General category of Components | Services | Reference |
---|---|---|
1. Assessment | Comprehensive assessment (may include CGA) | |
Current/primary Clinical diagnosis/status | ||
Mental health | ||
Cognition and delirium | ||
Medication review | [48] | |
Pain | ||
Nutrition | ||
Dental health | [57] | |
Elimination | [57] | |
Hearing and vision | [57] | |
Functional assessment | ||
Ambulation, mobility and transfer | ||
Falls history | ||
Confidence in coping and motivation | ||
Assessment of social factors and supports | ||
Review of home environment | ||
Patients’ needs and goals assessment | ||
2. Care Planning and Monitoring | Initial care plan discussed by interdisciplinary team | |
Weekly discussions – healthcare team members involving patients and/or family - on issues affecting participation in rehabilitation / functioning | ||
Weekly discussions and updates | ||
Weekly revision of care plans | ||
3. 1. Treatment | Continued medical care as initiated in acute care in addition to nursing, PT, SW and nutritional interventions | |
Nursing case management | ||
Acute, episodic medical care | ||
Specialized interventions such as respiratory therapy, enteral nutrition, IV therapy, wound care, dialysis, pain control, terminal care | ||
Geriatric consultation | ||
Medication reconciliation | ||
Mobility and rehabilitation training including transfers, stairs, strength and balance exercises and provision of mobility aids | [24, 26,27,28,29,30, 32, 33, 38, 40, 42, 45, 46, 48, 49, 52, 57] | |
Functional training including IADL and ADL training | ||
Specialized rehab including SLP, hearing and dental care practitioners | ||
Psychosocial care measures such as central dining, recreational activities, group exercises, spiritual care | ||
4. Discharge planning | Multidisciplinary discharge planning | |
Collaboration with community partners | [43] | |
Referrals/connection with exercise and social clubs | [48] | |
Referrals to homecare for nursing and PT | [19] | |
Referrals to homecare for nursing and personal care | ||
Discharge letter to FD | ||
Post discharge follow up call by a nurse/PT | ||
Post discharge follow up home visit by nurse to reinforce recommendations | [27] | |
5. Patient/family & staff education | Determine education needs of care partners; Coaching, health promotion/ safety involving caregivers before discharge | |
Staff and physician education related to care of older adults and successful delivery of the TCP | ||
Tailored education to patient/family, related to specific medical conditions; surgical procedures; drug regimens; nutrition and food preparation; and physical activity |