1.  Take care of yourself

• Make time for regular exercise
• Strengthen your core muscle group and lower back
• Wear comfortable, rubber soled shoes that provide support, a strong foundation, and prevent slipping

2.  Use good body mechanics to avoid injury and/or repetitive strain injuries.

Standing:

• Keep your feet flat on the floor, hip width apart for a wide base of support
• Keep your back straight, while maintaining it’s natural curves

Lifting:

• Keep your feet apart and your back straight
• Lower your body to get close to the object/person
• Bend from your hips and knees (DO NOT bend at the waist)
• When turning, rotate your entire body, not just your back
• Lift using your arm and leg muscles, keeping your knees bent and your back straight (DO NOT use your back muscles)
• If the weight is excessive, request assistance or use assistive equipment such as a patient lifter, hydraulic lift chair, transfer bench, sliding boards, etc.

Pushing or pulling:

• Use the weight of your body to help push or pull an object
• Use the appropriate body mechanics (as explained above under “Lifting”)

Reaching:

• Stand directly in front of and close to the object
• Avoid twisting or stretching
• Maintain good balance and a firm base of support

Sitting:

• Whenever possible, sit on a hard chair with a straight back
• Support your lower back whenever possible
• Keep your trunk extended (with your abdominals and lower back strong)
• Keep your shoulders retracted (pulled back)
• If doing something like using a computer or jotting down notes, put a pillow on your lap to raise the items closer to you to help keep your back straight

3.  Handling patients, and common medical devices such as blood pressure cuffs, syringes, and laptop computers can lead to common and painful hand injuries (e.g., tendonitis, sprains, carpal tunnel, DeQuervain’s)

• Maintain a comfortable neutral wrist position
• Do not rest your palms or bend wrists markedly down or inward while typing
• Do not turn your wrist towards your little finger (ulnar deviation) or towards your thumb (radial deviation)

Take preventative measures as much as possible. Chronic pain can be a barrier to productive outcomes and can lead to unwanted downtime. In the end, our patients (and others in our lives) need us in optimal physical condition. And we need to remember to take care of ourselves!

Gerard Mounic, Manager
Rehab Centers of Excellence
Visiting Nurse Service of New York

Approach 1. Who? What? When? How Much?

When starting an improvement project, teams often craft an aim. They decide what they want to improve, and:

• For whom? (e.g., patients with heart failure)
• By how much?  (e.g., reduce ED visits related to pain by 50%, or reduce delays in communication with the physician office to 4 hours).
• By when? (by August 1)

Here is an example:  By Labor Day, our agency will implement SBAR communications in every interaction with a provider or office practice.  We will train 95% of our permanent staff, who will all be able to teach back SBAR and demonstrate when and how to use it.

Approach 2. Hopes, Dreams, and Aspirations

An alternative approach to writing an aim statement is to think about your real hopes, dreams and aspirations.  A simple statement about these things can also motivate a team to get great results.

Here is an example:  By the time school starts in the fall, we want our nurses to be such concise communicators when interacting with a provider or office practice that the other person does not feel their time was wasted, was glad to receive the vital information, and is willing to act on the nurse’s concern.

You choose!  Either kind of aim statement helps gets your team moving on the right track to great results.

Jane Taylor, CHAMP Improvement Advisor

“A little nonsense now and then is relished by the wisest men!”

I first discovered this quote when I was around eleven years old.  It hung on a teabag tag from my mother’s teacup. The quote has sure had staying power!  It has served me very well over the years. I’ve used it at the most opportune and inopportune times, with patients, doctors and colleagues and in my personal life!  It means you can be smart, wise and funny at the same time.  Thanks to my patients, I’ve learned that almost everyone appreciates humor.  When used appropriately and at the right time humor can lift spirits, ease pain and allay anxiety.   And most importantly, it’s an intervention we can do without any adverse effects!!  Academics have been researching and finding clear evidence about the positive effects of humor on our health for years.

