Discharge and Care Transition Planning in Elder Mistreatment Cases Module 12 Nursing Responses to Elder Mistreatment An IAFN Education Course

Learning Objectives In this module, participants will learn to: Identify priorities in discharge/care transition planning in elder mistreatment (EM) cases on patient safety, health and well being Discuss issues to consider and actions to take when planning for discharge/care transition with patients in EM cases 2

Questions to Consider Who in your practice setting conducts discharge/care transition planning? What are procedures for discharge/care transition planning in your practice setting? Are there forms used for planning? Are procedures any different if the case involves actual or potential EM? What are key issues, challenges and questions that need to be addressed when planning for discharge/care transition in EM cases? 3

Checklist for Planning Using a standardized process to plan for discharge/care transition can help ensure a focus on patient safety, health and well being when formulating a plan, no matter what circumstances are involved 4

Checklist for Planning Involve the patient (and guardian/patient’s support system as appropriate to the case) in discharge/care transition planning 5

Checklist for Planning Work with other involved professionals as appropriate to streamline plans for follow-up care and services and maximize effectiveness of interventions 6

Checklist for Planning Make sure that the medical needs of patient have been met through discharge or care transition plan 7

Checklist for Planning Make sure that safety needs of patient have been met through discharge or care transition plan o Home environment safe? o If home is not an option, is alternate living environment safe? o Long-term care facility safe? 8

Checklist for Planning If patient is living in the community, determine home assistance needed o Does the patient have a non- abusive caregiver? o Can that caregiver provide the assistance needed? 9

Checklist for Planning If the patient is living in a long- term care facility, what changes are needed in the plan of care to meet patient needs? 10

Checklist for Planning Take actions as indicated by answers to previous questions o Educate patient o Coordinate with other professionals o Notify authorities as required by law o Help patient develop a plan for safety o Make sure patient has clothing and transportation o Arrange for follow-up medical appointments o Refer patient to services 11

Checklist for Planning Provide patient with oral and written discharge/care transition instructions Document discharge/care transition instructions in the medical record Identify situations requiring nurse follow-up with patients 12

Closing Assessment: Module 12 What one important thing did you learn in this module that you can apply in your practice setting? 13

Closing Assessment: Overall Explain whether or not your personal learning objectives for the course were met Identify the course’s strengths and what could be improved 14