche Model: The Aurora Health Care Experience -- Integration into the Electronic Health Record (EHR) -- Healthcare Reform and Cost of the Program -- References -- 6: Palliative Care as a Consultation Model -- Background -- Which Healthcare Problems Are Addressed by Palliative Care? -- Which Patients Will Be Best Served by Palliative Care? -- What Are the Barriers to the Provision of Palliative Care? -- Workforce Challenges -- Perception of Palliative Care -- What Are the Benefits of Palliative Care? -- Quality Outcomes -- Cost Outcomes -- How Does Palliative Care Help Align the Care Delivered to Patients with the Care They Desire? -- With So Many Choices, How Do Hospitals and Health Systems Know Which Model to Pick? -- Funding and Building a Program -- How Do You Get Buy-in From Health System Leaders? -- How Do You Develop a Business Plan to Determine the Costs and Benefits of the Model? -- "What Can We Implement and How Can We Get It for the Least Cost?"
  • Will the Care Be Paid for Under the Medicare Fee-for-Service Program and Who Will Bear the Costs as Health Systems Transition to Value-Based Purchasing? -- Developing a Program to Meet the Hospital's Needs -- What Are the Key Components and How Does the Model Work? -- Who Are the Interdisciplinary Team Members? -- Social Work -- Spiritual Care -- Complementary Therapists -- How Do Interdisciplinary Team Members Work Together? -- Leveraging the Electronic Medical Record -- Can Adult Patients/Family Caregivers Be Involved in the Planning and Advising of the Model of Care? -- What Training Is Required for Providers? -- How Can the Fidelity of the Implementation be Maintained? -- What Is the Role of the Geriatrician in Developing and Leading the Model? -- How Can Health Systems Integrate the Geriatrics and Palliative Medicine Practice Models to Provide a Portfolio of Strategies to Address the Needs of Patients? -- Monitoring Outcomes and Planning for Future Directions -- Is the Model Scalable? -- How Do We Know the Model Is Improving Care? -- What Are the Future Directions of Palliative Care Consultation Services? -- References -- 7: The Wisconsin Star Method: Understanding and Addressing Complexity in Geriatrics -- Evidence-Bases for the Wisconsin Star Method -- Using the Wisconsin Star Method -- Meaning-Centered Care with the Wisconsin Star Method -- Applying the Wisconsin Star Method to Teams and Systems -- Summary -- References -- Part II: Models to Address the Needs of Seniors in Transition from Hospital-to-Home -- 8: Care Transitions Intervention and Other Non-nursing Home Transitions Models -- Background -- Sites of Post-hospitalization Care -- Factors Contributing to Adverse Events During Care Transitions -- Common Themes in Optimal Care Transitions -- Communication Across Care Settings -- Patient/Caregiver Self-Management
  • Medication Management and Medication Reconciliation in Care Transitions -- Roles of Interdisciplinary Team Members, Patients, and Families in Care Transitions -- Interventions to Improve Care Transitions Post-hospitalization -- Transitional Care Model -- Care Transitions Intervention -- Re-Engineered Discharge -- ACE/Mobile ACE -- Care Transition Intervention Targeting Patients Experiencing Low Socioeconomic Status -- Outpatient-Based Models Shown to Reduce Unnecessary Hospitalizations/Readmissions -- Other Sites of Care Transitions -- Health Information Technology as a Tool to Assist with Care Transitions -- Electronic Health Record and Discharge Summaries -- ACE Tracker -- Telehealth and Readmissions -- Medicare Rule Changes Regarding Care Transitions and Impact on Hospitals -- New Financial Rules -- New Process Rules -- Future/Next Steps in Care Transitions -- Conclusions -- References -- 9: Project BOOST®: A Comprehensive Program to Improve Discharge Coordination for Geriatric Patients -- Interventions and Tools in Project BOOST® -- Implementation of Project BOOST® -- Resources Used and Skills Needed -- Staffing -- Costs -- Planning and Development Process -- Obtain Senior Administrator Support -- Estimate Financial Costs and Benefits -- Establish an Organizational Framework for QI -- Create an Interdisciplinary Project Team -- Analyze the Existing Processes -- Set Appropriate Project Goals -- Expect and Prepare for More Patient Questions -- Implement a New Process -- Evaluation -- Structural Measures -- Process Measures -- Outcome Measures -- Ongoing Refinement -- Effectiveness of Project BOOST® -- References -- Part III: Outpatient-Based Models of Care -- 10: The GRACE Model -- Background and Conceptual Model -- GRACE Team Care -- Overview -- Key Components -- In-Home Geriatric Assessment -- Individualized Care Plan and GRACE Protocols
  • GRACE Interdisciplinary Team Conference
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