Journal of General Internal Medicine, 22(0), 391-395. doi: 10.1007/s11606-007-0322-1, Wallston, K., Cawthon, C., McNaughton, C., Rothman, R., Osborn, C., & Kripalani, S. (2014). United States. Psychometric properties of the brief health literacy screen in clinical practice. Providers cultivate relationships through an evidence-based pattern of in-person visits and telephone calls. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Hispanic-serving hospitals report more barriers to reducing readmissions: Results of a national survey of hospital leaders. The association of comorbid diabetes mellitus and symptoms of depression with all-cause mortality and cardiac rehospitalization in patients with heart failure. In addition, the webinar content is supplemented with one-on-one discussions about applying patient engagement strategies, learning how to present cases to the team, and participating in clinical rounds focused on issues commonly experienced by this population (e.g., heart failure, diabetes, chronic obstructive pulmonary disease, geriatrics, palliative and hospice care, home care, community-based care, managing MCCs). . WebThe Young Scholars program is an initiative of ACC's Academic Cardiology Member Section and local State Chapters that aims to provide promising young students with an introduction to the field of cardiology and strengthen the pipeline of talent for the future. . Follow Us . University of La Verne, Physician Assistant Program: Western Michigan Homer Stryker M.D. Learn what is. The TCM emphasizes identification of patients health goals; design and implementation of a streamlined plan of care; and continuity of care across settings and between providers throughout episodes of acute illness (e.g., hospital to home) (Naylor et al., 1994; Naylor, 2004-2007; Naylor et al., 1999; Naylor et al., 2014). Take on leadership opportunities at the local, state or national levels to represent medical students and address their concerns. Joy in Medicine Health System Recognition Program, Recognizing health systems that care for the caregivers. Our clients, our priority. Measuring changes over time in key outcome domains such as patient symptoms, functional status (e.g., cognitive, physical, emotional), and quality of life, as well as family caregiver outcomes such as burden, is important to benchmark evidence of the impact of the TCM and continually improve performance (See Table 2). Comprehensive discharge planning for the hospitalized elderly. WebThe Medi-Gators Virtual Shadowing Program is a shadowing program delivered through Zoom created by University of Florida students and faculty at the UF College of Medicine. The rehospitalization rate at 30 days is substantially below the national average for all cause rehospitalizations among Medicare beneficiaries (MedPAC, 2015) and is half that of the 30-day rehospitalization rate for Medicare beneficiaries with four or more chronic conditions (Lochner et al., 2013). 47-76). A., Zhao, X., Novotny, P. J., Wampfler, J., Garces, Y., Clark, M. M., & Yang, P. (2012). The most rigorously tested of these approaches, the Transitional Care Model (TCM), has consistently demonstrated enhanced health and economic outcomes for older adults with MCCs. Rigorous evaluation of interventions based on the TCM and examination of detailed case summaries developed by participating APRNs has led to the development and continued refinement of the Models nine core components. %p{t%v$8hs?v#Tw(B'Z4e7OhR#Q_c@v< Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). In addition, the APRN prepares and accompanies each patient and family caregiver(s) to the first visit following the index hospital discharge, to establish collaborative relationships with community-based clinicians and model how patients can maximize time-limited visits and advocate to meet current and future care needs (Toles, Abbott, Hirschman, & Naylor, 2012). Journal of General Internal Medicine, 29(1), 119-126. doi: 10.1007/s11606-013-2568-0. Typically, this initial phase of intervention occurs over a two month period (range one to three months). Engages older adults in design and implementation of the plan of care aligned with their preferences, values and goals. Others may not have resources (e.g., EHRs) to apply the TCM components. hW[OW+GK_@r%j{c5^d/Q7iH* {f6)FIP#V@P,P"`5 Naylor, M. D. (2000). A significant reduction in total healthcare costs per member per month at 90 days and a cumulative per member savings of $2,170 at one year post-enrollment (p<0.05) also were observed in the TCM intervention group, relative to the comparison group (Naylor, Bowles, et al., 2013). American Journal of Public Health, 92(8), 1278-1283. (2013). BMC Health Services Research, 11, 93. doi:10.1186/1472-6963-11-93, McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006). Kiresuk, T., Smith, A., & Cardillo, J. Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. On behalf of our leadership and faculty at Valley Health System, I appreciate your interest in our new Emergency Medicine Resident Training Program. Jurnal of the American Geriatrics Society, 60(11), 2121-2126. doi: 10.1111/j.1532-5415.2012.04200.x, Stevenson, L., McRae, C., & Mughal, W. (2008). The PHQ-9: A new depression diagnostic and severity measure. Currently, the team is examining the potential of the TCM to add value to emerging care delivery models including PCMHs, accountable care organizations, community-based palliative care programs and population health models. Available www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf, Berwick, D. M., Nolan, T. W., & Whittington, J. A qualitative analysis of an advanced practice nurse-directed transitional care model intervention. Health Services Research, 39(4 Pt 1), 1005-1026. doi: 10.1111/j.1475-6773.2004.00269.x, Hirschman, K. B., Shaid, E., Bixby, M. B., Badolato, D. J., Barg, R., Byrnes, M. B., . The Ochsner Health board of directors oversees the systems leadership and long-range Following are the organizations with current recognition from the Joy in Medicine Health System Recognition Program: This list is up to date as of October 2022 and will be updated after each annual program. Both the cost to implement the program (e.g., time devoted by APRNs to implement transitional care services) as well as costs avoided (e.g., number of ED visits or rehospitalizations prevented), are valuable data to demonstrate the TCMs effects. Goal attainment scaling: Applications, theory, and measurement. w doi: 10.1002/14651858.CD000011.pub3. APRNs encourage consensus about plans of care among older adults, family caregivers, and members of the care team. Transitional care in the patient-centered medical home: Lessons in adaptation. history of mental or emotional health problems (e.g., depression or anxiety; hospitalization within the past 30 days or two or more hospitalizations within the past six months. Findings from three reported multi-site National Institute of Nursing Research (NINR) funded randomized clinical trials (RCTs) have consistently demonstrated the capacity of the TCM to improve acutely ill older adults experiences with care, and health and quality of life outcomes. APRNs are prepared to use the model with a multimodal approach. Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Arora, V., Gangireddy, S., Mehrotra, A., Ginde, R., Tormey, M., & Meltzer, D. (2009). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. Managed by Well-Ahead Louisiana within the LDH Office of Public Health (OPH), the Rural Health Scholars Program matches students from Louisiana colleges and universities who are studying to be a physician assistant (PA) or nurse practitioner (NP) with healthcare facilities in Health Professional Shortage Areas In a Medicare Payment Advisory Commission (MedPAC) recent Report to Congress, all-cause 30-day rehospitalization rates for Medicare beneficiaries decreased from an average of 19% to below 18%, at least in part due to major changes in incentives (MedPAC, 2015). To date (2009 through 2014), over 800 high risk patients admitted to the UPHS have enrolled in this service line. A personal health record also is provided and periodically updated. Medical Care, 34(3), 220-233. Karen B. Hirschman is the NewCourtland Term Chair in Health Transitions Research and a Research Associate Professor at the University of Pennsylvania School of Nursing in Philadelphia, PA.  Since 2004, she has been a member of the Transitional Dr. Hirschman is a member of the New Courtland Center for Transitions and The APRN collaborates with the entire team to identify and fortify sources of emotional support, including community based organizations, peer groups, and the inclusion of family and friends. Health Affairs (Millwood), 29(1), 116-124. doi: 10.1377/hlthaff.2009.0520, Lochner, K. A., Goodman, R. A., Posner, S., & Parekh, A. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. . A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Rosenwasser and Yelena Akelina, and based in our Microsurgery Laboratory, PH-1158. Specialty ID Program State. (2015). To further assist patients and family caregivers to understand early symptom recognition, providers consistently ask them to identify factors that contribute to exacerbations of chronic conditions (McCauley et al., 2006). As an AMA member, you can save up to $750 on a new Mercedes-Benz today. WebNew York, NY 10032. Dr. Med Care, 14(5 Suppl), 116-118. BMJ Open, 5(6). Psychosomatics. (2001). Annals of Internal Medicine, 120(12), 999-1006. High-value transitional care: Translation of research into practice. Post-hospital syndrome--An acquired, transient condition of generalized risk. Home Health Care Management & Practice, 22, 278-285. doi: 10.1177/1084822309353145. Guided by individual patient goals and unique learning styles and preferences, the APRNs utilize multiple teaching strategies and tools, including coaching, modeling and the use of teach-back (Ditewig, Blok, Havers, & van Veenendaal, 2010; Haynes, Ackloo, Sahota, McDonald, & Yao, 2008). For example, valid and reliable tools that prevent delirium or falls or more effectively manage pain may be core elements of plans of care. Journal of Evaluation in Clinical Practice, 19(5), 727-733. doi: 10.1111/j.1365-2753.2011.01659.x, Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Journal of Healthcare Quality. Compared to standard care patients, fewer all-cause rehospitalizations (104 vs. 162, p=0.047) were observed at one year post-index hospital discharge, contributing to lower mean total costs, with estimated per patient savings of $4,845 (p=0.002) (Naylor et al., 2004). Since 2004, she has been a member of the Transitional Dr. Hirschman is a member of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, Philadelphia, PA. Care Model team lead by Dr. Mary Naylor. For example, in a RCT targeting older adults hospitalized with heart failure who returned to their homes, time to first rehospitalization was significantly improved among intervention patients who received the TCM (p=0.026) when compared to a similar control group. doi: 10.1371/journal.pone.0115088, Berenson, R., & Horvat, J. Chapter 3: Hospital inpatient and outpatient services. Our services ensure you have more time with your loved ones and can focus on the aspects of your life that are more important to you than the cleaning and maintenance work. (2010). APRNs work with each older adult and their family caregivers to monitor and respond quickly to worsening symptoms. APRNs also maintain responsibility for day-to-day delivery of transitional care services, including oversight of other transitional care team members. We also discuss measuring the TCMs core components and the overall impact of this evidence-based care management approach. ISSN: 1091-3734 American Nurses Association - 8515 Georgia Avenue - Suite 400 - Silver Spring, MD 20910, Rhonda G. Cady, PhD, RN; Wendy S. Looman, PhD, APRN, CNP; Linda L. Lindeke, PhD, APRN, CNP, FAAN; Bonnie LaPlante, MHA, RN; Barbara Lundeen, MS, RN, PHN; Amanda Seeley, MSN, APRN, CNP; Mary E. Kautto, MA, BSN, RN, Balakumaran Mahathevan, RN, MScN; Jasmine Balakumaran, RN, MScN; Edward Cruz, RN, PhD; Jennifer Innis, NP, PhD; Natashia Deer, RN, MN, Suzanne DelBoccio, MS, RN, CENP, FACHE; Debra F Smith, MSW, LCSW, CCM; Melissa Hicks, MSN, RN-BC; Pamela Voight Lowe, MSN, RN, CPHQ, NE-BC; Joy E Graves-Rust; Jennifer Volland, DHA, RN, MBB, CPHQ, NEA-BC, FACHE; Sarah Fryda, BA, MS, Jean Scholz, MS, RN, NEA-BC; Judith Minaudo, RN, Brian Yeaman, MD; Kelly J. Ko; PhD; Rodolfo Alvarez del Castillo, MD, Continuity of Care Transitional Care Model, Substance Use Disorders and Related Concerns, The 200th Birthday of Florence Nightingale, Gaul, Higbee, Taylor, Ensign, Monson & Price on Nursing Education and Crisis in Competency, Parast and Heshka on Past, Present, and Future, Fogg-Martin on Calling Nursing Informatics Leaders", Jean-Gilles on