Journal of General Internal Medicine

, Volume 29, Issue 6, pp 932–939

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

  • Alicia I. Arbaje
  • Devan L. Kansagara
  • Amanda H. Salanitro
  • Honora L. Englander
  • Sunil Kripalani
  • Stephen F. Jencks
  • Lee A. Lindquist
Perspective

DOI: 10.1007/s11606-013-2729-1

Cite this article as:
Arbaje, A.I., Kansagara, D.L., Salanitro, A.H. et al. J GEN INTERN MED (2014) 29: 932. doi:10.1007/s11606-013-2729-1

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.

KEY WORDS

care transitionsgeriatricsutilizationhealthcare deliveryvulnerable populations

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Alicia I. Arbaje
    • 1
  • Devan L. Kansagara
    • 2
  • Amanda H. Salanitro
    • 3
  • Honora L. Englander
    • 4
  • Sunil Kripalani
    • 5
  • Stephen F. Jencks
    • 6
  • Lee A. Lindquist
    • 7
  1. 1.Division of Geriatric Medicine and Gerontology, Department of MedicineJohns Hopkins UniversityBaltimoreUSA
  2. 2.Section of General Internal Medicine, Portland VA Medical CenterOregon Health and Science UniversityPortlandUSA
  3. 3.Vanderbilt University School of MedicineNashvilleUSA
  4. 4.Division of Hospital MedicineOregon Health and Science UniversityPortlandUSA
  5. 5.Section of Hospital Medicine, Division of General Internal Medicine and Public HealthVanderbilt University School of MedicineNashvilleUSA
  6. 6.Consultant in Healthcare Safety and QualityBaltimoreUSA
  7. 7.Section of General Internal Medicine and Geriatrics, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoUSA