Partner With Me aids dementia inpatients
Reduced anxiety, better compliance reported
People who have cognitive problems often face difficulties when they are hospitalized. They are in different surroundings, with different schedules, different caregivers. Symptoms of cognitive problems can become more pronounced, agitation worse. They may become violent where before they were not. They may refuse medications or eat poorly. Often, they will not be discharged to home, but will have to go to a long-term care facility.
It was something that bothered Cynthia Barton, RN, MSN, GNP, a nurse practitioner at the University of California, San Francisco hospital’s Memory and Aging Center. "Patients — and their families — just aren’t prepared for that. They are more likely to not go home, they have more functional and cognitive difficulties post-hospitalization than pre," she says. "And if we were uncovering cognitive difficulties for the first time — or if they were getting markedly worse with the hospitalization — the families are so devastated. But we could have predicted this."
She and her colleagues wondered what they could do to prepare them for the potential that hospitalization may change the course of their or their loved one’s disease progression. They also wondered if they could make the hospitalization easier for the patient, the family, and also for providers who might not have extensive experience with dementia patients — there aren’t many orthopedic or other wards specifically for older people with cognitive problems.
Barton figured there were three things to consider. First, to prepare the family for what might change and how they can help. Second, to get information from the patient and family that can help make the hospitalization easier — information such as the bedtime routine, medication-taking tricks, what the patient prefers to be called — and share that with the staff. And lastly, to prepare the staff for patients with dementia and other cognitive problems and how they might respond differently than other patients.
Patients and families are given a prehospitalization checklist of items that can help make hospitalization easier (http://memory.ucsf.edu/sites/all/files/download/Pre-admitPWMfinal.pdf), a paper schedule for visitation with space for names and contact information (http://memory.ucsf.edu/sites/all/files/download/PWMHospSchedfinal.pdf), and a care plan (http://memory.ucsf.edu/sites/all/files/download/PWMchart.pdf).
Volunteers
"We also wanted to develop a specialized cadre of volunteers so that extra work wasn’t put on the nursing staff," Barton says. "That was the linchpin of this." The volunteers are there seven days a week. Many were family members of Alzheimer’s patients, those considering nursing or medicine as a career, retired staff, or Alzheimer’s lab workers; some spoke Spanish and Chinese, which was particularly helpful in the community being served. "The recruiting was amazing."
Training was done by the Northern California chapter of the Alzheimer’s Association, which used the Dementia Friendly Hospital’s Program created by the St. Louis chapter (http://www.alz.org/stl/in_my_community_62183.asp) — Barton notes they did not use the modules on diagnosis and medication, as they weren’t pertinent. "We focused on communication strategies and interactions with people." Staff on the pilot units also received that training. Volunteers also had one-on-one training with the project coordinator.
Volunteers interview the family members and transfer the information to a large laminated sheet that is over the patient’s bed. (For a sample of the questionnaire, see http://memory.ucsf.edu/sites/all/files/download/PWMQuest.pdf.) That provides key information to anyone who walks into the room — the patient’s preferred name, how to get the patient to take her meds, what helps her sleep. Barton has one example of a patient who was refusing her medication over and over. When they finally had the chance to ask a family member — five days later — what might work, they found that just saying, "bottoms up!" would get the pill down the hatch without a hitch. Having that information available at a glance can keep a situation calm, which can make a huge difference to patient, family, and provider.
A video on preparing for hospitalization that the original grant funded (https://www.youtube.com/watch?v=ONK9oDVOUaw) plays on the hospital channel regularly, and it is being presented to all the outpatient clinics at UCSF, too, Barton says. It is shown to preoperative patients, as well, and plays in the emergency department.
Previous literature has shown that this kind of thing works, but there is no hard data on this particular program yet. The initial program enrolled just 37 patients, Barton says. They do have positive comments from patients and families. But she would like for it to be used in enough patients to see if there are fewer readmissions and shorter hospitalizations. Right now, a medical center in San Francisco is considering the program, as is a facility in St. Louis. "I know this is seen as a benefit by families and nursing," she says. For now, that’s enough. They are working to translate the video to Chinese, though, and that would be for a fuller research project.
Not all aspects of the project were workable. They wanted the cheat sheet above the patient bed to be something that could travel with the patient from place to place, so if the patient had to go for a test to another department, the information would go with him, says Barton. They tried putting a little sticker shaped like a brain to indicate that this person has cognitive difficulties, and paper copy of the cheat sheet from above the bed in the chart, "but not everyone knew what that was. Now that we have an entire electronic record, maybe we could build something into the system."
Barton says that partnering with patient and family is something that should always happen, as should tailoring care to the cognitive ability of the patient. But it does not yet. "This makes it so much easier for nurses and patients. If we had known to say bottoms up’ days earlier, think how much stress that would have avoided. For everyone."
Barton gave a speech on the Partner With Me Program that can be seen at https://www.youtube.com/watch?v=jumMIu7s_q0. The program’s forms, links, and guides, many of which are linked above, are all available at http://memory.ucsf.edu/caregiving/hospitalization.
For more information on this topic contact Cynthia Barton, RN, MSN, GNP, Nurse Practitioner, UC San Francisco Memory and Aging Center, San Francisco, CA. Email: [email protected]