An Historical View of Nursing and Polio, Pattishall on Informatics: Protect Yourself and the Nursing Profession from Predatory Journals, Murry, Joshi, & Dolma on Delivering Nursing Care", Baiza and Francis on Exploring Race in Nursing", measuring the TCMs core components and the overall impact of this evidence-based care management approach, Centers for Medicare & Medicaid Services [CMS], 2012, Bentler, Morgan, Virnig, & Wolinsky, 2014, Fried, Ferrucci, Darer, Williamson, & Anderson, 2004, Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002, Potvin, Forget, Grenier, Prville, & Hudon, 2011, Naylor, Hirschman, O'Connor, Barg, & Pauly, 2013, Hibbard, Stockard, Mahoney, & Tusler, 2004, Ware, Kolinski, Turner-Bowker, & Gandeck, 2002, Bruera, Kuehn, Miller, Selmser, & Macmillan, 1991, Babor, Higgins-Biddle, Saunders, & Monteiro, 2001, Johnson, Rose, Dilworth, & Neilands, 2012, Ditewig, Blok, Havers, & van Veenendaal, 2010, Haynes, Ackloo, Sahota, McDonald, & Yao, 2008, Tappenden, Campbell, Rawdin, Wong, & Kalita, 2012, www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf, www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf, www.medpac.gov/documents/publications/jun14databookentirereport.pdf?sfvrsn=1, www.medpac.gov/documents/reports/chapter-3-hospital-inpatient-and-outpatient-services-(march-2015-report).pdf?sfvrsn=0, www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf, www.nextstepincare.org/Provider_Home/What_Do_I_Need/, Pediatric Care Coordination: Lessons Learned and Future Priorities, Internationally Educated Nurses Perceptions of Interprofessional Collaboration, Successes and Challenges in Patient Care Transition Programming: One Hospitals Journey, Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity, Care Transitions in Long-term Care and Acute Care: Health Information Exchange and Readmission Rates, deficits in basic activities of daily living (, a diagnosis of dementia or poor performance on cognitive impairment screening tools (e.g., <4 on the Six Item Screener [. The use of a consistent clinician who both designs the transitional care plan while the patient is hospitalized and implements the plan following discharge is an example of a measure used to assess adherence to Promoting Continuity.. Between in-person visits, APRNs contact patients by phone and they are available by telephone seven days a week. B{K(ttN Common domains included in the comprehensive assessment include: Depending on patient medical history, other domains assessed also may include: Table 2 lists tools that have been tested in prior TCM research and are commonly used at settings that have adopted or adapted the TCM. Definitions of empathy encompass a broad range of social, cognitive, and emotional processes primarily concerned with understanding others (and others' emotions in particular). PLoS ONE, 7(9), e45692. Journal of Comparative Effectiveness Research, 2(5), 457-468. doi: 10.2217/cer.13.58, Nicholas, J. (2014). As noted earlier, the research team is currently assessing the effects of longer-term follow-up on the care and outcomes of older adults with MCCs. WebThe University of Iowa EM-PA program is the national leader in Physician Assistant education. This Program is directed by Drs. The University of Pennsylvania team members hypothesize that some adaptations may further advance the models benefits, extending its reach and further improving outcomes. www.rwjf.org/pr/product.jsp?id=50968. We make sure that your enviroment is the clean comfortable background to the rest of your life.We also deal in sales of cleaning equipment, machines, tools, chemical and materials all over the regions in Ghana. (2008). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. Use of health information technology may greatly facilitate collaboration. The Kenan Primary Care Medical Scholars program honored its current students and celebrated 10 years of serving Promotes consensus on plan of care between older adults and members of the care team. From poster to print: Get published as a medical student, resident, Baylor Scott & White The Heart Hospital Plano | Bronze, Childrens Primary Care Medical Group | Bronze, The Christ Hospital Health Network | Bronze, Harvard Medical Faculty at Beth Israel Deaconess Medical Center | Silver, Icahn School of Medicine at Mount Sinai | Silver, Massachusetts General Physicians Organization | Bronze, Medical College of Wisconsin, Froedtert Hospital and Children's Wisconsin | Bronze, Michigan Medicine, University of Michigan | Bronze, Northwell Health Physician Partners | Bronze, Pediatric Physicians Organization at Childrens (PPOC) | Bronze, Penn Medicine Lancaster General Health | Bronze, Roswell Park Comprehensive Cancer Center | Bronze, Sea Mar Community Health Centers | Bronze, Southern California Permanente Medical Group | Gold, Tulane University School of Medicine | Bronze, UCHealth University of Colorado Hospital on the Anschutz Medical Campus | Bronze, University of Mississippi Medical Center | Bronze, The University of New Mexico School of Medicine | Bronze, UW Medicine | Valley Medical Center | Bronze, National Capital Region Military Health System, Wake Forest Baptist Health/Wake Forest School of Medicine. Reminder or dose organization systems, plans for obtaining refills, and access to community-services to assist with managing co-pays also are common strategies used to foster adherence. Group, M. N.-I. Continuity of care and the risk of preventable hospitalization in older adults. Apply for a leadership position by submitting the required documentation by the deadline. Finally, as part of the patient engagement process, advanced care plans are developed, documented, and shared with the care team members to ensure clarity and understanding about older adults preferences for care. APRNs visit their patients within 24 hours of hospitalization, daily throughout the hospitalization, within 24 hours following hospital discharge to SNF or patient home, and at least weekly throughout the first month. Series A: Biological Sciences and Medical Sciences, 59(3), M255-M263. Journal of Gerontological Nursing, 38(11), 40-47. doi: 10.3928/00989134-20121003-04, Transitional care model. (2008). Steis, M. R., Evans, L., Hirschman, K. B., Hanlon, A., Fick, D. M., Flanagan, N., & Inouye, S. K. (2012). Centers for Medicare & Medicaid Services. The Ochsner Journal, 14(4), 649-654. Some TCM users have chosen to adapt one or more core components to reflect