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In developed countries the care of complex older patients commonly entails their transfer from one health care setting to another and from one team of providers to another, as their medical and functional needs evolve. In theory, this allows an economical application of specialized resources to be applied at each stage. As an example (Figure 16-1), an elderly woman may be admitted to an acute hospital for diagnosis and initial management of community-acquired pneumonia. After stabilization and initiation of treatment, she is transferred to a skilled nursing facility (SNF) for rehabilitation, continued antibiotic treatment, and close monitoring by nursing. If she decompensates in some manner in the nursing facility (for example, by becoming acutely delirious), she may be transferred to an emergency department (ED) for urgent physician evaluation; rehospitalization may follow. After further diagnostic work and treatment, she returns to the nursing facility to complete her rehabilitative program before finally returning to her home in the community, where a visiting nursing agency assists family in her care. In this sequence her changing care needs prompted physical transfers and encounters with a succession of professionals—hospitalists and acute care nursing in the hospital; then a new provider, nursing, and rehabilitation staff at the SNF; then new providers and nursing in the ED; probably new hospitalists and nurses on her rehospitalization; and finally a new set of nurses, rehabilitation team, and outpatient provider when she returns home. To keep this patient from falling through the cracks, her various providers (and their organizations) must exercise considerable diligence and attention to detail. Active involvement from the patient and her family is necessary as well.

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Figure 16-1.
Graphic Jump Location

Common traffic pattern for older patients undergoing health care transitions. SNF, skilled nursing facility; ED, emergency department.

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This chapter discusses transitional care, the actions taken to ensure coordination and continuity of health care as patients are transferred among various care settings. Good transitional care entails not just the physical transfer of a patient, but the orderly transfer of responsibility of care of the patient as well. The chapter is meant to be of particular use for those clinicians (physicians, physician assistants, and nurse practitioners) charged with direct responsibility for managing care transitions.

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For a number of reasons, the challenges of transitional care appear to be growing in the United States. Compared to the situation faced by physicians a century ago, our patients are much older, with longer problem (and medication) lists, and greater functional disability. Families may live in other cities and offer little ability or willingness to provide care at home. Health care venues have proliferated and become specialized. Typical care settings found in many large American cities are listed in Table 16-1. Providers themselves have also become more specialized, and in some instances (as with hospitalists, intensivists, SNFists, or emergency medicine physicians), their specialty is defined by the setting in ...

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