One of the best nurse’s I’ve ever worked with could disarm and engage her patient in the first fifteen minutes of her meeting them with a funny comment, observation or quip.  Her patients saw caring and compassion along with her ability to meet them at one of the most human connections.  Patients really looked forward to seeing her again!

Certain cultures expect their caregivers to maintain a sense of decorum and seriousness. I once cared for an older woman, who had prematurely (according to her doctors) taken to her bed with a diagnosis of cancer. Her family moped around her.  They seemed to think that in order to show her how much they loved her they needed to be serious and sad all the time.  Are you scratching your head now and asking yourself what Willy Wonka has to do with this?  I’m getting there!  I knew my patient needed a break from her dreary space.  At some point during each visit, she would inquire about my children and this would make her smile. During one visit I saw an opportunity, I showed her a picture of my son making a silly face and said “I don’t know where he got that from!” making that same silly face, of course.  Laughter ensued followed by funny stories about her children over our next visits. I think my patient needed permission to enjoy what was left of her life and humor helped her do that.  Thankfully, her family followed her lead.  Although the family never accepted hospice services, I think my patient’s last days were better because humor came back into her life.

If you need a few suggestions to kick-start your foray into humor, take a look or re-look at my April Fools Blog/2011. You will find some quips, props and suggestions to celebrate the day and hopefully share a few laughs, giggles or even better …..Nonsense!

Debra Bertrand, CHAMP Facilitator

The goal of the 2012 AGS Beers Criteria is to improve care of older adults by reducing their exposure to PIMs. Although the criteria are intended for multiple uses, primary they are geared toward helping practicing clinicians improve the selection of prescription drugs; and to educate clinicians and patients on proper drug usage. AGS hopes that thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease adverse drug events in older adults, and (c) better patient outcomes (AGS Expert Panel,  2012).

In addition to the new criteria, this special issue of JAGS also includes some very valuable clinical tools such as a pocket guide, and educational resources. I liked the “AGS Beers Criteria Summary for Patients & Caregivers” and “10 Medications Older Adults Should Avoid“.  There also is a New Perspectives article by the co-chairs of the expert panel, and an editorial about AGS’s role, and caveats that Criteria should not substitute for professional judgment or dictate prescribing for an individual patient (Resnick & Pacala, 2012).

The AGS has spent considerable time and resources updating the criteria and disseminating the finished product to the field. Even more importantly, AGS is making the criteria and related professional and public education materials free on the AGS website to insure  high quality care for older adults. AGS plans to add a new Smartphone Application and Teaching Slide Presentation to its portfolio of materials based on the 2012 AGS Beers Criteria, and will mail a hard copy of the Criteria pocket card to members in April.

I was very honored to have worked with the late Mark Beers during my career. I think he would be very pleased to see how the criteria that bear his name have evolved through the leadership of the AGS, and would support its plans to keep the criteria current and evidence-based.

Stay tuned to CHAMP for more discussion on the Beers Criteria and some ideas about how to apply the criteria and resource materials to improving medication management in your agency.

Dennee Frey, CHAMP Pharmacy Expert

References

1. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. AGS updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Feb 29.

2. Resnick, B. and Pacala, J. T. 2012 Beers Criteria. J Am Geriatr Soc. 2012 Feb 29.

With just nine months of home care experience under my belt, one of my patients died alone at home.  Her home health aide and I were her only link to the outside.  I was the one who found her lying in her bed. Although I knew that her death was not imminent at the time, I felt responsible for her dying alone and carried this sadness for a long time.

I will always remember these patients even though I cared for them so long ago.  So how does the experiences of a novice home care nurse over thirty years ago have any relevance to today? Once again, you’re scratching your head, asking “Where is she going with this?”

