Introduction
Older patients often develop multiple conditions requiring attention and specific approaches to care. To treat such persons, health care providers cannot engage a single specialist as he/she may not have a full range of skill to address all arising problems. Thus, multiple people need to participate in patient care together, forming an interdisciplinary team of specialists as a result. Currently, there are many geriatric teams operating in different environments: hospitals, homes, and rehabilitation facilities. It should be noted that the majority of teams include nurses, whose role is often significant to the patient’s outcomes. In a model of care titled GRACE (Geriatric Resources for Assessment and Care for Elders), advanced practice nurses are responsible for care management and in-home assessment activities.
Models for Interdisciplinary Geriatric Teams
Many approaches to geriatric patient care are discussed in scholarly research. For instance, one can outline such models as BOOST (Better Outcomes for Older adults through Safe Transitions) and INTERACT (Interventions to Reduce Acute Care Transfers) (Hansen et al., 2013; Ouslander, Bonner, Herndon, & Shutes, 2014). The first format includes social workers, nurses, and therapists overseen by an advanced practice nurse and focused on the patient’s safe transition from a hospital to home-based care. The second model is mostly used in nursing homes – this program incorporates physicians, nurses, and administrators, creating an effective framework for addressing acute changes in one’s health.
Another approach, which is currently being implemented at my practicum site, is GRACE. The leading specialists engaged in this model are nurse practitioners and social workers (Ritchie et al., 2016). They lead care management practices performed by a team of mental health specialists, community workers, pharmacists, and medical directors. GRACE focuses on individualized plans for patients with several conditions such as hearing loss, depression, difficulty walking, and others. In comparison to such models as INTERACT, GRACE does not view acute changes as the only requirement for action – the environment of the patient is also considered as a factor that needs management (Kubat, 2016).
The Role of the Advanced Practice Nurse
While advanced practice nurses have a similar set at all places of work, their roles may differ according to the specific site. For instance, in home-based care, nurse practitioners act as managers and evaluators of other specialists’ work. According to the GRACE model, their collaboration with social workers is aimed at reviewing all factors affecting patients’ health and improving them through working with other medical professionals (Ritchie et al., 2016). In the INTERACT model, nurses in nursing homes evaluate acute conditions of patients to decide whether treatment is necessary (Ouslander et al., 2014). In a hospital, nurses may be responsible for discharge planning and lowering the length of one’s stay (Hansen et al., 2013).
Analysis
In the first case study, Mrs. Martinez does not have many activities available to her during her free time. According to the GRACE model, it is not necessary to transfer Mrs. Martinez to a nursing home. Instead, a social worker and an advanced practice nurse should assess her living conditions and work together with the rest of the team to improve her environment (Kubat, 2016). Moreover, they should regularly check on Mrs. Martinez and design a specific plan that would both relieve her daughter form daily care and help Mrs. Martinez find an interesting way to spend time. Leisure time activities can drastically improve one’s mental and physical health (Ritchie et al., 2016). Therefore, they are directly connected to the model of care and should be addressed by the care team.
Conclusion
Models of interdisciplinary care teams address different problems of older people in various conditions. Some approaches work in nursing homes, where acute changes are easy to monitor and treat. Other programs are focused on helping patients to leave the hospital and adjust to home-based care. GRACE is a model that assesses patients’ surroundings and creates personal plans for health management. In all models, nurses play a significant role, leading teams, evaluating their direction and actions, and choosing the path for future care.
References
Hansen, L. O., Greenwald, J. L., Budnitz, T., Howell, E., Halasyamani, L., Maynard, G.,… Williams, M. V. (2013). Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine, 8(8), 421-427.
Kubat, B. (2016). The amazing GRACE care team model. Caring for the Ages, 17(5), 6-7.
Ouslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. Journal of the American Medical Directors Association, 15(3), 162-170.
Ritchie, C., Andersen, R., Eng, J., Garrigues, S. K., Intinarelli, G., Kao, H.,… Barnes, D. E. (2016). Implementation of an interdisciplinary, team-based complex care support health care model at an academic medical center: Impact on health care utilization and quality of life. PloS One, 11(2), e0148096.