Assistant professor at the UNC School of Nursing designs innovative solution to help patients and caregivers transition to care at home
After acute hospital care, one in five older adults transfers to a nursing home for three to four weeks of rehabilitation and nursing care before returning home. These frail older adults experience very high risk for poor outcomes at home, and are frequently rehospitalized for recurring medical problems. UNC School of Nursing Assistant Professor Mark Toles, PhD, RN, and his colleagues developed Connect-Home —a group of innovative tools and strategies to support older adults and their caregivers during transitions from the nursing home to home.
A signature trait of Connect-Home is the design to prepare older adults and their caregivers to manage the patient’s serious illnesses. For example, patients must learn new ways to safely move around the house, to care for healing wounds and fractures, and to work with a large health care team. Owing to the complexity of care for multiple illnesses, family members must also learn to participate. For example, both the patient and their caregivers must understand advance care plans, administering medications, scheduled home health care visits, and key questions to explore with the patient’s physicians.
By Nancy LaMontagne from the Carolina Nursing Magazine