Is anyone noticing a worrisome trend in today’s nursing job market? I saw it happen in the ‘90’s. When budgets get cut, the economy ails, health care businesses, insurers, hospitals and others fear their bottom line is imperiled, this happens.  Veteran nurses get offered retirement packages, hiring freezes are put in place and nurses are laid-off.  But, I think something else is happening in this job market. As home care nursing job listings are declining, I’ve also noticed that ads have been posted seeking nurses with less experience. I’m guessing that some administrators have no choice but to fill open positions with cost savings in mind.

I’m worried. Hospital experience can provide a solid foundation for home care nursing.  But it doesn’t prepare most nurses for the isolation and autonomy required in home care practice. I’ve transitioned many hospital nurses into home care.  Their biggest adjustment is not having a colleague within reach to consult with.  I’ve heard this from very confident and experienced nurses, too.  As a matter of fact, when I don’t hear this from a nurse who is new to home care, I worry a bit.

Novice nurses may be able to manage medications, assess pain, or dress wounds.  But are they prepared to deal with the challenges that home care nursing can present?  Perhaps Administrators, CEOs, COOs, etc. should either offer special preceptor programs for the novice nurse or find some way to raise job experience requirements for those new to home care nursing.  Both patients and nurses would benefit from this. What do you think?

Debra Bertrand, CHAMP Facilitator

Here are a few more clues.  This condition can be transient, reversible or chronic.    There are four different types and sometimes a patient can have more than one of them.  It can be caused by medication, inflammation, irritation, or a neurological condition.  Treatment modalities can include surgery, medication, physical therapy, biofeedback, or behavioral therapy.  The most important fact is that it is treatable or at the very least, symptoms can be manageable.

OK, I’ll stop all of the intrigue.   But I’m trying to demonstrate a larger point.  Urinary incontinence is a problem, which many have great difficulty talking about.  Over 50% of geriatric patients do not report their incontinence to their doctors.  Many think that incontinence is a part of aging.  We shouldn’t be surprised about this.  Have you seen the adult diaper ads in magazines and on TV during the evening news?  I’m even guilty of including a box of Depends in my joke gift basket for friends celebrating milestone birthdays. How many times have you heard someone say that they wore a diaper at the beginning of their life and have to wear a diaper at the end of it?

As home care clinicians we can do much to help our patients with urinary incontinence.  Opening up a dialogue can be half the battle.  Informing our patients about diagnostic and treatment options can give them hope and may result in an improvement in their quality of life.   Here are three tools available on the CHAMP web site.

• The Daily Bladder Diary is a convenient tool to help providers gather more information about a patient’s incontinence and determine effectiveness of treatment.

• Urinary Incontinence Assessment in Older Adults: Part l Transient Urinary Incontinence  is a “Try This” issue that describes two methods to assist nurses in assessing acute urinary incontinence and its treatable underlying causes. Includes a Bladder Diary. Published by the Hartford Institute for Geriatric Nursing.

• Urinary Incontinence Assessment in Older Adults:  Part II Persistent Urinary Incontinence is a “Try This” issue that describes two evidence-based tools to assist nurses in assessing quality of life and symptom distress for chronic urinary incontinence. Published by the Hartford Institute for Geriatric Nursing.

Debra Bertrand, CHAMP Facilitator

Source for statistics:
Weiss, Barry D.  M.D., Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients, Am Fam Physician. 1998 Jun 1;57(11):2675-2684.

Since then he’s had to cope with the long road to recovery.  He is gradually regaining the energy he once had and is still trying to recover emotionally.  Mr. Cortez and his wife feel more comfortable because homecare professionals come in to check on him.  The nurses and physical therapists are teaching them both how to recognize signs and symptoms of problems and what to do if they occur.  Yet in order for all of this to be successful, there needs to be coordination between the hospital, physicians, therapists and other nurses.  Follow-up and referrals to other services when warranted are also essential, and must goals be identified for both the patient and the family.  As CHAMP’s Care Coordination, Management & Transitions evidence-based brief identifies several factors that need to be in place for successful coordination:

• A comprehensive assessment for risks, conditions and syndromes
• Individualized evidence-based care plans
• Engagement of the patient and their caregiver
• Involvement of all members of the home-care team
• Input of geriatric experts from all disciplines
• Systematic follow-up

Mr. Cortez said that when he was in the hospital he felt he was in a “whirlwind,” and that at times it was hard to “come to grips” with what people were telling him.  Now that he is home learning a “new way of life,” having a visiting nurse is something that he doesn’t take for granted.  According to his wife, “Having someone here helps the both of us and can validate if how I am caring for him is correct.”  Although it may seem minor at the time, positive affirmations from nurses and therapists can make all the difference in how patients cope with illness.

The transition from the hospital to the home can be scary for a patient and their family.  Mr. Cortez knows he still has a long road ahead of him, yet having professionals that guide him and his family can help ease that transition and decrease their burden. Keeping the lines of communication between all involved is important in making the patient’s return home safe and supportive.

Paula Wilson, Clinical Coordinator
Center for Home Care Policy and Research
Visiting Nurse Service of New York

If you’re ready for a meaningful challenge that will change how you look at yourself and your job, and you want to develop leadership abilities that can help you make even more significant contributions to the field of geriatrics, please consider applying for the GNLA.  Here’s what Amy Cotton, now President of the National Gerontological Nursing Association, says about her experience in the program:

“I found the GNLA experience transformative for my nursing leadership development.  The didactic and mentored experience was relevant, intensive and rewarding.  I learned new skills in the areas of strategic engagement, leading inter-professional groups, developing health policy advocacy strategies and identifying solutions for challenging health care delivery issues.  My leadership sphere of influence has grown both regionally and nationally.  I highly recommend this experience for nurses interested in increasing organizational influence and advancing their skills to improve health care delivery for older adults.”

Please see below (or click here) to find out more about the GNLA and how to apply (you have until April 2nd to submit an application).

And let me close by saying thank you for what you do every day!

Brenda Cleary, PhD, RN, FAAN
Ageing Initiatives Administrator, Sigma Theta Tau International

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More about the Geriatric Nursing Leadership Academy (GNLA):

The Geriatric Nursing Leadership Academy (GNLA), a premier leadership development opportunity offered through the Honor Society of Nursing, Sigma Theta Tau International, is for nurses dedicated to transforming care for older adults and their families across settings and to improving overall geriatric health outcomes and influencing various levels of health policy.  It is an 18 month intensive, mentored leadership program that has already changed the lives of Fellows, their Mentors and the 20,000 patients they care for across 20 states.

A Fellow must have a baccalaureate or higher degree in nursing as well as leadership potential, knowledge and competence in geriatric nursing, a commitment to profoundly impact the quality of care and health outcomes for older adults and the support of his or her employing organization. A Mentor must have extensive leadership experience, a proven track record of successful mentoring relationships and the time necessary to invest in a Fellow’s journey.  Fellows and Mentors attend two intensive three-day leadership workshops, and with guidance from the Mentor and GNLA faculty consultant, the fellow designs an individualized leadership development plan and project.

The GNLA was created through a partnership between The John A. Hartford Foundation and its Centers for Excellence in Geriatric Nursing and Sigma Theta Tau. The 2012-2013 GNLA is made possible with a Retirement Research Foundation grant and additional support from The John A. Hartford Foundation and Hill-Rom.

Applications are accepted 15 February through 2 April 2012.  For additional information and to apply click here.

Many look at Super Bowl Sunday as the ‘holiday’ that lies between Martin Luther King Day and President’s Day.  Yes, there’s a movement to make the Monday after the Super Bowl an official holiday. “No Way”, you exclaim? “Yes Way”, I respond!  I look at Super Bowl Sunday, no matter who’s playing, as an opportunity to cast all diets and nutritional advice aside.  Chicken wings, nachos, a variety of meats in tube form await!  It’s fun to eat stuff that you stay away from most other days of the year.  It’s also a blast to jump around, yell and scream with abandon.  The Super Bowl is our modern day Roman Forum.  Our gladiators wear helmets, pads and lycra, not loincloths and sandals.  Let the games begin!