local customs and practices. (2014). Anxiety, depression, and 1-year incident cognitive impairment in community-dwelling older adults. (2012). Others may not have resources (e.g., EHRs) to apply the TCM components. (2008). Information deficits in home care: A barrier to evidence based disease management. [email protected] Applications to Garnet Health Medical Centers Residency Programs will only be accepted through ERAS, Association of American Medical Colleges (AAMC) Electronic Residency Application Service. Outcomes have demonstrated reduced rehospitalizations and total healthcare costs, after accounting for the additional costs of the intervention (Naylor et al., 1994; Naylor et al., 1999; Naylor et al., 2004). Transitional Care Model (TCM) Components and Definitions. Promotes communication and connections between healthcare and community-based practitioners. &6aqzu Journal of the American Geriatrics Society, 51(4), 556-557. For older adults with multiple chronic conditions (MCCs), other risk factors such as functional deficits or social barriers add to the complexity of managing their healthcare needs (Anderson, 2010). Transitions of care measures. New England Journal of Medicine, 368(2), 100-102. doi: 10.1056/NEJMp1212324. Robert Wood Johnson Foundation. Note: Some tools above are also collected consistently from all enrollees (intervention and comparison). The APRN reviews prescription and over-the-counter medications with each patient and their family caregivers. Each year, theJoy in Medicine Health System Recognition Program recognizes organizations from across the country for their dedication to building well-being and reducing physician burnout in their organization. Kroenke, K., & Spitzer, R. L. (2002). WebHer work has focused in the areas of public policy, community based strategies, program planning, health advocacy and healthcare education. In Report to the Congress: Medicare payment policy (pp. The University of Pennsylvania team recognizes that, while some healthcare settings and communities choose to adopt the TCM core components as described above, multiple factors may affect how other sites implement this evidence-based care management approach. Gerontologist, 52(3), 394-407. doi:10.1093/geront/gnr078. This requires extensive interactions between APRNs, patients, and family caregivers that begin with tools to measure engagement and activation; involvement of entire care team; identification; documentation; and update of patients health goals. The Edmonton symptom assessment system as a screening tool for depression and anxiety. doi: 10.1371/journal.pone.0045692. AMA delivers. WebThe CHRISTUS Ochsner SWLA Foundation as an umbrella overseeing all philanthropic efforts for its hospital system matches generous donors with ideal programs to strengthen its healthcare facilities, add advanced technology and equipment, and extend the healing ministry of Jesus Christ, ensuring that every individual experiences Gods. Health Qual Life Outcomes, 9, 105. doi: 10.1186/1477-7525-9-105. International Psychogeriatrics, 27(1), 157-166. doi:10.1017/S1041610214002014, Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Anderson, G. (2004). Engagement of older adults and their family caregivers in development and implementation of plans of care is an essential TCM component (Levine, Halper, Peist, & Gould, 2010; Naylor, Hirschman, O'Connor, Barg, & Pauly, 2013). Citation: Hirschman, K., Shaid, E., McCauley, K., Pauly, M., Naylor, M., (September 30, 2015) "Continuity of Care: The Transitional Care Model" OJIN: The Online Journal of Issues in Nursing Vol. As a result of frequent episodes of acute illness, this patient group (when compared to all other Medicare beneficiaries) also experiences significantly higher rates of healthcare encounters, including physician and emergency department (ED) visits and hospitalizations (Anderson, 2010; Berenson & Horvat, 2002; Pham, O'Malley, Bach, Saiontz-Martinez, & Schrag, 2009). e"aEJKX-TyFh%=Vhi0a; doi: 10.1136/bmjdrc-2014-000077

. Naylor, M. D. (2004-2007). Under this model, care is both delivered and coordinated by the same master's prepared advanced practice registered nurse (APRN) in collaboration with patients, their family caregivers, physicians, and other health team members (Naylor, 2012). These core components consist of: screening; staffing; maintaining relationships; engaging patients and family caregivers; assessing and managing risks and symptoms; educating and promoting self-management; collaborating; promoting continuity; and fostering coordination. I verify that Im in the U.S. and agree to receive communication from the AMA or third parties on behalf of AMA. Coleman, E. A., & Boult, C. (2003). The University of Pennsylvania team has greatly benefited from the partnership of multiple funders, health systems, payers, purchasers, and nationally recognized leaders in health system. WebNovember 7, 2021The program is designed to increase the number of students underrepresented in medicine and students from economically and educationally disadvantaged backgrounds who graduate from medical school. Additionally, we are testing the model with expanded patient populations (e.g., patients with cancer). There are way too many choices on the market, including knock-off brands that are cheaply built. The Black scholars in our list were identified as highly cited and searched people using our machine-powered Influence Ranking algorithm, which produces a numerical score of academic achievements, merits, and citations across Wikipedia, wikidata, Crossref, Semantic Scholar and an ever WebThe Unity Health Psychiatry Residency Program is dedicated to helping you become the best physician you can be. In 2011, an average of $2,097 was spent annually on healthcare for Medicare beneficiaries 65 and older with up to one chronic condition compared to $11,628 for those with four to five conditions and $31,543 with six or more conditions (Lochner et al., 2013). A member of Ochsners team since 1994, Dr. Hart will lead Ochsners more than 4,500 employed and affiliated physicians and focus on building and growing world-class healthcare programs for patients across the Gulf South. Otolaryngologists receive mean compensation of $461,000. A new method for detection of delirium. Kim, H., Helmer, D. A., Zhao, Z., & Boockvar, K. (2011). Hospital readmission in persons with stroke following postacute inpatient rehabilitation. A., Williams, M. V., Scott, T., Parker, R. M., Green, D., Peel, J. Mary D. Naylor is the Marian S. Ware Professor of Gerontology at the University of Pennsylvania School of Nursing, Philadelphia, PA. Dr. Naylor is the Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing in Philadelphia, PA. She is the architect of the Transitional Care Model. An ongoing study, Local Adaptations of the Transitional Care Model (Grant No. Bruera, E., Kuehn, N., Miller, M. J., Selmser, P., & Macmillan, K. (1991). Retrieved from www.medpac.gov/documents/reports/chapter-3-hospital-inpatient-and-outpatient-services-(march-2015-report).pdf?sfvrsn=0, Morandi, A., Bellelli, G., Vasilevskis, E. E., Turco, R., Guerini, F., Torpilliesi, T., . WebHe is a graduate of the Global Clinical Scholars Research Training Program at Harvard Medical School. . . The team also hypothesizes that the nature and extent of some adaptations may substantially reduce or eliminate the TCMs demonstrated benefits. Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). Index of ADL. Bentler, S. E., Morgan, R. O., Virnig, B. Rehospitalization for heart failure: Predict or prevent? Jack, B. W. (2007). Burwell, S. M. (2015). Clinical Nursing Research, 23(6), 581-600. doi: 10.1177/1054773813488417, Selby, D., Cascella, A., Gardiner, K., Do, R., Moravan, V., Myers, J., & Chow, E. (2010). Moser, D. K. (2015). Lawton, M. P., & Brody, E. M. (1969). The alcohol use disorders identification test guidelines for use in primary care (2nd ed.). from www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf. Complete a bachelor's degree, a master's degree, a residency , and then obtain state licensure are the steps to follow to make. Screening for alcohol and substance use for older people in geriatric hospital and community health settings. endstream endobj 704 0 obj <>/Metadata 200 0 R/PageLabels 700 0 R/Pages 701 0 R/StructTreeRoot 385 0 R/Type/Catalog>> endobj 705 0 obj <>/MediaBox[0 0 612 792]/Parent 701 0 R/Resources<>/ExtGState<>/Font<>/Pattern<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 706 0 obj <>stream Language barriers and understanding of hospital discharge instructions. This Friday, were taking a look at Microsoft and Sonys increasingly bitter feud over Call of Duty and whether U.K. regulators are leaning toward torpedoing the Activision Blizzard deal. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). Annals of Internal Medicine, 150(4), 236-242. doi: 150/4/236 [pii], Potvin, O., Forget, H., Grenier, S., Prville, M., & Hudon, C. (2011). The AMA promotes the art and science of medicine and the betterment of public health. Journal of General Internal Medicine, 13(12), 791-798. 2015 OJIN: The Online Journal of Issues in Nursing Article published September 30, 2015, Alhurani, A. S., Dekker, R. L., Abed, M. A., Khalil, A., Al Zaghal, M. H., Lee, K. S., . Learn more with the AMA's COVID-19 resource center. doi: 10.1136/bmjopen-2014-006975. iPhone or Journal of Palliative Care, 7(2), 6-9. A systematic review of different models of home and community care services for older persons. Ostir, G. V. (2012). Key patient and family caregiver outcomes have been used to assess the effectiveness of the TCM both in past research and in the implementation of the model in multiple health systems and communities. hbbd```b``= "H&Dr7A$c0{!dZ "Yt_i"5=H`d~$mEAE~ $V-?fKR`5@3 Retrieved from www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. The Edmonton symptom assessment system (ESAS): A simple method for the assessment of palliative care patients. Spalding, M. C., & Sebesta, S. C. (2008). In collaboration with patients, family caregivers, and other team members, APRNs may also identify additional appropriate services, such as palliative or hospice care, and work with patients to ensure seamless transitions to such programs. In each RCT, the TCM was refined and the length of the intervention modified to address unique needs of increasingly complex groups of older adults with MCCs (Naylor et al., 1999; Naylor et al., 2004; Naylor et al., 2014). Decubitus, 2(3), 44-46, 50-41. WebOakley tinfoil carbon - Die qualitativsten Oakley tinfoil carbon im berblick Unsere Bestenliste Nov/2022 - Umfangreicher Kaufratgeber Beliebteste Produkte Beste Angebote : Alle Preis-Leistungs-Sieger Direkt weiterlesen! Journal of the American Geriatrics Society, 52(5), 675-684. doi: 10.1111/j.1532-5415.2004.52202.xJGS52202 [pii], Naylor, M. D., Hirschman, K. B., Hanlon, A. L., Bowles, K. H., Bradway, C., McCauley, K. M., & Pauly, M. V. (2014). Widely disseminated, the TCM (2014) has been recognized as a top-tiered, evidence based approach that, if scaled, could have a major positive effect on the population of Medicare beneficiaries transitioning from hospital to home (Coalition for Evidence-Based Policy, 2010). . Advancing high value transitional care: The central role of nursing and its leadership. vNCZ_&js _2p5kj DY8M4^N.?qMTOuor L#S'*pn1eX_ ,9vipppaso ?x?rq5np8s|"#r9N$wbM7 <0~8g{J[KTC\"er8xkW2;/-*8#v"b~=('jZv}b4o.zY]X2~Dky=o/E42zqT6z6-]?4_rIB^VEyW^U`<9^l~WtRf'mgbY -^lVW>4$HYgc~.s'e\cREAA+7b|2nd>?Lo.ZrAy:L=P|%"MN wO&evT6:c[Wm$YcM55{*iG8Og&S'LusYgXLYd,"Y(S(SOR/I"(=5xa1xir@P46>QBM:MOq5 FEN, $f B{vwU-Yd3kytQYYevP"2nKpD| This multidisciplinary approach recognizes all team members as partners in a care process focused on unique needs of patients and their family caregivers. Journal of Palliative Medicine, 9(2), 296-303. doi: 10.1089/jpm.2006.9.296, Vogeli, C., Shields, A., Lee, T., Gibson, T., Marder, W., Weiss, K., & Blumenthal, D. (2007). AMA's Health Systems Science Scholars program helps improve patient experience and population health, reduce cost of care and health care professional wellness. WebPosted Jan 16, 2021. by. We will also discuss measuring the TCMs core components and the overall impact of this evidence-based care management approach. What do family caregivers need? Cochrane Database Syst Rev(2), CD000011. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Krichbaum, K. (2007). . Use of health information technology, including electronic health records (EHRs) and secure email systems, may greatly facilitate collaboration. Moving from policy to action: Fighting the nations drug overdose and death epidemic, and more in the latest National Advocacy Update. Depression is a risk factor for rehospitalization in medical inpatients. The Times of Houma Thibodaux. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Validation of the mini nutritional assessment short-form (MNA-SF): A practical tool for identification of nutritional status. Kartha, A., Anthony, D., Manasseh, C. S., Greenwald, J. L., Chetty, V. K., Burgess, J. F., . 729 0 obj <>/Filter/FlateDecode/ID[<696BFA967A014D4388AE451D856C93B5>]/Index[703 51]/Info 702 0 R/Length 124/Prev 1041158/Root 704 0 R/Size 754/Type/XRef/W[1 3 1]>>stream A., & Hall, W. J. WebSupplemental Instruction (SI) is an academic support program that employs successful senior students as SILs to facilitate regular peer learning sessions. (2012). Try harder isnt the fix for physician burnout. B., & Monteiro, M. G. (2001). Visit our online community or participate in medical education webinars. 0 The promotion of healthy behaviors is consistently addressed in the care plan and may include strategies to increase exercise, make appropriate food choices, and obtain preventive care (e.g., immunizations; Nicholas & Hall, 2011; Spalding & Sebesta, 2008). Assessing patient, family caregiver, and collaborating clinician perspectives about the model (e.g., overall experience with care and specific dimensions such as care continuity) provides additional important dimensions of the TCMs perceived value. The TCM supplements care provided to patients in the hospital and substitutes for care provided by professional nurses in patients homes. Attiullah, N. (2006). Nursing Physician Assistant Radiologic Technology Clinical Laboratory Technology Shreveport nor Ochsner-LSU Health Shreveport assume responsibility for any medical charges. (2014). Changes in resource use (e.g., time to first rehospitalization, total number of all-cause hospitalizations, total number of days hospitalized) are central to promoting support for the investment in TCM. doi: 10.1093/gerona/59.3.M255, Garrison, G. M., Mansukhani, M. P., & Bohn, B. Uses APRNs who assume primary responsibility for care management throughout episodes of acute illness. WebAbout Our Coalition. WebExplore education and research opportunities and resources at Ochsner, where academic leaders, faculty members, and scientists work together to improve patient care. Elizabeth Shaid, MSN, CRNPEmail: [emailprotected], Kathleen McCauley, PhD, RN, FAANEmail: [emailprotected], Mark V. Pauly, PhDEmail: [emailprotected], Mary D. Naylor, PhD, RN, FAANEmail: [emailprotected]. California district attorney announces settlement in Truth in Advertising case and more in the latest State Advocacy Update. Callahan, C. M., Unverzagt, F. W., Hui, S. L., Perkins, A. J., & Hendrie, H. C. (2002). Washington, DC: The Center for Medicare Advocacy Conference on Medicare Coordinated Care. Each year, the Joy in Medicine Health System Recognition Program recognizes organizations from across the country for their dedication to building well-being and reducing physician burnout in their organization. The association of longitudinal and interpersonal continuity of care with emergency department use, hospitalization, and mortality among Medicare beneficiaries. 71753) funded by the Robert Wood Johnson Foundation, is helping our team to identify how health systems and communities throughout the United States are adapting common core components. While the TCMs overall impact on resource use was significant through one year, large reductions in rehospitalizations during the first six months of follow-up that were sustained over time accounted for this difference. Establishes and maintains a trusting relationship with the patient and family caregivers involved in the patients care. WebCougars can also enter the Honors Program, study abroad in Seville, receive the $10,000 Horizon Scholarship, join Beta Beta Beta, and attend the 1859 Lecture Series. Our cleaning services and equipments are affordable and our cleaning experts are highly trained. ;o!BE. The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. (2013). APRNs identify formal and informal services received prior to hospitalizations and determine need for continuation of services following patient transition(s) to home. Circulation, 126(4), 501-506. doi: 10.1161/circulationaha.112.125435, Ditewig, J. Desai, A. S., & Stevenson, L. W. (2012). Specifically, evidence-based transitional care, a set of time limited services provided during an episode of acute illness between and across settings, is now a recognized approach to improve care for older adults (Coleman & Boult, 2003; Krichbaum, 2007; National Transitions of Care, 2008; Naylor, 2000). Heidrich, S. M., & D'Amico, D. (1993). Kathleen McCauley is the Class of 1965 25th Reunion Term Professor and a Professor of Cardiovascular Nursing at the University of Pennsylvania School of Nursing in Philadelphia, PA. She has been a member of the Transitional Care Model team as a clinical expert for over 20 years. Pilot finding among a set of chronically ill older adults who had a hospitalization in the prior 30 days before enrollment revealed that the group who received a combined PCMH plus TCM intervention had a longer time to first rehospitalization or death than those who received the PCMH only. Anderson, G. (2010). One young physician offers insight on her approach to the issue. T_0o@aA_H7%6 WK Each APRN begins to work with the patient, family caregivers, and care team at hospital admission; the same APRN implements the plan of care in the skilled nursing facility (SNF), if referred, or in the patient home, substituting for traditional skilled care provided by nurses. Lincoln, RI: QualityMetric Incorporated. Naylor, M. D. (2015). The PHQ-9: Validity of a brief depression severity measure. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 67(8), 875-881. doi: 10.1093/gerona/glr247, Pham, H. H., O'Malley, A. S., Bach, P. B., Saiontz-Martinez, C., & Schrag, D. (2009). Journal of Cardiovascular Nursing, 14(3), 1-14; quiz 88-19. HW7"#|x 1%T%bK"E}}>{g~z8WTOk7~-X]KOV'>'TWr-. Bipartisan House group seeks Medicare pay fixes. Currently, the team is examining the potential of the TCM to add value to emerging care delivery models including PCMHs, accountable care organizations, community-based palliative care programs and population health models. 