Pathways through the transitions of care for older adults

287 Pages·2011·1.689 MB·English

by  Dilworth-Anderson, Peggye

ANNUAL REVIEW OF GERONTOLOGY
AND GERIATRICS
VOLUME 31, 2011
Editors
Series Editor Laura L. Carstensen, PhD
Toni C. Antonucci, PhD Stanford University Fairleigh S. Dickinson
Associate Vice President for Research Jr. Professor in Public Policy
Elizabeth M. Douvan Collegiate Professor Professor of Psychology, Director
of Psychology Stanford Center on Longevity
Research Professor and Program Director Stanford, California
Life Course Development Program of the
Institute for Social Research Kyriakos S. Markides, PhD
University of Michigan Professor and Director, Division of
Ann Arbor, Michigan Sociomedical Sciences, Department of
Preventative, Medicine and Community
Associate Editors Health
Marie Boltz, PhD, RN, GNP-BC Annie and John Gnitzinger Distinguished
New York University College of Nursing Professor of Aging Studies
John A. Hartford Foundation Editor, Journal of Aging and Health,
Claire Fagin Fellow Galveston, Texas
Associate Director for Practice, Hartford
Institute for Geriatric Nursing and Steven N. Austad, PhD
Assistant Professor Professor, University of Texas Health
New York, New York Science Center
Department of Cellular & Structural
Harvey L. Sterns, PhD Biology Barshop Institute for Longevity
Professor of Psychology & Aging Studies
Director and Senior Fellow San Antonio, TX
Institute for Life-Span Development and
Gerontology, Chair, Faculty Senate Series Editor Emeritus
The University of Akron K. Warner Schaie, PhD
Research Professor of Gerontology The Pennsylvania University
Northeastern Ohio Universities University Park, Pennsylvania
College of Medicine and Pharmacy
Akron, Ohio Founding Editor
Carl Eisdorfer, PhD, MD
Keith E. Whitfi eld, PhD University of Miami
Professor, Department of Psychology and School of Medicine
Neuroscience Miami, Florida
Duke University, Durham, North Carolina
Annual Review of
Gerontology and Geriatrics
Pathways Through the Transitions of Care
for Older Adults
VOLUME 31, 2011
Volume Editors
PEGGYE DILWORTH-ANDERSON, PhD
MARY H. PALMER, PhD, RNC, FAAN
Series Editor
TONI C. ANTONUCCI, PhD
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This book is dedicated to my parents Guy Cleve Dilworth and Bertha Louis
Little Dilworth, the beacon of my life and the mirrors of my ancestors.
—Peggye Dilworth-Anderson, PhD
This book is dedicated to my parents, Joseph George Happel, Jr.,
and Anita Walkling Happel, who, by their words and actions, taught me
that how we conduct our relationships defi nes our own humanity.
—Mary Happel Palmer, PhD, RNC, FAAN
Contents
About the Volume Editors ix
Contributors xi
Previous Volumes in the Series xv
Acknowledgments xvii
Foreword Eric A. Coleman, MD, MPH xix
Introduction xxiii
Setting the Stage on Transitions of Care
1 A Contextual Conceptualization on Transitions of Care
for Older Persons: Shaping the Direction of Care 1
Peggye Dilworth-Anderson, Tandrea S. Hilliard,
Sharon Williams, and Mary H. Palmer
2 The Older Person in Transition: Implications for Pathways
of Transitions of Care 15
Alicia I. Arbaje, Romsai T. Boonyasai,
and Peggye Dilworth-Anderson
3 Family Involvement in Care Transitions of Older Adults:
What Do We Know and Where Do We Go From Here? 31
Laura N. Gitlin and Jennifer Wolff
Health Issues and Transitions of Care
4 Physical Health Problems: Shaping Transitions of Care 65
Toni P. Miles and Karla T. Washington
5 Comorbidities and Their Impact on Transitions of Care 93
Aida B. Wen and Patricia Lanoie Blanchette
viii Contents
Legal, Ethical, and Decision-Making Issues
on Transitions of Care
6 Planning and Decision Making for Care Transitions 111
Silvia Sörensen, Wingyun Mak, and Martin Pinquart
7 Advance Care Planning and End-of-Life Decision Making 143
Jung Kwak, Jessica Y. Allen, and William E. Haley
Educating the Workforce for Transitions of Care
8 Educating Direct Care Workers on Transitions of Care 167
Robyn I. Stone and Natasha S. Bryant
9 The Interdisciplinary Team and Improving Transitions of Care 189
Teresa M. Treiger and Cheri Lattimer
Charting the Future on Transitions of Care
10 Public Policy Implications for Pathways Through Transitions:
The Rise of the Transitional Care Concept 209
Susan C. Reinhard and Keith D. Lind
11 Coming Full Circle: Planning for Future Pathways of
Transitions of Care for Older Adults 231
Kathryn G. Kietzman, Harold Alan Pincus,
and Phuong Trang Huynh
12 Conclusions and Recommendations 255
Peggye Dilworth-Anderson, Jan Busby-Whitehead,
and Mary H. Palmer
Index 263
About the Volume Editors
Peggye Dilworth-Anderson, PhD, is a professor of Health Policy and Management
in the Gillings School of Global Public Health at the University of North Carolina
(UNC) at Chapel Hill, and an interim co-director of the UNC Institute on Aging
(IOA). Her areas of expertise include minority aging and health, family caregiving,
