Instructor’s Manual Nursing Responses to Elder Mistreatment
Total Time 12. Discharge and Care Transition Planning 1.25 hours in Elder Mistreatment Cases 2.25 hours with optional activity Purpose This module will discuss issues specific to discharge and care transition planning for patients in elder mistreatment cases. In suspected and known elder mistreatment cases, addressing the patient’s follow-up medical and safety needs is the final component of the initial nursing response. Discharge planning may occur prior to release from a health facility. Care transition planning may occur in a home health care setting or as part of ongoing care planning in a long-term care facility. Whatever the setting, the focus should be on determining, in conjunction with patients, the most suitable strategies for helping them regain their health and enhance their safety.
Topics Key issues and actions to be considered during discharge/care transition planning.
Learning Objectives By the end of this module, participants will be able to: Identify priorities in discharge/care transition planning in elder mistreatment cases on patient safety, health and well being; and Discuss issues to consider and actions to take when planning for discharge/care transition with patients in elder mistreatment cases.
Instructor Preparation Clarify instructor roles in teaching this module. A nurse educator should be the lead facilitator, with legal and elder mistreatment experts available to answer questions as they arise. Preview activities, sequence and time allotments: 1. Large group discussion of practices related to discharge and care transition planning in elder mistreatment cases, with a focus on patient health, well being and safety. (55 minutes) (Slide 2-12)
12. Discharge and Care Transition Planning Page 1 Instructor’s Manual Nursing Responses to Elder Mistreatment
2. Optional small group practice on planning for discharge/care transition, using case illustrated through an online video. (60 minutes) 3. Closing assessment—Module 12 and overall course. (20 minutes) (Slide 13-14) Preview materials for Module 12 in the Instructor’s Manual, Participant Materials and Slides. Note that information from the following key resources is woven into this module: American Medical Association. (1992). Diagnostic and treatment guidelines of elder abuse and neglect. Chicago, IL: Author. Aravanis, S., Adelman, R., Breckman, R., Fulmer, T., Holder, E., Lachs, M., O’Brien, J., & Sanders, A. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archive of Family Medicine, 2, 371–388. Retrieved from http://archfami.ama-assn.org/cgi/reprint/2/4/371. Brandl, B., Bitondo Dyer, C., Heisler, C., Marlatt Otto, J., Stiegel, L., & Thomas, R. (2007). Elder abuse detection and intervention: A collaborative approach (Chapter 7, 9-10). New York: Springer Publishing Company. Kahan, F., & Paris, B. (2003). Why elder abuse continues to elude the health care system. The Mount Sinai Journal of Medicine, 70(1), 62-68. Retrieved from http://www.mssm.edu/msjournal/70/v70_1_page_62_68.pdf. Landefeld, C., Palmer, R., Johnson, M., Johnson, C., & Lyons, W. (Eds.). (2004). Current geriatric diagnosis and treatment (p. 418). New York: Lange Medical Books/McGraw Hill. National Clearinghouse on Abuse in Later Life. Safety plan (Online suggestions) (2003); A sample safety plan (2006); Safety planning: A guide for individuals with physical disabilities (2000); Safety planning: How you can help (cognitive disabilities) (2003); and Anticipate: Identifying victim strengths and planning for safety concerns (2003). Madison, WI: Wisconsin Coalition Against Domestic Violence. Retrieved from http://www.ncall.us/resources.html. Pan-American Health Organization. (2008). PAHO manual: Diagnostic and management guide I, abuse (mistreatment) and neglect (abandonment). In A global response to elder abuse and neglect: Building primary health care capacity to deal with the problem worldwide. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/ageing/publications/ELDER_DocAugust08.pdf. University of North Carolina Center for Aging and Health. (2005). Elder abuse and neglect. Elder mistreatment learning module. Chapel Hill, NC: University of North Carolina at Chapel Hill School of Medicine. Retrieved from http://www.med.unc.edu/aging/eldermistreatment/overview.htm. For optional Activity 2, review this video: Hartford Institute for Geriatric Nursing, New York University, College of Nursing and American Journal of Nursing. (December 2008). How to try this series: Elder Mistreatment Assessment (online video). New York: Authors. This video can be retrieved in several ways: It can be viewed at no cost though http://consultgerirn.org/resources. (Click on the Clinical Resources/Tools link to
12. Discharge and Care Transition Planning Page 2 Instructor’s Manual Nursing Responses to Elder Mistreatment
get to Assessment Tools. Click on the Expand All link, then scroll down to Issue 15: Elder Mistreatment Assessment and click on the video). It can be viewed or downloaded at no cost through www.nursingcenter.com/AJNolderadults. (Click on the How to Try This link to access the video.) Alternately, the DVD can be purchased through Terra Nova Films at www.terranova.org. To do this activity, make enough copies for all participants of the Worksheet for Discharge or Care Transition Planning in Elder Mistreatment Cases, found in the Participant Materials. To the extent possible, locate and review participants’ practice settings policies, procedures and forms related to discharge and care planning in mistreatment cases and referring to/coordinating services with other agencies on behalf of patients. Have enough copies of the course evaluation form for all participants.
Lesson Plan 55 minutes total Activity 1: Crafting a Discharge/Care Transition Plan Slides 2-12 This activity allows participants to discuss practices related to discharge/care transition planning in elder mistreatment cases in their practice settings and identify key issues to consider and actions to take when doing this planning. A focus of the planning is facilitating patient safety, health and well being. The information in this section was adapted in part from the resources listed above in Instructor Preparation. Introduce the purpose of this module and review learning objectives (see above). (5 minutes) (Slide 2) Ask participants to consider the following questions: (Slide 3) ? Who in your practice setting conducts discharge/care transition planning? ? What are procedures for discharge/care transition planning in your practice setting? Are there forms used for planning? Are procedures any different if the case involves actual or suspected elder mistreatment? ? What do you think are key issues, challenges and questions that need to be addressed when planning for discharge/care transition in elder mistreatment cases? Facilitate a large group discussion on these questions, weaving in a review of the teaching points below. (50 minutes)
12. Discharge and Care Transition Planning Page 3 Instructor’s Manual Nursing Responses to Elder Mistreatment
Teaching Points Focus on patient safety, health and well being. The details of a discharge/care transition plan should be individualized for each patient in known and suspected elder mistreatment cases, due to the varied circumstances patients face (e.g., where they are living, who is mistreating them, if they have a support system, whether they feel they continue to be at risk for mistreatment and their level of physical and cognitive functioning). Using a standardized process to plan for discharge/care transition— such as the one discussed below—can ensure a focus on patient safety, health and well being, no matter what circumstances are involved. (Slide 4) CHECKLIST FOR DISCHARGE/CARE TRANSITION PLANNING IN ELDER MISTREATMENT CASES1 Involve the patient in discharge/care transition planning to the extent possible (and guardians and the patient’s support system as appropriate to the case). (Slide 5) Consider: ___ Has the patient been informed about the incidence of elder mistreatment and that it can increase in frequency and severity over time? Has she/he been informed why interventions to provide care and prevent further harm are important? ___ Has the patient made her/his wishes and preferences known regarding subsequent treatment, care and safety options? ___ If there is some question about the patient’s capacity to make decisions related to her/his health, have steps been taken to evaluate the patient’s capacity, determine if there is a legal guardian and contact that person, or to begin the process of having a guardian appointed by the court? ___ Has the patient provided information about whether there are non-abusive family members, caregivers and friends who may be able and willing to help the patient address her/his needs in the future (e.g., in safety planning and providing assistance with activities of daily living)? Work with other professionals as appropriate to streamline follow- up care and services and maximize effectiveness of interventions. (Slide 6) Consider:
12. Discharge and Care Transition Planning Page 4 Instructor’s Manual Nursing Responses to Elder Mistreatment
___ Does the mistreatment need to be reported to any authorities? Was it reported and if so, to whom and when? What follow-up actions have been or will be taken by those authorities? ___ If the patient is living in a long-term care facility, who has been notified within the facility? Has the facility notified any other agencies (e.g., long-term care ombudsmen)? What follow-up actions have been or will be taken by the facility or those other agencies? ___ Is there a team of professionals (e.g., medical/legal/social services) involved in planning subsequent interventions in the case? Who is involved? What interventions/follow-up actions were recommended? ___ Are these recommendations consistent with the patient/guardian’s wishes and preferences? If not, why not? ___ Are there other professionals who need to be involved (e.g., a geriatrician for a comprehensive geriatric assessment, APS/home health agency staff to do an in-home assessment and sexual assault/domestic violence victim advocates to provide ongoing victim support, advocacy and safety planning and connect victim with resources)? What are the procedures for making referrals to/coordinating services with them? Were they contacted? Are they willing and able to carry out the recommended interventions? If not, what are the alternatives? Make sure that the medical needs of the patient have been met through the discharge or care transition plan. (Slide 7) Consider: ___ Have acute injuries been treated? Is follow-up treatment necessary? If so, what is the follow-up treatment plan for each injury? Are there non-acute injuries that still need treatment? Have follow-up medical appointments been scheduled? If so, when and where are the appointments? ___ Is there a need to examine, treat and/or document developing or healing/healed injuries? If so, have follow-up appointments been made? When and where? ___ Are there other physical or mental health concerns related to mistreatment that need to be addressed? If yes, identify concerns, assess needs and make referrals for services according to organizational policy and procedures.
