. Below is an Attachment of a peer-reviewed journal articles that you have been assigned.Read and provide a written review of the articles with YOUR ASSIGNED TOPIC AS COMMUNICATION & ''BEHAVIORS''...

. Below is an Attachment of a peer-reviewed journal articles that you have been assigned







Winter 2012–13 • Vol. 36 .No. 4 | 109 GENERATIONS – Journal of the American Society on Aging Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. The Institute of Medicine report, Retooling for an Aging America (2008), criticized our present healthcare system as being fragmented and lacking incentives for effective collaboration between providers. Several models for enhanc- ing the quality of care during discharge from the hospital appear to be effective, even in the management of chronically ill older adults. But these models have not been tested in older adults who experience severe cognitive and psychiatric disturbances (Epstein-Lubow and Fulton, 2012; Tew, 2005). By 2030, one-fifth of the U.S. population will be age 65 or older, and the prevalence of dementia in this group is estimated to be as high as 12 percent to 14 percent (Plassman et al., 2007). Older adults with dementia represent a particularly challenging segment of our popula- tion. Many require custodial care as their disease progresses. They exhibit such behavioral pro- blems as persistent motor or verbal agitation, intrusiveness, wandering (or repeated attempts to flee), resisting personal care—even unpro- voked physical aggression (Chow et al., 2012). For this population, stabilizing their be- haviors in the hospital setting is only half the battle. In our experience, transition back to the community can often trigger a recurrence of disruptive behaviors because of the patient’s distress over relocation. Patients who appeared stable decompensate temporar- ily following transfer back to the community. This creates frustration among caregivers who were informed the patient was “doing better.” Critical for these patients is enhanced communication during transitions and support for caregivers awaiting patients’ transfer to home. This article reviews a transitional care intervention that was designed and implemented in a geropsychiatric hospital caring for behavior- ally disturbed demented adults. In this program, a transitional care nurse provides enhanced bi-directional communication, nursing home By James D. Tew, Jr. Care Transitions and the Dementia Patient: A Model Intervention Builds Communication, Trust—and Better Care Care transitions can heighten anxiety and aggressive behavior in older adults with dementia but careful communication between providers can mean a good transition, and prevent re-admissions. Older adults with dementia represent a particularly challenging population segment. GENERATIONS – Journal of the American Society on Aging Pages 109–112 110 | Winter 2012–13 • Vol. 36 .No. 4 Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. outreach, training, and post-discharge follow- up for area facilities receiving patients from the forty-two-bed geriatrics unit at Pittsburgh’s Western Psychiatric Institute and Clinic. The program was initially supported by a grant from the Practice Change Fellows Program (www. practicechangefellows.org), and has been fully funded by our hospital for the past two years. Case Study: How a Poor Transition Can Create Mistrust A strong but moderately demented nursing home resident, age 80, does not understand she needs assistance with basic hygiene and inconti- nence care. She is afraid and angered when staff attempt to assist her. This eventually results in an episode of aggression. Nursing home management, concerned about safety, sends her to an emergency room for evaluation, and she is admitted to a hospital unit. In the hospital, higher staffing ratios allow for experimentation with behavioral management strategies; a medical work-up reveals an occult infection; a toileting schedule reduces the need for incontinence care; and verbal reassurance prevents the patient from becoming panicked when she is disoriented. Within a week, the woman is less distraught and suitable for discharge. The hospital’s dis- charge planner communicates this to the nursing home admissions department. Hospital notes are faxed to the nursing home confirming improve- ment, and the patient is accepted for return. Mini- mal communication between care providers occurs. On the transfer day, a stack of paperwork is forwarded from the nursing home admissions department to the clinical nursing unit. The patient arrives at the nursing home distraught from the ambulance ride. She is frightened, and appears ready to aggressively protect herself. Medication with anti-anxiety drugs prior to the transfer was not helpful. Within the first few days of her arrival, she seems as distraught as she was the day she left. Nursing staff feel they were misled by the hospital. Within forty-eight hours she is aggressive again, but the consulting nursing home physician is not scheduled to examine her until the following week. With nowhere else to turn, the nursing home sends her back to the hospital. The hospital staff become frustrated when they see the re-admission. They presume the nursing home staff to be incompetent or uncaring. Challenging Transitions Can Undermine Trust Between Facilities The above scenario is not uncommon. Hospitals and nursing homes have become administra- tively more complex. Admissions departments and discharge planners handle much of the communication around transitions. But if the patient is unstable during the transfer, nursing home staff only see a disturbed patient arrive on the unit. The hospital is per- ceived as dishonest, and the nursing home clinical and admissions staff may develop a fundamental mistrust of the hospital. They may send patients back very quickly (an avoidable rehospitalization). Even worse, they may determine all patients being referred from psychiatric wards are unsafe for their facility and close their