Residential and Health Care Transition Patterns Among Older Medicare Beneficiaries Over Time

Sato, Masayo; Shaffer, T.; Arbaje, Alicia I.; Zuckerman, Ilene H.

doi:10.1093/geront/gnq105

Cited by 33 publications

(24 citation statements)

References 15 publications

(12 reference statements)

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“…1 Almost one-fifth of seniors are re-hospitalized within 30 days of hospital discharge, costing Medicare $17.4 billion yearly. 2 Nationwide, approximately 22 % of older adults experience a transition annually.…”

Section: The Challenge Of Ensuring Optimal Care During Transitionsmentioning

confidence: 99%

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

et al. 2014

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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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Section: The Challenge Of Ensuring Optimal Care During Transitionsmentioning

confidence: 99%

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

et al. 2014

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“…From 1992 to 2007, evidence shows that hospitalization rates refl ect for older adults were approximately four times higher than the general population (Coleman, Min, Chomiak, & Kramer, 2004). Older adults have complex therapeutic regimens during hospitalizations (Anderson & Horvath, 2002), experience adverse events during hospitalizations, and thereby experience more care transitions (Coleman et al, 2004;Sato, Shaffer, Arbaje, & Zuckerman, 2010). For example, older adults are vulnerable to the hazards of hospitalization, including experiencing functional decline and medical complications (such as delirium, adverse drug reactions, pressure ulcers, bowel and bladder dysfunction, malnutrition, and dehydration) (Creditor, 1993;Fernandez, Callahan, Likourezos, & Leipzig, 2008) and thus they are more likely to have increased needs for postdischarge services, transition to postacute facilities, and go home with skilled health care services.…”

Section: The Vulnerability Of Older Adults and Implications For Subopmentioning

confidence: 99%

The Older Person in Transition: <I>Implications for Pathways of Transitions of Care</I>

Arbaje¹,

Boonyasai²,

Dilworth‐Anderson³

2011

annu rev gerontol geriatr

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Older adults face many care transitions and often have diffi culty navigating a complex, fragmented health care system. Health care providers, older adults, and their caregivers face challenges in communicating effectively during care transitions. Suboptimal care during transitions can lead to poor patient satisfaction, clinical deterioration, and unplanned use of health services such as return to the acute care setting shortly after discharge from the hospital. This chapter highlights characteristics older adults bring to the health care experience, with special attention given to those characteristics that make them more vulnerable to transitions of care problems in contrast to other age groups. This chapter also discusses issues that lead to care fragmentation and increased numbers of care transitions among older adults. Lastly, this chapter makes recommendations to address and reduce the fragmentation in care delivery for older adults. Ultimately, the implications for pathways of transitions of care are addressed in this chapter.

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“…Few predominant transition patterns were present; most patterns were unique, which makes predicting (and accommodating) patients' care transitions diffi cult. The heterogeneity of transition patterns of older adults challenges approaches to improving transitions outcomes, as it becomes ineffi cient to plan for all possible care patterns [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

Care Transitions Intervention and Other Non-nursing Home Transitions Models

Bowman

Flood

2015

Geriatrics Models of Care

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Residential and Health Care Transition Patterns Among Older Medicare Beneficiaries Over Time

Abstract: The study provides a description of annual care transition patterns across six years. Knowledge of the consistency of care transition patterns may serve as a baseline from which to compare future patterns and aid in designing interventions targeted at specific transitions.

Cited by 33 publications

References 15 publications

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

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

The Older Person in Transition: <I>Implications for Pathways of Transitions of Care</I>

Care Transitions Intervention and Other Non-nursing Home Transitions Models

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