12. Discharge and Care Transition Planning Page 5 Instructor’s Manual Nursing Responses to Elder Mistreatment
___ If the patient is being released, have her/his needs for clothing (e.g., if clothing was taken as evidence), hygiene (e.g., is there a place she/he can wash/shower) and transportation been addressed? Make sure that the safety needs of the patient have been met through the discharge or care transition plan. It is helpful if planners have a form that can be used to facilitate safety planning. (Do not hand a safety planning form to the patient and expect her/him to do it on her/his own). If such a tool is not available through the practice setting, ask your local domestic violence/sexual assault victim advocacy program for help in creating one or check out the resources offered by the National Clearinghouse on Abuse in Later Life at http://www.ncall.us/resources.html. See Module 5. (Slide 8) Consider: ___ Does the patient indicate any concerns about her/his safety? If there is a concern for safety, offer to assist the patient to consider safety options. ___ Will the patient have the opportunity to consult with a social worker, APS representative, domestic violence or sexual assault victim advocate or other helping professionals to develop a short and/or longer-term safety plan? If so, when? Discharge/care transition planners can coordinate efforts with them. ___ If the patient is being released and going home, or is already in the home, is the home/community environment safe? Has a safety plan been developed if there is any concern about safety? Has written material been provided that is safe for the patient to take home? (For example, an abuser may harm the patient if she brings home a brochure on domestic violence.) Has the patient been referred to appropriate agencies to further assist with safety issues (e.g., to obtain a 911 cell phone, change locks, arrange for in-home assistance or call for crisis counseling and support)? ___ If home is not an option, is there another safe place for the patient to go (e.g., housing through other family members or friends, a community shelter or long-term care facilities)? What steps will be taken to enhance the patient’s safety in that other setting? ___ If the patient is living in a long-term care facility, what changes are necessary to meet patient safety needs?
12. Discharge and Care Transition Planning Page 6 Instructor’s Manual Nursing Responses to Elder Mistreatment
Who is suspected of mistreatment? If it is a family member, what is being done to protect the patient from further harm by this person and his allies? If it is a staff member, what changes will be made to ensure that the staff member does not have continued access to this patient? Does the patient feel it is safe to remain at this facility? If so, are there steps that can be taken to make the patient feel more secure? If the patient does not feel safe at the facility, what are the alternatives? If the patient is living in the community, determine home assistance needs. (Slide 9) ___ What home assistance does the patient need in order to function? ___ Does the patient have a non-abusive caregiver and can that caregiver provide the level of assistance needed? If not, make referrals for services based on patient need and caregiver capacity. Does the caregiver have physical or cognitive impairments which may influence her/his ability to care for the patient? Is she/he receiving assistance to address these impairments and does the assistance allow her/him to adequately care for the patient? If not, what are the alternatives for care? Is the caregiver capable of tending to the basic needs of the patient—nutrition, hygiene, health care, social interaction, etc.? Does the caregiver understand how to treat or address patient injuries and other patient health issues? Is the caregiver capable of administering prescribed medications as prescribed? Is the caregiver capable of keeping follow-up appointments? Has the caregiver been given instruction in proper care delivery? Have caregivers who are at risk of mistreating those for whom they care been provided referral information (e.g., for counseling and support, caregiver training and substance abuse treatment)? If the patient is living in a long-term care facility, what changes are needed in the plan of care to meet patient needs? For example, changes in physical location, staff assigned to her/him, activities she/he participates in and who can visit her/him or is allowed into the facility. (Slide 10) Take actions as indicated above. For example: (Slide 11)
12. Discharge and Care Transition Planning Page 7 Instructor’s Manual Nursing Responses to Elder Mistreatment
___ Educate the patient about the incidence of elder mistreatment and its tendency to increase in frequency and severity overtime. See Module 3. ___ Notify authorities if required by law. Explain to the patient the roles of authorities and what to expect from them. See Module 4. ___ Help the patient develop a plan for safety. See Module 5. ___ Coordinate to ensure the patient has clothing and transportation home or to the location to which they will be traveling. ___ Arrange for follow-up medical appointments for the patient. ___ Refer the patient to services to address her/his needs. ___ Coordinate with other professionals to provide services to the patient, streamline contact with the patient and maximize the effectiveness of interventions. See Module 8. Provide the patient (and/or guardian) with oral and written discharge/care instructions. (Slide 12) ___ Include a summary of the exam (e.g., injuries and treatment received, tests conducted, evidence collected, medication prescribed/provided and dosage and information provided), follow- up appointments needed or scheduled, and referrals for services. Document discharge/care instructions in the medical record. See Module 11. (Slide 12) Identify situations requiring nurse follow-up with patients. For example, if a patient needs to be informed of lab test results, if a patient was told she would be called with a reminder about a follow- up medical appointment, if there are missed medical appointments and if there are out-of-pattern behaviors by a patient. (Slide 12)
60 minutes total Activity 2 (Optional): Practicing Planning for Discharge/Care Transition This activity provides participants an opportunity to practice planning for discharge/care transition. In Module 7 and 8, we reviewed the case of Mrs. Schmidt using the film, How to Try This: Elder Mistreatment Assessment (Chapter 1, Assessment of Elder Mistreatment: Protecting a Vulnerable Population). The film shows an assessment for elder mistreatment by a geriatric nurse, a nurse case review and an in-house multidisciplinary case review.