845-333-1754. Switzerland: World Health Organization. Advances in Skin & Wound Care, 25(2), 61. doi: 10.1097/01.ASW.0000411403.11392.10. A randomized clinical trial. Health Technology Assessment, 16(20), 1-72. doi: 10.3310/hta16200, Toles, M. P., Abbott, K. M., Hirschman, K. B., & Naylor, M. D. (2012). Outreach to all involved physicians (e.g., primary care, specialists, hospitalists) and other team members in various settings (e.g., nurses, social workers, pharmacists physical therapists, staff in skilled nursing facilities and community-based organizations) is important to achieve shared understanding of patient goals and care plans. A single set of numerical cutpoints to define moderate and severe symptoms for the edmonton symptom assessment system. Archives of Internal Medicine, 169(2), 199-201. doi: 10.1001/archinternmed.2008.565. PLoS ONE, 9(12), e115088. Health Affairs (Millwood), 27(3), 759-769. doi: 10.1377/hlthaff.27.3.759. De Alba, I., & Amin, A. Six overlapping categories of problems have been associated with negative outcomes among hospitalized older adults with MCCs who transition to post-acute settings or their homes: lack of patient engagement; absent or inadequate communication; lack of collaboration among team members; limited follow-up and monitoring; poor continuity of care; and, serious gaps in services as patients move between healthcare professionals (clinicians) and across care settings (Bowles, Pham, O'Connor, & Horowitz, 2010; Naylor, 2012; Stevenson, McRae, & Mughal, 2008). Taking call againbut what about the kids? 2022 American Nurses Association. Cowan, M. J., Shapiro, M., Hays, R. D., Afifi, A., Vazirani, S., Ward, C. R., & Ettner, S. L. (2006). These council reports have proposed strategies establishing the AMA vision for health system reform to cover the uninsured and expand health insurance coverage and choice. A key feature of the TCM is establishing and maintaining trusting relationships with patients and family caregivers. New England Journal of Medicine, 372(10), 897-899. doi:10.1056/NEJMp1500445. The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. Reeves, G. C., Alhurani, A. S., Frazier, S. K., Watkins, J. F., Lennie, T. A., & Moser, D. K. (2015). Engaging older adults in their transitional care: what more needs to be done? Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. There are three levels of recognition in the Joy in Medicine Health System Recognition Program: Bronze, Silver and Gold. Baker, D. W., Gazmararian, J. Finally, a central focus of the teams current efforts is a rigorous examination of adaptations of the TCM by local health systems and communities throughout the United States, with the goal of understanding how such adaptations may extend the reach and improve the benefits derived from this evidence-based strategy. Clarifying confusion: The confusion assessment method. Setting value-based payment goals--HHS efforts to improve U.S. health care. Primary Care Companion to The Journal of Clinical Psychiatry, 9(4), 256-262. Journal of Clinical Psychiatry, 67(10), 1536-1541. https://doi.org/10.3912/OJIN.Vol20No03Man01. In addition to the tremendous human burden, societal costs associated with caring for these older adults are significant. Moving to a culture of safety in community home health care. %PDF-1.6 % School of Medicine: UT Health San Antonio, STX-MSTP (MD/PhD Program) MGH Institute of Health Professions: Columbia University Vagelos College of Physicians & Surgeons: California Health Sciences University College of Osteopathic Medicine Journal of Pain and Symptom Management, 39(2), 241-249. doi: 10.1016/j.jpainsymman.2009.06.010, Sloan, J. (2009). We have wide a network of offices in all major locations to help you with the services we offer, With the help of our worldwide partners we provide you with all sanitation and cleaning needs. Predictors of rehospitalization among elderly patients admitted to a rehabilitation hospital: The role of polypharmacy, functional status, and length of stay. Trabucchi, M. (2013). These APRNs provide patient-centered, comprehensive, holistic care that is culturally sensitive to the individualized needs of patients and their family caregivers (Bradway et al., 2012). High rates of preventable hospitalizations and ED visits are among the most burdensome consequences. Disease Management, 9(5), 302-310. doi: 10.1089/dis.2006.9.302, MedPAC. Information for research of yearly salaries, wage level, bonus and compensation data comparison. In partnership with clinical leaders at diverse PCMHs, application of the TCM has been extended to include older adults identified in primary care settings. Nursing Administration Quarterly, 36(2), 115-126. doi: 10.1097/NAQ.0b013e31824a040b, Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. (2013). Medication management is an integral component of the care plan (Curry, Walker, Hogstel, & Burns, 2005). Additionally, our research team has established metrics to benchmark adherence to each TCM core component. Ochsner Physician Scholars. Journal of Gerontological Nursing, 31(4), 32-42. . Interventions for enhancing medication adherence. Journal of Nursing Administration, 36(2), 79-85. Take on a leadership role in the RFS, and make an impact on issues facing residents and fellows, patients and the medical profession. The TCM is designed to prevent breakdowns in care across settings (e.g., hospital to home) by having the same clinician deliver and coordinate the intervention throughout the entire care episode. Coordinating care between hospital and home: Translating research into practice, Phase I & II. Bridging troubled waters: Family caregivers, transitions, and long-term care. Karen B. Hirschman is the NewCourtland Term Chair in Health Transitions Research and a Research Associate Professor at the University of Pennsylvania School of Nursing in Philadelphia, PA.  Since 2004, she has been a member of the Transitional Dr. Hirschman is a member of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, Philadelphia, PA. Care Model team lead by Dr. Mary Naylor. Clinical utility of the Braden scale for predicting pressure sore risk. Ability of hospitalized patients to identify their in-hospital physicians. Recognition levels are valid for two years before organizations can apply to renew or increase their recognition. Learn more with the AMA about how two physician leaders work to reduce physician burnout at a leading health system in the southeastern U.S. Learn more about the Joy in Medicine Health System Recognition Program. The TCM supplements care provided to patients in the hospital and substitutes for care provided by professional nurses in patients homes. First, each APRN completes a four week live TCM webinar series (TCM, 2014). 