After completing your required readings in the Psychological Lives of Older Adults module, you will apply what you have learned by developing an intervention to improve the psychological well-being of an older adult who is transitioning from the hospital to home.
You can gain glean insights from a few programs that assist older adults transition from the hospital to home-based or hospice care, but I want you to use research and the theories presented earlier in the Major Theories of Wellness and Aging module to make your care transition plan unique.
Existing Similar Programs:http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx
Your program should attempt to accomplish the following goals:
- Avoid hospital re-admittance or additional health complications.
- Improve self-efficacy in home healthcare routines (medications, physical therapy/rehabilitation, etc.)
- Encourage adaptive coping mechanisms and self-compassion.
- Connect your client with social support.
Here is a description of your client and her needs:
Your client, Grace, is a 76 year-old widow who has two sons who live in the greater Houston area, but are 20 miles or more from Grace’s home. Grace became weak and dehydrated after an upper respiratory virus, and was hospitalized after a fall, in which she suffered a concussion. Grace has shown some signs of mild depression and anxiety. She is being released home and you need to develop a transitional care plan to ensure her health and well-being.
You should develop a series of questions to assess Grace’s needs and then develop a care transition plan. Your plan should include 1) specific strategies that you will use to accomplish the goals listed above, 2) specify how often Grace will be visited by home health professionals, 3) and how you will assess the success of your intervention.
Your transitional care plan will be evaluated based on your ability to apply research and theory to Grace’s specific needs and the goals of the program, 2) your ability to develop questions that are appropriate for an older adult with Grace’s medical complaints, and 3) your ability develop an program assessment plan to evaluate the efficacy of your care transition plan.
Will provide supportive/reference paper which you may use. You are also free to research.