ABSTRACT
With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care “receivers” and tailoring home care to meet patient needs, (3) building “recovery plans” into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.
REFERENCES
Sato M, Shaffer T, Arbaje AI, Zuckerman IH. Residential and health care transition patterns among older Medicare beneficiaries over time. Gerontologist. 2010;51(2):170–178.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.
Callahan CM, Arling G, Tu W, et al. Transitions in care for older adults with and without dementia. J Am Geriatr Soc. 2012;60(5):813–820.
Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation. BMJ Qual Saf. 2011;20(9):773–778.
Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. NEJM. 1995;333:1190–1195.
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675–684.
Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111(2):179–185.
Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358–1367.
Coleman EA, Smith JD, Frank JC, Min S-J, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817–1825.
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.
Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358–1367.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187.
Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004;1:CD000313.
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary CareA systematic review. Ann Intern Med. 2012;157(6):417–428.
Englander H, Kansagara D. Planning and designing the care transitions innovation (C-TraIn) for uninsured and Medicaid patients. J Hosp Med. 2012;7(7):524–529.
Arbaje AI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist. 2008;48(4):495–504.
Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545–551.
Anderson G, Horvath J. Chronic conditions: making the case for ongoing care. Baltimore: Robert Wood Johnson Partnership for Solutions; 2002.
Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House staff member awareness of older inpatients’ risks for hazards of hospitalization. Arch Intern Med. 2008;168(4):390–396.
Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–223.
Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “she was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16):1782–1793.
Lindquist LA, Go L, Fleisher J, Jain N, Baker D. Improvements in cognition following hospital discharge of community dwelling seniors. J Gen Intern Med. 2011;26(7):765–770.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
Kane RL. Finding the right level of posthospital care: “we didn’t realize there was any other option for him”. JAMA. 2011;305(3):284–293.
Vasquez MS. Preventing rehospitalization through effective home health nursing care. Home Healthc Nurse. 2008;26(2):75–81.
Wier LM, Andrews RM. Hospital utilization among oldest adults, 2008. Rockville: Agency for Healthcare Research and Quality; 2010.
Murtaugh CM, Litke A. Transitions through postacute and long-term care settings: patterns of use and outcomes for a national cohort of elders. Med Care. 2002;40(3):227–236.
Wolff JL, Meadow A, Weiss CO, Boyd CM, Leff B. Medicare home health patients’ transitions through acute and post-acute care settings. Med Care. 2008;46(11):1188–1193.
Madigan EA. A description of adverse events in home healthcare. Home Healthc Nurse. 2007;25(3):191–197.
Rosati RJ, Huang L. Development and testing of an analytic model to identify home healthcare patients at risk for a hospitalization within the first 60 days of care. Home Health Care Serv Q. 2007;26(4):21–36.
Levine C, Albert SM, Hokenstad A, Halper DE, Hart AY, Gould DA. “This case is closed”: family caregivers and the termination of home health care services for stroke patients. Milbank Q. 2006;84(2):305–331.
Fortinsky RH, Madigan EA, Sheehan TJ, Tullai-McGuinness S, Fenster JR. Risk factors for hospitalization among Medicare home care patients. West J Nurs Res. 2006;28(8):902–917.
Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. The Gerontol. 2013;53(3):430–440.
Lindquist LA, Cameron KA, Messerges-Bernstein J, et al. Hiring and screening practices of agencies supplying paid caregivers to older adults. J Am Geriatr Soc. 2012;60(7):1253–1259.
Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474–479.
Schoenborn N, Arbaje AI, Eubank KJ, Maynor KA, Carrese JA. Clinician roles and responsibilities during care transitions of older adults. J Am Geriatr Soc. 2013;61(2):231–236.
Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157(3):207–210.
Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306(15):1688–1698.
Lindquist LA, Baker DW. Understanding preventable hospital readmissions: masqueraders, markers, and true causal factors. J Hosp Med. 2011;6(2):51–53.
DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis: the VA National Center for patient safety’s prospective risk analysis system. Jt Comm J Qual Improv. 2002;28(5):248–267. 209.
Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. 2nd ed. Boca Raton: CRC Press; 2012.
Carayon P, Wood KE. Patient safety - the role of human factors and systems engineering. Stud Health Technol Inform. 2010;153:23–46.
Ms B. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates; 1994.
Dekker S. Patient safety: a human factors approach. 2011.
Givens JL, Selby K, Goldfeld KS, Mitchell SL. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc. 2012;60(5):905–909.
Pronovost PJ, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769–770.
Transitions of Care Measures: Paper by the NTOCC Measures Work Group. National Transitions of Care Coalition. 2008. www.ntocc.org.
Care Transitions: Performance Measurement Set (Phase I: Inpatient Discharges & Emergency Department Discharges). Report from the Physician Consortium for Performance Improvement (PCPI). American Medical Association. 2009. http://www.ama-assn.org.
McDonald KM, Schultz E, Albin L, et al. Care coordination measures atlas. Rockville: Agency for Healthcare Research and Quality; 2010:11-0023-EF.
Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. N Engl J Med. 2011;365(24):2287–2295.
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The authors would like to acknowledge Drs. Elizabeth Eckstrom, Hollis Day, and Steve Counsell for their guidance in the preparation of this manuscript.
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The Association of Specialty Professors provided funding for the conceptualization of priority areas for publication, of which this manuscript is one. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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Arbaje, A.I., Kansagara, D.L., Salanitro, A.H. et al. Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs. J GEN INTERN MED 29, 932–939 (2014). https://doi.org/10.1007/s11606-013-2729-1
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DOI: https://doi.org/10.1007/s11606-013-2729-1