Tara A. Cortes

The Transition of Elderly Patients Between Hospitals and Nursing Homes: Improving Nurse-to-Nurse Communication

Lack of patient information is a particular problem when a patient is transferred from one health care facility to another. The lack of information needed to develop a timely and effective plan of care for an older adult transferred to the nursing home facility may exacerbate disruptions in the older adults care. Also, adjustment or readjustment to the nursing home or hospital environment may be prolonged. Persistence of problems or difficulty in adjustment may then lead to exacerbation of the disease processes and, ultimately, hospital readmissions. Evidence suggests that elderly patients discharged from the hospital have high readmission rates. Although the patient is most affected by a breakdown in communication, everyone in the nursing home involved in the residents care is also affected. All staff who provide care to the resident, including nursing, medicine, nutrition, pharmacy, social work, and physical therapy staff members, must be cognizant of issues related to communication for patients being transferred. In this article, the authors discuss the development, implementation, and results of a model designed to increase the communication surrounding the transition of elderly patients from an inpatient unit to and from nursing homes.

A Case Exemplar for National Policy Leadership: Expanding Program of All-Inclusive Care for the Elderly (PACE).

In November 2015, President Obama signed the Program of All-Inclusive Care for the Elderly (PACE) Innovation Act, which expands a proven model of care to serve high-cost and high-need populations. Specifically, the law provides the Centers for Medicare & Medicaid Services with the authority to waive Medicaid requirements that could not be waived without additional statutory authority. Those requirements include the age of the beneficiary to be served and nursing home eligibility as a condition for PACE enrollment. The law also allows providers and other entities who are not current PACE providers the opportunity to become PACE providers and serve a predominately dually eligible population that has high needs and high cost through a coordinated, integrated model. The current article describes the impact of nursing on the legislation and policy that has shaped the evolution of the PACE program for more than 40 years. [Journal of Gerontological Nursing, 42(3), 9-14.].

Ensuring specialty nurse competence to care for older adults: reflections on a decade of collaboration between specialty nursing associations and the Hartford Institute for Geriatric Nursing.

Geriatric preparation of specialty nurses is critical because their direct care and administrative responsibilities profoundly impact the care of countless older patients in all settings. For a decade, the Hartford Institute for Geriatric Nursing, NYU College of Nursing, has worked with 54 national specialty nursing associations, and intensely with 14, to develop strategies for new standards for quality care for older patients. A successful blueprint for specialty associations to sustain and enhance these outcomes will be presented.

Developing Passion and Excellence in Critical Care Nursing: Proposed Solutions to Current Challenges in Critical Care

This article addresses significant challenges in the delivery of critical care services in hospitals including the need for partnerships between service and education, the need to strengthen interdisciplinary teams, and educational challenges in preparing critical care nurses at both the specialist and generalist levels. Each of these challenges has a direct impact on the quality-of-care outcomes for critical care patients.

Geriatric Interdisciplinary Team Training 2.0: A collaborative team-based approach to delivering care

ABSTRACT Interprofessional collaborative education and practice has become a cornerstone of optimal person-centered management in the current complex health care climate. This is especially important when working with older adults, many with multiple chronic conditions and challenging health care needs. This paper describes a feasibility study of the Geriatric Interdisciplinary Team Training 2.0 (GITT 2.0) program focused on providing interprofessional care to complex and frail older adults with multiple chronic conditions. A concurrent triangulation mixed-methods design facilitated program implementation and evaluation. Over three years (2013–2016), 65 graduate students from nursing, midwifery, social work, and pharmacy participated along with 25 preceptors. Participants were surveyed on their attitudes toward interprofessional collaboration pre and post-intervention and participated in focus groups. While attitudes toward interprofessional collaboration did not change quantitatively, focus groups revealed changes in language and enhanced perspectives of participants. Based on the evaluation data, the GITT 2.0 Toolkit was refined for use in interprofessional education and practice activities related to quality initiatives.

A post-master's advanced certificate in gerontology for NPs

Abstract: This article describes an innovative post-masters advanced certificate in gerontology program developed by the Hartford Institute for Geriatric Nursing at the New York University Rory Meyers College of Nursing. The program provides advanced practice registered nurses geriatric content to meet eligibility criteria for the Adult-Gerontology Primary Care NP certification exam and develops interprofessional care providers to care for complex older adults.This article describes an innovative post-masters advanced certificate in gerontology program developed by the Hartford Institute for Geriatric Nursing at the New York University Rory Meyers College of Nursing. The program provides advanced practice registered nurses geriatric content to meet eligibility criteria for the Adult-Gerontology Primary Care NP certification exam and develops interprofessional care providers to care for complex older adults.