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Supporting Older Veterans and Their Caregivers

Nurses partner with caregivers to keep veterans out of hospitals and living at home

Duke Commemorates Veterans Day
An interdisciplinary team of caregivers is reaching out to older veterans.

A Medicare report revealed that one in five hospitalized patients age 65 or older suffering from heart failure, heart attacks or pneumonia returns to the hospital within a month to receive care. Most of the time the reason for the return is the patient's multiple co-morbidities, complex medication regiments or frailty, which complicates the transition from the hospital to home.

Knowing this information, Cristina Hendrix and an interprofessional team developed the Transitional Care (TLC) Partners program at the Durham VA Medical Center in North Carolina. Staffed by nurse practitioners, social workers, occupational therapists and a physician, the program works with older veterans and their caregivers to reduce the rates of readmissions, emergency department visits or admittance into a nursing home.

“When a patient has to continue with a complex regiment at home, it can be a bit daunting for them and their caregivers,” says Hendrix, associate professor at Duke University School of Nursing and TLC Partners program lead. “We wanted to develop a program that would allow these patients an opportunity to comfortably recover in their own home, as well as provide support to the caregiver that would decrease uncoordinated or fragmented care.”

TLC Partners is based on Dr. Mary Naylor’s Transitional Care Model, which addresses the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute care setting to their home or other care setting. With TLC Partners, before a patient is discharged from the hospital a nurse practitioner meets with both the patient and the caregiver and provides health education such as medication management and symptom management. They also provide training of skills for at-home care such as proper use of home oxygen.

Veterans Day

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As part of Duke’s annual tradition, students, employees and visitors will gather together at 11 a.m. Nov. 11 in front of Duke Chapel to commemorate Veterans Day. Read more here.

“An interdisciplinary team is important for the overall care of the patient,” Hendrix says. “For instance, even though social workers aren’t direct care providers, they are very important in linking the dyads of care for the patients and their caregivers to community-based support."

An example of the interdisciplinary care the team provides for a patient includes the nurse practitioner reconciling the patient’s home medications, educating the patient and caregiver on the use of home oxygen and monitoring the resolution of the chronic illness. The social worker can submit a revised VA Means Test, apply for food stamps and find other community resources to assist with the patient’s medical bills. The occupational therapist can identify needs for adaptive equipment and home modifications such as a hospital bed, manual wheelchair, oxygen tank holder, overbed table for meals, car transfer devices and a ramp for the home.

“In providing this type of interdisciplinary care, we aim to reduce the burden and anxiety for the patient and the caregiver, as well as improve the preparedness of the caregiver,” says Hendrix.

As a result of TLC Partners, the hospital was able to see a reduction in 30-day readmissions among patients who had early follow-up after discharge. The program has also resulted in improved quality of transitional care.

The TLC Partners program has won numerous awards for its innovative approach to continuum of care and interprofessional approach to patient care. One award was the 2014 National Hartford Centers of Gerontological Nursing Excellence/Hartford Gerontological Nursing Leaders Innovation Award. Hendrix and the team won the first award that recognizes and celebrates innovative programs and projects that highlight excellence in gerontological nursing.

“My culture is traditionally rooted in the principle of filial piety and respect for one’s elders is the highest virtue, so being able to develop a program that reflects this is dear to me,” Hendrix, who is Asian, says. “As nurses not only do we have an obligation to care for our patients but to optimize the ability for them to live in their home as long as possible. And when we provide caregivers with the ability to help them, it’s a win-win for all.”

Hendrix adds: “The program has not only been beneficial to veterans but for the field of nursing research as well. Clinical partnerships such as TLC afford educators, researchers and nursing students an opportunity to test their developed theories.”

At the program's start in 2010, funding was through the Veterans Health Administration’s Office of Geriatrics and Extended Care to field test innovative alternatives to institutional extended care for veterans. After three years, the Durham VA began financially supporting the program under its Home Based Primary Care program.  The program is now led by Dr. Jeannette Stein, medical director for Durham VA Medical Center. The program has a streamline focus on providing care to patients with heart failure as this group is rehospitalized frequently and shows the greatest benefit when receiving home-based care.