doors altogether to such people. As trust is undermined, facilities communicate less, resorting to blaming each other for failures in transition. A transitions program to build trust and communication Under the supervision of an attending psychia- trist, our transitional care nurse (who attended a brief training on healthcare coaching at the University of Colorado’s Care Transitions Intervention) developed and implemented a program for patients being discharged from our Transition to the community can trigger difficult behaviors in elders with dementia. Care Transitions in an Aging AmericaPages 109–112 Winter 2012–13 • Vol. 36 .No. 4 | 111 Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. hospital. As our most challenging transitions involve dementia cases, this was the focus of the program, which adopted the following four basic interventions: • Better anticipation of discharge needs by the inpatient treatment team. The transi- tions nurse attends each of four weekly treat- ment team meetings, anticipates challenging discharges before they occur, and asks the team what behavior plans are working. She commu- nicates the answer directly to receiving clinical staff (as opposed to faxing it to the admissions department, and assuming it will be forwarded and understood). • Enhanced, standardized bi-directional communication at discharge. With input from area nursing home staff, the transitional care nurse developed a Standardized Nursing Report for the day of transfer. This report includes information on the patient’s clinical diagnoses, behavioral management strategies, and nursing needs. It is quick to administer, but still more comprehensive than a typical nursing report (which can be highly variable in quality). Many area nursing homes have their receiving nurse fill out a blank copy of the form during the pre-discharge, nurse-to-nurse report between facilities. In the past year, our transitions nurse has completed more than 200 nurse-to-nurse discharge reports. Receiving nurses have been very vocal in their apprecia- tion of this report. • Support throughout the transition. Our transitions nurse offers telephone (and in some cases, on-site) follow-up for up to two weeks following transfers to offer support, problem solving, and even to relay decision support from the discharging psychiatrist, when needed. Managing a challenging transition can involve more than five phone calls in the first several days to provide support, reassurance, and to relay clinical questions to the discharg- ing physician for clarification. Area nursing homes have this nurse’s phone number, and she has become the “face” of our hospital. • A relationship with nursing homes that extends beyond individual patient trans- fers. Our transitional care nurse provides periodic visits to area nursing homes—inde- pendent of any pending discharges—to check on the status of shared patients, to establish rapport with nursing home staff and adminis- tration, and to offer basic trainings on behav- ioral management techniques. She attends weekly treatment team meetings in one of our highest volume nursing homes. When transfers go poorly, it is an opportunity to learn rather than to blame. Benefits and Challenges of a Transitional Program Our Integrated Health and Aging Unit is the largest specialized geropsychiatry unit in the Pittsburgh region. We receive patients from more than a dozen area nursing homes, and we accept extremely challenging demented patients on transfer from community hospitals. Finding facilities to accept our patients once they have stabilized is daunting. For years, placement has been a problem—one without a clear solution. Area nursing homes came to fear our patients, and did not believe us when we told them they were ready for discharge. When we cannot discharge, our unit hospital remains full, and new patients cannot access our services. From fiscal year 2010 to the first half of fiscal year 2012, the number of admissions to our unit dropped from forty-eight per month, to forty-one per month, to thirty-nine per month, largely because we struggled to find post- discharge placement for challenging patients. In part, thanks to the enhanced relationship we now enjoy with several of our highest volume referring and accepting facilities, some of our For years, placement of patients with dementia has been a problem—one without a clear solution. GENERATIONS – Journal of the American Society on Aging Pages 109–112 112 | Winter 2012–13 • Vol. 36 .No. 4 Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. most challenging patients have been success- fully re-integrated into nursing home care. We have far fewer incidents of extremely long lengths of stay. With our transitions program in full swing, we have been averaging more than fifty-five admissions per month, for the past eight months. Correspondingly, hospital lengths of stay have dropped. But still there are challeng- es: the transitional care nurse position is funded by the hospital, and we do not have a model to bill for her services. But with greater attention focused on reducing hospital re- admissions, and increasing the pressure to reduce lengths of stay, we hope to create a business model that argues for long-term sustainability and possible program expansion. James D. Tew, Jr., M.D., is assistant professor of psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute & Clinic, in Pittsburgh, Pennsylvania. References Chow, T. W., et al. 2012. “Trajecto- ries of Behavioral Disturbance in Dementia.” Journal of Alzheimer’s Disease 31(1): 143–9. Epstein-Lubow, G., and Fulton, A. T. 2012. “Post-Hospital Transitions for Individuals with Moderate to Severe Cognitive Impairment.” Annals of Long-Term Care: Clinical Care and Aging. 20(3): 18–24. Institute of Medicine. 2008. Retooling for an Aging America: Building the Health Care Workforce. www.iom.edu/Reports/2008/ Retooling-for-an-Aging-America- Building-the-Health-Care-Work force.aspx. Retrieved September 27, 2012. Plassman, B. L.