With the demand for specialized geriatric care provided by skilled nursing staff increasing, facilities around the country are forming dedicated geriatric nursing units to meet the need.
Priscilla Merryman, MBA, MSN, RN, NEA-BC, director of the medicine service at UNC Hospitals, Chapel Hill, NC, described the facility's dedicated 31-bed Acute Care for the Elderly, or ACE unit that provides a holistic brand of specialty care tailored to the unique needs of older adults.
"The unit has a resource room for group events and family activities, along with kitchen and toileting training facilities for treatment at the point of care," she said. "We use good hand-off communication processes on our ACE unit, as well as daily team rounds with geriatric nurses, geriatric nurse practitioners, geriatricians, geriatric pharmacists, therapists and care management representatives.
"The unit has an occupancy rate of over 90 percent, which demonstrates the demand for specialized care from skilled staff in an ideal environment."
Geriatric Resource Nurses
Geriatric nurse practitioner John Gotelli, MSN, NP-C, teaches and coaches nurses from the ACE unit, as well as those from other units who want to become geriatric resource nurses.
"It's an intense 2-day Geriatric 101 program from the perspective of the bedside nurse," he said.
"We talk about the prevention and treatment of delirium, bowel and bladder management, fall prevention while encouraging mobility, nutritional issues, spirituality and other relevant topics. The nurses learn to identify the nuances in the care of a 90-year-old with pneumonia as compared to a 65-year-old with pneumonia, for example."
The UNC geriatric resource nurses offer clinical expertise and immediate feedback for nursing colleagues with questions or concerns about the challenges faced by older adult patients.
"Whether it's lighting, communication or placing objects within reach, environmental factors play an important role in geriatric patient safety," Merryman pointed out.
"Our resource nurses are aware of special risks, everything from sensory impairments to high-risk medications or the presence of a urinary catheter. Our nurse-driven catheter removal procedure allows them to pull the catheter to reduce the risk of infection and promote patient safety."
Fay Smith, MSN, RN, FNP-BC, participates in holistic evaluations along with geriatricians, physical and occupational therapists, nutritionists, clinical pharmacists and psychiatrists at UNC.
UNC Health Care System is dedicated to a continuum of care for older adults.
"This extensive consultative evaluation results in recommendations from a specialized geriatric standpoint, after a referral from their primary care physician; thereafter, recommendations are incorporated in their geriatric plan of care," noted Smith, a family nurse practitioner in the Geriatric Specialty Clinic, part of UNC Physicians and Associates, the faculty practice plan for the UNC-Chapel Hill School of Medicine.
Smith's geriatric practice extends beyond traditional clinic walls.
"This is done by establishing minority clinics, continual care retirement community (CCRC) clinics, specialized senior center services, research, and outreach efforts in order to concentrate on a larger geriatric population," she explained.
"We can make recommendations to caregivers in those communities as well, so they can promote the health of the residents they serve."
Welcome to the Neighborhood
Debby Allen, MSN, ANP, community director for Isabella Geriatric Center, NY, NY, described her organization's proactive approach to meeting the needs of older adults:
"For many years, we've been thinking ahead in terms of our programs, believing that the old, rigid way of doing business is over. We understand the importance of listening to residents and their families, accommodating their needs whenever possible, and creating environments where seniors feel comfortable and happy."
As part of the resident-centered movement, senior management at Isabella renamed nursing units "neighborhoods," with each housing residents who share some common needs.
"One of my neighborhoods provides care for ventilator-dependent adults, and it's known as Breath of Life," Allen said. "Our step-down neighborhood, which is home to residents who have been weaned off ventilators, is called Birds of Paradise. Our younger adult neighborhood for 18- to 62-year olds is called Baker's Place. Each neighborhood has its own distinct culture and sense of what's important."
Neighborhoods at Isabella are staffed with RNs, LPNs, CNAs, social workers, dietitians, respiratory therapists, recreational therapists and music therapists who work collaboratively to meet the individual needs of residents.
"For example, one woman who had been a newspaper writer was trying to complete a book chapter despite her physical disabilities," Allen said. "Since she was unable to move with any part of her body, we were able to provide her with a computer that will accept commands based on the way in which she blinks her eyes. We've also brought in Internet access and Skype so residents can keep in touch with family members."
The geriatric center at Isabella is part of a comprehensive continuum of care that also includes a home health agency, adult day health program and independent housing for seniors.
"We want to be sure we do right by our residents and families, meeting their needs in every shape and style," Allen said. "When one of our ventilator-dependent patients wanted to return home, for example, we trained her and her family members on the correct procedures to follow.
"Under the watchful eyes of our nursing staff, we gave the family the opportunity to care for the resident for 2 weeks prior to her going home. We were also able to coordinate home care as well to ensure that she and her family would have the right level of ongoing support at home."
Seamless Patient Care
Gail Green, MSN, RN, chief nursing officer of Reno, NV-based Renown South Meadows Medical Center, Renown Rehabilitation Hospital, Renown Skilled Nursing Facility and Renown Home Care, is extremely proud of the continuum of care her health network offers older adults.
"The relationship component starts at the corporate level with a senior leadership structure in which the corporate CEO leads the strategic planning," she said. "We strongly believe in our vision of making a genuine difference in the lives we touch by optimizing every patient's healthcare experience."
The leadership infrastructure within Renown Health supports a robust continuum of care.
"The CEO for Renown South Meadows Medical Center and myself as CNO are accountable for acute care, skilled nursing, rehab and home care services," Green said. "We have aligned ourselves to support the integration within that continuum.
"We're fortunate to have our own insurance company, Hometown Health, that provides additional components of care. We have a fabulous opportunity to work with our Renown Medical Group as well. When a hospitalized patient doesn't have a primary care physician, we can set up an appointment with one of the doctors in the medical group within 24 hours, and make referrals to other relevant services such as home care."
The information technology infrastructure at Renown Health supports seamless patient care.
"We are so far along in our electronic medical record journey, sharing patient information within our network," Green said. "If I'm discharged home from South Meadows and later admitted to home care, rehab or our tertiary care center for cardiac services, that EMR follows me. Renown Medical Group physicians can also access the information, and patients can electronically connect to their physicians to check lab results, ask questions or schedule appointments."
The integrated medical record helps with issues around medical decision-making and end-of-life as well.
Sandy Keefe is a frequent contributor to ADVANCE.
"It can be troublesome to track advanced directives, so now we can scan the documents into the patient's medical record and pull them up online throughout our health system," said Green. "The nurse can simply review the directive with the patient and ask if there have been any changes."