health disparities, and long-term care. Her current research focuses on health dis-
parities pertaining to Alzheimer’s disease and related dementias. Currently, she is
the principal investigator of two projects that focus on health disparities pertain-
ing to caregiving to older adults with Alzheimer’s disease and related dementias.
Her research has led to publications which span over three decades. In addition
to research, she has been active in supporting and training students and junior
faculty members in aging research. She directs a National Institute on Aging (NIA)
T32 training program at the IOA titled, “Pre-Doctoral and Post-Doctoral Training
in Healthcare and Aging Research.” Funding through a KO7 leadership grant
from the NIA has allowed her to develop a research and academic training struc-
ture on ethnic minority aging at UNC. In 2006, she received a mentorship award
from the GSA in recognition for outstanding mentorship to researchers, faculty,
and students interested in the science of minority aging,
Dr. Dilworth-Anderson serves in several consulting and advisory posi-
tions related to health issues in later life, and she has served in several leader-
ship roles in the fi eld of aging. She is a member of the Medical and Scientifi c
Advisory Council of the Alzheimer’s Association. She is the past president of the
Gerontological Society of America (2009–2010) and has served as a member
of the National Research Advisory Council for the National Institutes of Health
(NIH)/NIA (2007–2011). She has received numerous awards for her work; and in
2010, she was the recipient of the Ronald and Nancy Reagan Research Award for
her research on Alzheimer’s disease. She is a fellow of the Gerontological Society
of America and the National Council on Family Relations. She currently serves on
the editorial boards of A lzheimer’s & Dementia and Aging and Mental Health .
Dr. Dilworth-Anderson completed her undergraduate training in sociology
from Tuskegee Institute and received her master’s and doctoral degrees in sociol-
ogy from Northwestern University, with additional postdoctoral training from
the Midwest Council on Social Research in Aging.
x About the Volume Editors
Mary H. Palmer, PhD, RNC, FAAN , is a professor and the Helen W. and Thomas
L. Umphlet Distinguished Professor in Aging at the University of North Carolina
(UNC) at Chapel Hill. She is an interim co-director of the UNC Institute on
Aging and the project director of a Health Resources and Services Administration
Comprehensive Geriatric Education Program grant titled, “Improving the Care
of Acutely Ill Elders.” This project uses geriatric clinical simulations to prepare
nurses and other health care providers caring for older adults who experience
transitions in their health status or experience sentinel events such as a fall.
Dr. Palmer has conducted research, published, and lectured extensively on uri-
nary incontinence in adults. Her research has led to a better understanding of
the correlates of and risk factors for urinary incontinence in different adult pop-
ulations. Dr. Palmer is the author of award winning books on urinary continence
and is a member of the 5th International Consultation on Incontinence commit-
tee on incontinence in the frail elderly.
Dr. Palmer is a past chair of the Clinical Medicine Section (now Health
Sciences Section) of the Gerontological Society of America and served as chair
of its Fellows Committee. She was a co-convener of the 2010 annual scientifi c
meeting of the Gerontological Society of America. Dr. Palmer is the nurse rep-
resentative to the International Continence Society’s Ethics Committee, and she
serves on the Public Education Committee of the American Geriatrics Society.
Dr. Palmer is an associate editor for the J ournal of the American Geriatrics Society
and serves on the editorial boards of G eriatric Nursing and Clinical Geriatrics . Dr.
Palmer is a fellow in the American Academy of Nursing, the American Geriatrics
Society, and the Gerontological Society of America.
Dr. Palmer received her bachelor of science in nursing and master of sci-
ence degrees from the University of Maryland at Baltimore, her PhD in Behavioral
Sciences and Health Education from the Johns Hopkins University School of
Hygiene and Public Health (now Bloomberg School of Public Health), and a
master of fi ne arts in Creative Writing at Goddard College. She was a senior staff
fellow in the Behavioral Sciences Laboratory of the Gerontology Research Center,
National Institute on Aging, National Institutes of Health from 1994–1996. Honors
include fellowship in the UNC Institute for the Arts and Humanities Academic
Leadership Program, the 2009 American Geriatrics Society Outstanding Service
Award from its Public Education Committee, and the 2009 American Geriatrics
Society and the National Association for Continence “Rodney Appell Continence
Care Champion Award.”