Interprofessional Collaboration and Care Transitions
Mrs. Lee is an 88-year-old resident in your 60-bed assisted living facility with multiple chronic conditions: heart failure, diabetes, and osteoarthritis. She recently returned from a 5-day hospital stay for exacerbation of heart failure. The hospital discharge summary lists 12 medications, including a new diuretic and a new anticoagulant. The hospital did not send a transition-of-care plan. Mrs. Lee's primary care physician is not on staff and visits only every two weeks. The facility has a consulting pharmacist who reviews medications monthly. The nursing staff includes one RN (you) and four LPNs. The LPNs are responsible for medication administration. Mrs. Lee's family is involved but lives out of state. Since returning, Mrs. Lee has been more confused and has had two falls. The staff is concerned about medication interactions and her safety. The administrator asks you (the RN) to coordinate her care.
1. What are the key risks during this care transition, and what immediate actions should you take as the RN?
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Key risks: medication discrepancies (hospital meds vs. facility list), adverse drug events (especially with new diuretic and anticoagulant), falls, delirium, and lack of a clear follow-up plan. Immediate actions: 1) Medication reconciliation: Compare hospital discharge list with facility MAR; clarify discrepancies with the hospital and primary care physician. 2) Assess for delirium: Use a tool like CAM; monitor mental status. 3) Fall risk assessment: Implement fall precautions (e.g., bed alarm, non-skid footwear, frequent checks). 4) Vital signs and labs: Monitor blood pressure, heart rate, weight, and electrolytes (especially potassium with diuretic). 5) Contact primary care physician: Schedule an urgent visit or telehealth consult to review medications and develop a plan. 6) Engage family: Inform them of changes and plan. 7) Consult pharmacist: Request an urgent medication review. 8) Document everything. 9) Consider temporary 1:1 supervision if safety is a concern.
2. How would you facilitate interprofessional collaboration to ensure a safe transition and ongoing care?
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Facilitate collaboration by: 1) Scheduling a care conference with the primary care physician (in person or via telehealth), pharmacist, nursing staff, and family (via phone/video). 2) Creating a shared care plan that includes medication schedule, monitoring parameters, fall prevention, and follow-up appointments. 3) Using a transition-of-care tool (e.g., INTERACT) to standardize communication. 4) Assigning a point person (yourself) to coordinate with the hospital and physician. 5) Ensuring the pharmacist provides a detailed medication review and educates staff on interactions. 6) Training LPNs on monitoring for side effects and when to report. 7) Establishing a communication loop with the family through weekly updates. 8) Documenting all communications in the resident's record. 9) Advocating for the resident's needs by ensuring the physician is aware of the facility's capabilities and limitations. 10) Following up to ensure recommendations are implemented.