Models of Interdisciplinary Geriatric Care Teams
With the growing population of frail elders, there is an increase of geriatric patients requiring ongoing care for multiple medical conditions. This creates the need for interdisciplinary geriatric care teams. Often, the dynamics and culture of these teams differ across various sites of care such as assisted living, home care, hospitals, long-term care, and rehabilitation facilities. As an advanced practice nurse, it is important to understand your role in the care team as well as your potential impact on patient care. In this Discussion, you explore models of interdisciplinary geriatric care teams for different sites of care and the varying roles of the advanced practice nurse. Consider the following three case studies:
Case Study 1:
Mrs. Martinez is an 83-year-old Mexican American widow who lives in her own home and is cared for by her adult daughter. Mrs. Martinez owns the home, and her daughter lives with her and provides the care. Her daughter brought her mother to the clinic today to ask to speak to the social worker. She requests that her mother be placed in a nursing home. The daughter states that her mother has nothing to do during the day. The television is on the weather channel most of the day because Mrs. Martinez has limited English capability and is unable to read closed captions. Mrs. Martinez also has two sons who do not live in the local area, but they do call regularly and check in with their mother and sister. The two sons are opposed to moving their mother to a nursing home because they had promised her that they would “never put her away.”
Case Study 2:
Mr. Williams, a 79-year-old African American widower, resides in a foster care home. He has lived there for 4 years since his wife died. He is a former minister. His medical history includes long-term diabetes, high blood pressure, and benign prostatic hypertrophy. The home care provider has requested a home visit to evaluate Mr. William’s ability to remain in the home. The provider states that because Mr. William’s vision is seriously compromised (he is nearly blind), and because he has been unable to get to the toilet as quickly as necessary (he is very unsteady on his feet), his care is becoming burdensome. According to the home care provider, for safety reasons, Mr. Williams may not fit the criteria for remaining in the foster care home.
Case Study 3:
Mrs. Randall is a 77-year-old female who resides in a long-term care facility. She has a history of frequent falls and is severely cognitively impaired. The nursing staff at the long-term care facility called the nurse practitioner at the medical home office to report the recent development of productive cough and high fever. There have been cases of flu in the facility; however, Mrs. Randall has had a flu shot. The nurse practitioner in the office requests a chest x-ray in the long-term care facility. The nurse on duty in the facility states that there is no portable chest x-ray equipment available. She further requests that Mrs. Randall be transferred to the emergency room of the local hospital. Mrs. Randall’s daughter has durable power of attorney for health care decisions for her mother. The long-term care facility has notified the daughter of the change in her mother’s condition. The daughter says whatever the nursing home wants is fine with her.
•Review this week’s media presentation, as well as the American Geriatrics Society and Arbaje et al. articles in the Learning Resources.
•Research models of interdisciplinary geriatric care teams that are used at various sites such as assisted living, home care, hospitals, long-term care, and rehabilitation facilities.
•Consider the model used for the interdisciplinary geriatric care teams at your current practicum site. Compare this model to models used at other sites.
•Reflect on how the role of the advanced practice nurse differs according to the site of care.
•Select one of the three case studies. Consider how care should be facilitated for the patient in the case you selected based on the model used for the interdisciplinary geriatric care teams at your practicum site.
Do a comparison of the model used for the interdisciplinary geriatric teams at your current practicum site to models used at other sites.
Then, explain how the role of the advanced practice nurse differs according to the site of care.
Finally, explain how care should be facilitated for the patient in the case you selected based on the model used for the interdisciplinary geriatric teams at your practicum site.