12. Discharge and Care Transition Planning Page 8 Instructor’s Manual Nursing Responses to Elder Mistreatment
Re-familiarize participants with the case by reviewing the film, starting 1.18 minutes through 27.25 minutes. You may choose to fast forward through select sections, depending upon if participants have good recall of what was discussed in that section. (25 minutes) Then ask participants to work in pairs or small groups to answer the questions on the Worksheet for Discharge/Care Transition Planning in Elder Mistreatment Cases as they relate to Mrs. Schmidt’s case. (The worksheet is at the end of the Participant Materials for this module.) Instruct them to skip the sections that do not apply to this case. Instruct them to use the space between questions to make notes on what is already known about Mrs. Schmidt and her situation, what still needs to be clarified or determined, and what discharge/care transition actions might be suggested to the patient/guardian. (20 minutes) Follow with a large group discussion on suggested actions. Stress the importance of focusing on promoting patient health, well-being and safety through the discharge/care transition plan. Also, note that in actual discharge/care transition planning, the patient/guardian would ideally play an active role, in conjunction with medical providers, in deciding actions. (15 minutes)
20 minutes total Activity 3: Closing Assessment Slide 13-14 For Module 12: Ask participants to write down one important thing they learned in this module that they can apply in their practice settings. In a facilitated large discussion, ask participants to share new information learned. (5 minutes) (Slide 13) For overall course: Return to the list created during Module 1 from participants’ input on what they hoped to learn from the course. In a large group discussion, ask participants to explain whether or not their personal learning objectives for the course were met. Ask them to identify the course’s strengths and what could be improved. (10 minutes) (Slide 14) Close by asking them to fill out the course evaluation form and provide to instructors before leaving. (5 minutes)
12. Discharge and Care Transition Planning Page 9 1 The following resources were drawn from or useful in developing this checklist: American Medical Association, Diagnostic and treatment guidelines in elder abuse and neglect (Chicago, IL: Author, 1992); S. Aravanis, R. Adelman, R. Breckman, T. Fulmer, E. Holder, M. Lachs, J. O’Brien & A. Sanders, Diagnostic and treatment guidelines on elder abuse and neglect. Archive of Family Medicine, 2 (1993), 371-388, http://archfami.ama-assn.org/cgi/reprint/2/4/371; B. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A collaborative approach (New York: Springer Publishing, 2007); F. Kahan and B. Paris, Why elder abuse continues to elude the health care system, The Mount Sinai Journal of Medicine, 70(1) (2003), 62-68, http://www.mssm.edu/msjournal/70/v70_1_page_62_68.pdf; C. Landefeld, R. Palmer & M. Johnson (Eds.), Current geriatric diagnosis and treatment (New York: Lange Medical Books/McGraw Hill, 2004): 418; Pan-American Health Organization, PAHO manual: Diagnostic and management guide I, abuse (mistreatment) and neglect (abandonment), annex 3, A global response to elder abuse and neglect: Building primary health care capacity to deal with the problem worldwide (Geneva, Switzerland: World Health Organization, 2008), http://www.who.int/ageing/publications/ELDER_DocAugust08.pdf; and University of North Carolina Center for Aging and Health, Elder Abuse and Neglect, Elder mistreatment learning module (Chapel Hill, NC: University of North Carolina at Chapel Hill School of Medicine, 2005), http://www.med.unc.edu/aging/eldermistreatment/overview.htm.