27 Rings - New York Yankees 24 Rings - Montreal Canadiens 17. Retireved from www.medpac.gov/documents/publications/jun14databookentirereport.pdf?sfvrsn=1, MedPAC. This may include hospitalized older adults with specific diagnoses known to have higher than average hospitalization risks, such as patients with heart failure or pneumonia (De Alba & Amin, 2014; Desai & Stevenson, 2012), or hospitalizations or emergency department (ED) visits in the prior 30 days (Garrison, Mansukhani, & Bohn, 2013). For common symptoms or risks, a set of evidence-based decision responses are available for use by APRNs. Also important is inclusion of patients and family caregivers in team meetings and documentation and periodic updates of care plans (United Hospital Fund, 2014). Among the more than 20 million Medicare beneficiaries, 37% have five or more chronic conditions (Centers for Medicare & Medicaid Services [CMS], 2012). Assessment of older people: Self-maintaining and instrumental activities of daily living. This article provides a detailed summary of the evidence base for the TCM and the models nine core components. In this comparative effectiveness study, older adults who received the TCM had significantly fewer all-cause rehospitalizations through six months post-index hospitalization (Naylor et al., 2014). 4002121291 Louisiana State University/Ochsner Clinic Foundation Louisiana. Kaiser, M. J., Bauer, J. M., Ramsch, C., Uter, W., Guigoz, Y., Cederholm, T., . Among stringently matched pairs in this study, significant decreases in the total number of rehospitalizations (p<0.05) and total hospital days (p<0.05) were observed at 90 days. Psychiatric Annals, 32, 509-521. Hello, and welcome to Protocol Entertainment, your guide to the business of the gaming and media industries. Table 2. At Saint Peters Healthcare System in New Jersey, a simulation center helps teach medical students and resident physicians the human side of medicine. If you have any questions about the Joy in Medicine Health System Recognition Program, please contact us. JAMA, 281(7), 613-620. doi: joc80991 [pii], Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). JAMA Internal Medicine, 173(20), 1879-1885. doi: 10.1001/jamainternmed.2013.10059, Ottenbacher, K. J., Graham, J. E., Ottenbacher, A. J., Lee, J., Al Snih, S., Karmarkar, A., . Scales such as the Patient Activation Measure (PAM) or Goal Attainment Scaling (GAS) may be useful to engage patients and family caregivers (Hibbard, Stockard, Mahoney, & Tusler, 2004; Kiresuk, Smith, & Cardillo, 1994). Multiple chronic conditions among Medicare beneficiaries: State-level variations in prevalence, utilization, and cost, 2011. QR$vq5/ ^r; fG=VQr=\RYVd\TgCVrM n0Wx89v}g'tI}r>. _@j\`\Pm^WqlrV!Q? o{ In 2019, Medscape found that the average physician salary is $313,100. B., Blok, H., Havers, J., & van Veenendaal, H. (2010). However, among Medicare beneficiaries with four or more MCCs, the 30-day rehospitalization rate was 36% (Lochner, Goodman, Posner, & Parekh, 2013). A., & Wolinsky, F. D. (2014). Findings from multiple studies reinforce the poorly managed healthcare needs of older adults with MCCs as leading factors often contributing to devastating human and economic consequences (Arora et al., 2009; Krumholz, 2013; Naylor, 2012; Vogeli et al., 2007). Mark V. Pauly is the Bendheim Professor, Professor of Health Care Management, and Professor of Business Economics and Public Policy at the Wharton School at the University of Pennsylvania in Philadelphia, PA. Key evidence-based risk factors used to screen patients who would benefit from the TCM have been identified by the University of Pennsylvania team and reinforced by other scholars. Geriatric screening and preventive care. Copyright 1995 - 2022 American Medical Association. The Journal of the American Board of Family Medicine, 26(1), 71-77. doi: 10.3122/jabfm.2013.01.120107. Curry, L. C., Walker, C., Hogstel, M. O., & Burns, P. (2005). A decade of transitional care research with vulnerable elders. The Braden scale for predicting pressure sore risk: Reflections after 25 years. The Commonwealth Fund (#2004-0068) and Transitional Care Model for Elders, Jacob and Valeria Langeloth Foundation. Journal of the American Geriatrics Society, 59(8), 1421-1428. doi: 10.1111/j.1532-5415.2011.03521.x, Sand-Jecklin, K., & Coyle, S. (2014). The triple aim: Care, health, and cost. Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. wn%7'-cLCrFcVmVOX&imb 1+c.uO?{y/^bYdE!F77(0 x:o]A/WIK~JQ5Qb[{#@!k* 4A Medical Care, 50(4), 283-289. doi:10.1097/MLR.0b013e318249c949. Medical care, 40(9), 771-781. Among this patient group, these system issues have been linked to poor ratings of the care experience and further declines in health status (Coleman & Boult, 2003; Naylor et al., 2004). Domains and Examples of Standardized Tools Used for Clinical Assessment over Time, Six Item Screener (Callahan et al., 2002), Confusion Assessment Method Diagnostic Algorithm (CAM) (Inouye et al., 1990) or Family CAM (FAM-CAM) (Steis et al., 2012), Timed Up and Go (Shumway-Cook et al., 2000), Basic activities of daily living (Katz & Akpom, 1976), Instrumental activities of daily living (Lawton & Brody, 1969), Symptom Bother Scale (Heidrich & D'Amico, 1993), Edmonton Symptom Assessment Scale-Pain and Anxiety (Bruera et al., 1991; Selby et al., 2010; Vignaroli et al., 2006), Patient Health Questionnaire (PHQ-9) (Kroenke & Spitzer, 2002; Kroenke et al., 2001), Health Care Empowerment Inventory (HCEI) (Johnson, Rose, Dilworth, & Neilands, 2012), - Type of advance directive (e.g., Living Will, POLST, DPOAHC), Brief Health Literacy Scale (BHLS) (Sand-Jecklin & Coyle, 2014; Wallston et al., 2014), Alcohol Use Disorders Identification Test (AUDIT-C) cut-point of 5 risky alcohol use in geriatric population (Babor et al., 2001; Draper et al., 2015), Number of medications taken daily or schedule complexity, Verify self-monitoring being completed by Patient as part of self-management, - watch patient do what they need to for self-care (e.g., checking blood glucose, weighing self, checking blood pressure), - this should consistently go in the SOAP note, Unexplained weight loss of 10 pounds or 5% of body weight or persistent weight loss, Mini Nutrition Assessment (MNA) (Kaiser et al., 2009), Braden Scale for Predicting Pressure Sore Risk (Braden, 2012; Braden & Bergstrom, 1989), Next Step in Care Assessment - guided conversation (United Hospital Fund, 2014). 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