OPTIMISTIC RNs and NPs are responsible for assisting in care delivery, as well as working to support, educate, and train clinical staff so they are able to improve the standards of geriatric medical practice and palliative care in LTC facilities. The RNs and NPs work together on collaborative care reviews (CCRs) for stable but medically complex patients. CCRs use principles of geriatric assessment to define the best care for patients and ultimately prevent them from developing conditions that could lead to unnecessary hospitalizations.
The CCRs include structured interview questions and directions for physical examinations that focus on geriatric syndromes such as cognition and function optimization, medication appropriateness, weight changes, skin problems, falls, vaccinations, and pain. This assessment then guides the RN or NP to seek information from the patient and their family about their care goals. The CCR is then discussed with a project geriatrician and a treatment plan is finalized, then implemented as an order to the family and facility staff. These records and standards are then used as a reference when deciding how to care for these patients in the future, thus making their care more personalized and more likely to be successful.