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Coordinating and Managing Care during Transitions among Care Settings

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1.  Case Study: Millie Larsen 

A.   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. View Millie's unfolding case. 

2.  Concept maps are graphical tools used to organize and represent knowledge in an organized manner. Concept maps facilitate critical thinking by allowing students to create visual frameworks of important constructs or components of a given situation and create propositional links between them. They stimulate critical thinking and creativity and can be particularly useful when helping students think about the importance of improving transitions across care settings to produce better patient outcomes. Below are several recent articles that have been published detailing the use of concept mapping in nursing education. 

  • All, A., Huycke, L. I., & Fisher, M. (2003). Instructional tools for nursing education: Concept maps. Nursing Education Perspectives, 24(6), 311-317. 
  • Gul, R. B. & Boman, J. A. (2006). Concept mapping: A strategy for teaching and evaluation in nursing education. Nurse Education in Practice, 6(4), 199-206. doi:10.1016/j.nepr.2006.01.001 
  • King, M. & Shell, R. (2002). Teaching and evaluating critical thinking with concept maps. Nurse Educator, 27(5), 214-216. 

3.  Assessment Tool: 

  • Students should access and use 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.

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