Date of Award

Summer 6-11-2022

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Dr shin, Chanam

Faculty Reader

Professor Pam Davies

Executive Summary

Executive Summary

Background and Significance: In 2015, the rate of Emergency Department (ED) visits for adults 65 and over in the United States had increased from 53,833 to 56,803 per 100,000 (Kwiatkowski & Gyurmey, 2019). Among older adults with multiple chronic health conditions, increased ED visits and hospital admissions are associated with fragmented and uncoordinated care, which is often accompanied with unfulfilled and delayed services (Béland et al., 2006; Bird et al., 2007). In addition, increased ED visits and hospital admissions are associated with functional decline and loss of independence (Calderón-Larrañaga et al., 2019; Courtney et al., 2009).

Problem and Purpose Statement: Functional decline and loss of independence associated with fragmented and uncoordinated care often cause the need for complex care and prolonged hospitalization, which can result in an increase in burden of care and health care costs (Calderón-Larrañaga et al., 2019; Courtney et al., 2009). All these factors can contribute to low the quality of life (QOL) for these older adults. The purpose of this project was to evaluate the AgingOptions’ LifePlanning (LP) program in order to improve the structure of the program and the process in delivering services.

Methods: For the quality improvement project, self-administered questionnaires were collected by email or in-person, from six participants who were the AgingOptions client’s family member or healthcare proxies (HP). The collected data were analyzed using Statistical Package for the Social Sciences (SPSS) software.

Results/Outcomes: Most of the participants (70%) reported that the clients had increased follow-up care with a geriatric-focused primary care physician or geriatric nurse practitioner with improved satisfaction in their QOL, and their families had experienced a perceived reduction in the burden of care. Overall, the LP program consisting of integrated care with multidisciplinary team (i.e., an attorney, a financial officer, a geriatric care manager, and a geriatric provider) was helpful for clients to fulfill their wishes and needs in health, family burden, and their satisfaction in QOL.

Sustainability: For the sustainability of the program, periodical program evaluations should be maintained. A recurrent evaluation will provide an opportunity to improve the program by identifying the factors that were effective and those that were not.

Implications for Practice: The results of this project might be helpful for professionals and organizations in guiding the care for older adults who need life planning. In addition, the findings of this project might provide a glimpse into future improvements of the LP program by ensuring the client’s communication and understanding of the contents of the LP process.


Béland, F., Bergman, H., Lebel, P., Clarfield, A. M., Tousignant, P., Contandriopoulos, A. P., & Dallaire, L. (2006). A system of integrated care for older persons with disabilities in Canada: Results from a randomized controlled trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 61(4), 367-373.

Bird, S. R., Kurowski, W., Dickman, G. K., & Kronborg, I. (2007). Integrated care facilitation for older patients with complex health care needs reduces hospital demand. Australian Health Review, 31(3), 451-461.

Calderón-Larrañaga, A., Vetrano, D. L., Ferrucci, L., Mercer, S. W., Marengoni, A., Onder, G., Eriksdotter, M., & Fratiglioni, L. (2019). Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways. Journal of Internal Medicine, 285(3), 255–271.

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24‐week exercise and telephone follow‐up program. Journal of the American Geriatrics Society, 57(3), 395-402.

Kwiatkowski, J., & GYURMEY, T. (2019). Program of All-Inclusive Care for the Elderly (PACE): Integrating health and social care since 1973. Rhode Island Medical Journal, 102(5), 30-32.