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Penn Nursing Leads the Way with Improved Care Model for Veterans

Work by Penn Nursing’s Mary Ersek, Joan Carpenter, and Stephanie Oram aimed at improving care for veterans through a holistic and integrated approach will be put into action in VA Community Living Centers across the country.

The work of Penn Nursing’s Mary Ersek, PhD, RN, FPCN as well as post-doctoral fellow Joan Carpenter, PhD, CRNP, ACHPN and project manager Stephanie Oram, is about to be put into action when a new family-staff Partnership Program aimed at improving care across the network of 135 nursing homes owned and operated by Veterans Affairs, also known as VA Community Living Centers (CLC), launches early next year. Through establishing care goals that both direct day-to-day care decisions and life sustaining treatment and preferences, the Partnership Program will enhance resident outcomes using a holistic and integrated approach.

Promoting person-centered care (PCC) through family and staff collaboration, the VA CLC Partnership Program will carefully consider the following: residents’ preferences and interests, prior to the onset of dementia, via the families’ knowledge, previous conversations, and/or existing advance directives; the family’s knowledge; and staff’s observations of behaviors that may either reflect preferences and/or assist in the understanding of dementia-related behaviors.

Those with the greatest opportunity to interact with residents, like family members or nursing assistants, will take on central roles in an interdisciplinary team (that might also include a primary-care provider and social worker among others) that explores causes of distress and quality of life. Then, based on knowledge of residents’ life experiences, values, and preferences, the CLC Partnership will work to establish a care plan that best serves the residents’ needs.

The Partnership program is one of three projects funded through the Implementing Goals of Care Conversations with Veterans in VA Long-Term Care (LTC) Settings grant as part of the Quality Enhancement Research Initiative (QUERI), and is set to formally begin at the Coatesville and Philadelphia VA CLCs in January 2017, with expansion to other CLCs in Pennsylvania, Ohio, and possibly Michigan, thereafter.