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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #2, #30, #3, #48, #30, #31, #41, #48


Learning Objectives

  • Describe what a care transition is and identify different types of transitions in care commonly experienced by older adults.

  • Understand how health system fragmentation and communication failures lead to poor-quality care transitions.

  • Identify outcomes of poor-quality care transitions and how these outcomes affect patients, caregivers, and the health delivery system.

  • Describe features of effective transitional care and transitional care interventions.

Key Clinical Points

  1. Older adults are at increased risk for experiencing adverse outcomes following poor-quality transitions in care.

  2. Effective communication lies at the core of safe transitions, especially for vulnerable older adults including those with cognitive impairment.

  3. Providers managing care transitions should actively engage both the patient and their identified caregiver in decision making about and in preparing for care transitions.

  4. High-quality transitional care programs can improve posthospital outcomes.


Older adults regularly experience changes in health status that contribute to frequent transitions between different levels and settings of care. These movements within and across care settings are commonly referred to as “transitions in care,” and typically involve the management of a patient’s care passing from one team of providers to another. Transitions in care are widely recognized as a point of heightened vulnerability for lapses in patient safety, as patients are at risk of “falling through the cracks” due to inadequate care coordination, preparation, and support prior to and during the transition period. Inadequate care coordination and management of care transitions contribute to $25 to $45 billion in unnecessary care costs resulting from hospital readmissions and other avoidable complications. Poor-quality transitions in care also contribute to substantial patient and caregiver stress and dissatisfaction. For these reasons, there is a sense of urgency in the United States to improve care management and coordination during transitions in care.

Older adults are at particularly high risk for experiencing adverse events during transitions in care. This is likely due to a number of factors including their disproportionately high rates of utilization of a range of different acute and postacute health services, increasing rates of multiple chronic conditions, and higher rates of cognitive impairment which may limit their ability to communicate or recognize care needs.

This chapter provides an overview of transitions in care commonly experienced by older adults in the United States and discusses “transitional care,” which is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location. Transitional care is an emerging concept in geriatric medicine and is increasingly recognized as fundamental to ensuring safe and effective management of both chronic and acute illness in older adults and necessitates the involvement of all members of ...

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