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Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs

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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.

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Acknowledgments

Contributors

The authors would like to acknowledge Drs. Elizabeth Eckstrom, Hollis Day, and Steve Counsell for their guidance in the preparation of this manuscript.

Funders

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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The authors declare that they do not have a conflict of interest.

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Correspondence to Alicia I. Arbaje MD, MPH.

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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

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