Annals of Long Term Care

Introduction
In 2003, over 13.2 million persons age 65 years and older were discharged from hospitals.1 Because of their higher prevalence of frailty and slower period of recovery, the transitional period from hospital to home presents major challenges for older patients and their family caregivers.2,3 The first few weeks after discharge abound with issues in symptom management and personal care.4,5 Close surveillance post-discharge may prevent serious adverse outcomes such as rehospitalization and use of emergency care services for patients, as well as undue caregiver stress and burden for their family caregivers. Because most older adults rely heavily on their family for optimal convalescence at home,6 expanding the focus of surveillance to the patient-caregiver dyad as a unit of care may be a more effective approach. In fact, a recent study about transitions to home conducted by Coleman and colleagues7 showed that coaching of patient–caregiver dyads to ensure that patients’ needs are met after hospital discharge has the potential to reduce the rate of subsequent hospitalizations.

This article describes the geriatrics Post-Hospital Clinic (PHC) recently established for geriatric patients and their family caregivers, and uses case examples to illustrate how the structure and function of the clinic have initially benefited these dyads. In 2008, the PHC officially began as a clinical demonstration project and formal measurement of clinical outcomes such as rehospitalization, use of emergency care services, and medication discrepancies; caregiving preparedness is underway.

Post-Hospital Clinic for Older Patients and Their Family Caregivers
Located at the Durham Veterans Affairs Medical Center in North Carolina, the Geriatric Evaluation and Management (GEM) clinic provides primary care services for approximately 350 older veterans, the majority of whom are age 80 years and older. Given their high rates of comorbid illness and frailty, an average of 2-3 patients require hospital admission each week. These patients are primarily managed by geriatric fellows under the supervision of geriatric faculty, who have clinic sessions one-half day per week. Providers and staff recognized the importance of prompt follow-up appointments for patients with their primary care providers after hospital discharge, but the sheer volume and limited availability of appointments made this a major challenge. This situation served as the primary impetus to develop a complementary service, the PHC, embedded within the GEM clinic to provide a mechanism whereby older patients and their caregivers can be followed within 1-2 weeks after hospital discharge. The primary provider staffing the PHC is a geriatric nurse practitioner (GNP), who recently joined the GEM team with the specific mission of providing prompt hospital follow-ups and improving patient and caregiver education. A social worker, pharmacist, and geriatrician are available to the PHC from the GEM clinic depending on patient and caregiver needs. The PHC is located in the same facility as the GEM clinic and shares the same electronic medical records.

The PHC began in late 2006 (Figure). Because the point of care focuses on the dyad, an hour is allotted for each scheduled visit. The GNP medically evaluates patients, including medication reconciliation, and assesses, educates, and supports the needs of their family caregivers, all necessary components of effective care transitions.8 In the following sections, a brief description of specific interventions is followed by an illustrative case. However, it should be noted that in most situations, dyads received the full spectrum of interventions and, hopefully, garnered the expected benefits.

Prompt Medical Evaluation to Prevent Worsening of Patient Condition
With aging, the capacity for uncomplicated convalescence diminishes.