This teaching strategy focuses on assessing expectations, coordinating and managing care, and making situational decisions with older adults. The strategy enhances students’ human flourishing, nursing judgment, and spirit of inquiry.
1. Overview: Millie Larsen is an 84-year-old Caucasian female who lives alone in a small home. Her husband Harold passed away a year ago and she has a cat, Snuggles, who is very important to her. Millie has one daughter, Dina Olsen, who is 50, lives nearby, and is Millie’s major support system. Her current medical problems include: hypertension, glaucoma, osteoarthritis of the knee, stress incontinence, osteoporosis, and hypercholesterolemia. Tell students to become familiar with Millie Larson’s unfolding case study.
2. Students should access and become familiar with The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. This assessment tool identifies 10 screening criteria to assess older adults’ potential high risk for poor outcomes after hospitalization for acute or exacerbated chronic illnesses.
3. The following tools can be used in a variety of teaching/learning settings to enhance student learning and understanding of common problems associated with poor transitions, and improvements made to produce better outcomes for older adults during transitions: a) case studies and b) concept mapping.
- Case studies are useful in helping students better understand the challenges individuals and families face during end-of-life transitions. Case studies foster students’ critical thinking, by illustrating and contextualizing the complexities associated with end-of-life care. This approach is best suited for small group discussions or post-clinical debriefings/discussions.
- Concept mapping facilitates students’ critical thinking related to the needs of older adults and their families during end of life decision making. Concept mapping, based on a clinical situations or case studies, stimulates student thinking and broadens their conceptualization of important end of life care needs, as well as allowing them to individualize those needs to a specific context, individual, and family situations.
4. The above tools should address common problems during transitions across care settings, such as communication failure, poor care planning, poor continuity of care, increased medication errors, and inadequate patient and caregiver education. These tools should also further emphasize the essential and important role of the interdisciplinary team during discharge planning to other care settings.