So you must be scratching your heads by now wondering where I’m going with this.  Should this be any different than most of my blog posts?   What does the Super Bowl have to do with geriatric home care?  Bear with me and let me take you back to those folks who are oblivious to their surroundings. Think about our homebound male patients.  Can you imagine being a guy – who in his younger days loved or even played football – having an endless stream of female caregivers interact with him on a regular basis? I’m sure that many are grateful for their care.  But, most men like to converse with other men and miss their companionship.  How can you be sure that our male patients with dementia don’t miss the company of their male friends also?  Maybe locked inside of your male patient there’s a football fanatic or someone who longs for the good old days of male bonding activities.  Even our most oriented male patients must long for these days, too!

Don’t lose sight of whom you’re taking care of.  That old sick man may have been a quarterback or tackle back in the day.  The Super Bowl has been around for a long time.  The first game was played in 1967, Green Bay Packers against the Kansas City Chiefs.  Your 80 year old patient was 35 years old that day!  Try to picture him in front of his black and white TV, smoking a cigar, nibbling on onion dip and chips and reveling in the first of many games to follow. Even though your patients may be seriously ill or in failing health, they are still in this world! Strike up a conversation about the game during your visit this week.  Ask him if he remembers where he was on that first Super Bowl Sunday or if he played football.  You’ll be treating him in more ways than just a patient!

Touchdown!!!!!!!!!!!!!!!!!!!

Debra Bertrand, CHAMP Facilitator

Preventing rehospitalization is nothing new for home care agencies.  We’ve been held accountable for a while now.  Now the ‘re-hospitalization onus’ will be on them and us.   Hasn’t it always been in the healthcare landscape ‘them then us’, for that matter?? Maybe hospitals will see greater value in improving communication with their home care partners now that their bottom line will be impacted.  Hospital administrators are finding Medicare’s levy unfair because hospitals have no control over the patients’ home environment and community resources.  Hello???  Welcome to our world!!!!  Here’s an opportunity for home care to come to the rescue.  Making home care services a part of the rule not the exception in discharge planning would seem to be a logical step to address this problem.

I’ve been reading about how hospitals, especially teaching hospitals and large urban medical centers, are gearing up for this Medicare change. Examples of care transition ‘coaches’ visiting patients in the hospital, at home and on the phone makes me wonder why hospitals feel like they need to create another layer of care especially when home care has been there all along and does this quite well.  Another example: hospital nurses becoming more involved with assuring follow-up appointments for their patients before they are discharged.  I’ll bet hospital nurses have a lot to do already without adding the burden of after care.

Because we already know that problems with medications are at the head of the list of reasons for hospital readmission, efforts to employ evidence-based practices in medication management will continue to have a major impact on re-hospitalization rates helping ‘them and us’.  If you’re involved with the day-to-day care of patients, you may find a new tool we’ve added to the CHAMP Resource section helpful: “Improving Medication Adherence in Older Adults: What Can We Do?”  Problems with medication adherence can be very challenging.  This tool lists factors that contribute to non-adherence and strategies that can be used to use to address each one.  You’ll also find many other evidence-based tools in the Tools section of the CHAMP web site by selecting topics such as “Medication Management,” “Behavior Change and Adherence,” and “Rehospitalization” from the ‘All Topics’ drop-down menu.

Perhaps hospital and home care partnerships will become more widespread in an effort to assure that the inpatient remains an outpatient for as long as possible.

Medicare may force the hand of hospitals to look upon home care as the answer to stemming their re-hospitalization tide.  I hope so.

Debra Bertrand, CHAMP Facilitator