Huge numbers of older persons transition from hospitals to the nursing home. Often, an older hospitalized patient needs skilled nursing care before they are ready to return home. In other cases, a nursing home patient who needed hospitalization is returning to the nursing home. Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.
But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous. The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.
The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities. These nurses noted that very difficult transitions were the norm. Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.
Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital. They lacked essential details about their patient’s clinical status. The problem was not the lack of paper work that accompanied the patient. In fact, nurses often received reams of paper work, often over 80 pages. The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.
Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.
For better or worse, Twitter can change the world. I got a whiff of that potential last spring,while participating in a regular Twitter chat (#eldercarechat), someone raised (Tweeted?) the question of what we want government to do to improve thelives of the nation’s 60 million caregivers, and added that weneeded something like a PeaceCorps for family caregivers. That idea resonated with me—and with what I myself need at thisjuncture in my life. My young adult children, five between the ages of 19 and 23, struggle to find work—regular work, much less meaningful work—so that they can pay their bills, including college tuition and loans.
My 92-year old grandmother has moved to Alaska to be with my aunt, and spends many of her days alone, her mind still longing for human connections, her body unable to gether there. What if we could buildsomething akin to the Peace Corps,a national program that could simultaneously address a spectrum of issues, such as workforce development, economic security, intergenerational respect, skillbuilding, and national service?
What if a program existed that could, for instance, employ my 20-something kids, rely on the skills and experience of retirees, like my own 69-year-old parents,and provide companionship to mygrandmother?What if we had a CaregiverCorps? I tweeted. Within a day, I had launched a petition to the White House calling for Americato create such a Corps. Within a month, the New Old Age blog of The New York Times had featured the idea.
Even now, late summer, the idea continues to be discussed: mentioned in the Times, and talked about online. Moving from something as ephemeral as a Tweet to somethingas enduring as a national program, of course, will take more than a season. To that end, I have spent subsequent months writing about the idea for various online platforms, and networking with individuals and organizations who are intrigued by the possibility. Anne Montgomery, my colleague at the Center for Elder Care and Advanced Illness at Altarum Institute and a veteran Hill staffer, has done the same.