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APHA Scientific Session and Event Listing

Carrie L. Graham, PhD, MGS¹, Holly Brown-Williams², and Susan L. Ivey, MD, MHSA¹. (1) Health Research for Action, School of Public Health, University of California, Berkeley, 140 Warren Hall #7360, Berkeley, CA 94720-7360, 510-643-7143, clgraham@berkeley.edu, (2) Health Research for Action, University of California, Berkeley; School of Public Health, 140 Warren Hall, MC 7360, Berkeley, CA 94720-7360

Transitional care is an emerging concept that refers to care provided to patients as they transition from one health care site to another. It can include care provided during the transition from acute care or skilled nursing care to home and community based care. The concept of transitional care has become increasingly relevant for gerontological researchers and geriatric care providers because older adults are especially at risk for poor outcomes as they transition from once care site to another. Discharging older adults from the hospital or nursing home with inadequate information, training and follow-up care has been identified as a primary reason for poor post-discharge outcomes, including readmissions. Segmented funding streams make it difficult for providers to follow patients moving through different care sites. Certain populations of older adults are especially vulnerable during care transitions, including those with multiple chronic conditions, mental health problems, non-English speakers, recent immigrants, and isolated seniors with no caregivers.

Researchers, providers and policymakers are increasingly looking for cost effective models of transitional care to meet patients' needs when moving from one care site to another. This session provides an update on the state of transitional care in the US. It includes papers that give an overview of the problems associated with care transitions, and presents findings from evaluations of different transitional care models. It also includes a description of one community-based initiative providing transitional care to older adults.

Learning Objectives: At the conclusion of this session, the participant (learner) will be able to

• Identify the major points of breakdown in the care of older adults as they transition across care sites or the continuum of geriatric care.
• Identify the 5 main vulnerable groups particularly at risk for poor outcomes after hospital discharge.
• Describe the main aspects of successful transitional care interventions.

Keywords: Access and Services, Case Management

Presenting author's disclosure statement:

Any relevant financial relationships? No