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APHA Scientific Session and Event Listing

Carrie L. Graham, PhD, MGS¹, Holly Brown-Williams², Susan L. Ivey, MD, MHSA¹, and Winston Tseng, PhD¹. (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

Background: Older adults are increasingly discharged from the hospital in weaker condition and with greater post discharge needs. Poor discharge planning and lack of communication across care sites makes transitioning from hospital to home especially dangerous for frail older adults. The Hospital to Home study is a regional assessment of the transitional care needs of culturally and economically diverse older adults living in the San Francisco bay area.

Methods: This mixed methods study assessed the needs and barriers to care faced by older adults and their caregivers as they are discharged from the hospital and adjusting to life at home. Qualitative data includes: 20 focus groups with informal caregivers who recently assisted a care recipient home from the hospital; 4 focus groups with registered nurses and social workers; and 5 case studies of patients in the process of transitioning out of acute care settings. Mixed method data included: 40 key informant interviews with geriatric care providers and 17 key informant interviews with policy makers.

Results: In-depth qualitative findings identify major gaps in care for older adults as they transition from the hospital to home- and community-based services. The research included a special focus on identifying vulnerable groups and the needs of informal caregivers. The particular issues facing racial/ethnic minorities, non-English speakers, isolated seniors and LGBT seniors were also examined. Recommendations for changes in policy and practice will be presented.

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

• Identify 4 groups of older adults most at risk for poor outcomes after hospital discharge.
• Identify the major points of breakdown in the care of older adults as they transition across care sites.
• Articulate the 3 main policy changes to address the transitional needs of older adults.

Keywords: Ethnic Minorities, Access to Care

Presenting author's disclosure statement:

Any relevant financial relationships? No