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General Principles in Older Adults

Older adults with chronic illnesses are frequently in contact with the health care system. They periodically require hospitalization for acute exacerbations of chronic illness, falls, infections, and other problems. For these patients, hospitalization often marks the beginning of a journey through a series of disconnected settings and providers. Because of this lack of connection, the journey is not smooth. Mishaps along the way are sometimes insignificant, sometimes even undetected, but others are life altering. The discussion here focuses on how this journey became so complex, the risks of the journey, and the best practices and innovations aimed at minimizing these risks.

Definitions

The term care transition refers the transfer of a patient’s care from one team of health care providers to another. Transitions usually occur when a patient physically moves between sites of care. Care transitions can be grouped into 3 broad categories. The first category, perhaps the most studied, includes community dwellers discharging from the hospital. For example, an older adult may develop a chronic condition for which he receives care from his primary care physician. Exacerbation of the chronic condition might prompt hospitalization, where hospital-based physicians, nurses, and therapists care for the patient. The patient may then move to a skilled nursing facility (SNF) for rehabilitation and/or nursing care and in that setting encounter an entirely new care team. When rehabilitation goals are achieved, the patient may return home, resume care with his primary care physician and may also receive home care from a new team to complete any remaining tasks in recovering from the original exacerbation. In this example, the patient underwent 3 separate transitions in care: primary care provider to hospital provider, hospital to SNF, SNF provider back to primary care provider and to a new home health care team. The second category includes nursing home residents transitioning to and from the hospital. Although many of the problems seen in these transitions are the same as those encountered for community dwellers, additional challenges exist in transitions for these frail, functionally, and often cognitively, impaired patients. Finally, the third category includes patients who are facing the end of life. They often experience multiple transitions in providers in the moves between home, emergency room, and hospital with disease progression. For these patients, again, transitions carry the same risks as those for the community dwellers with chronic diseases, but also special problems come up for those near the end of life. Transitional care broadly refers to time-limited care processes aimed at ensuring safe and minimally disruptive transfers of care between different sites and providers.

Background

The frequency of care transitions may be in part a consequence of changes in the structure and financing of the health care system over the past 30 years. In 1983, faced with ever-increasing costs, Medicare adopted a prospective payment scheme, whereby hospitals were no longer paid individual fees ...

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