Good Communication is Vital to Improving Care Transitions in Frail Geriatric Patients

April 1, 2021
April 1, 2021

This is the second of two blog posts based on a recent webinar discussing the new learning module created by HealthStream and the Duke School of Nursing and School of Medicine about how to optimize inter-professional frail elder care. This post is based on remarks by Dr. Mitchell Heflin, an associate professor of medicine at the Duke School of Medicine and senior fellow in the Center for the Study of Aging and Human Development.

What’s in my patient’s best interest? My colleague Dr. Eleanor McConnell and I partnered with HealthStream and about 20 Duke Health faculty members over the last year to explore the best interests of elderly patients. Based on our findings, HealthStream created an online learning program for inter-professional teams who care for frail elders.

Our study group found that older adults face great challenges in four major areas: transition of care, medication management, delirium, and malnutrition. We identified gaps in the training and education of care providers related to each of these and set out to develop a new learning model to address them.

We acknowledge the importance of evidence, experience, and expertise, but we also place a premium on listening and eliciting the patient’s values and preferences. Using video examples, we offer practical language for inter-professional communication, along with ways to elicit information from the patient.

Simply stated, it’s critical to take stock of what patients and families really want. Every member of the care team must be empowered to listen to patients and families and communicate what they’ve heard, especially during the transition of care.

Transition of Care

In one video, the patient, Mr. Taylor, is clearly upset after hearing he will soon be discharged from the hospital. A CNA attending to his care elicits key information by expressing empathy, saying, “You look tired today, Mr. Taylor.” Mr. Taylor explains that he faces tough decisions with his transition from the hospital to home. The conversation that follows demonstrates the power of relying on the full capacity of every member of the inter-professional team.

Through a few simple comments and questions, the CNA initiates a critically important exchange where we learn of Mr. Taylor’s concerns about going home and getting better, as well as other clues that will inform planning for his post-acute care needs. The CNA in the video plays a critical role in building a relevant and effective treatment plan by using effective language and listening carefully to the patient. Communication across the team is at the core of person-centered care in each of our decision-making modules.

Medication Management

Safe and appropriate medication management is another key to transitions of care. This accounts for safe choices of medications, ready access, and determining a system for delivering those medicines appropriately and on time during the next phase of care.

Patient and family education is essential to medication management. Examples include teaching about medicines, determining who can help to organize medicines in a pillbox, contacting the pharmacy that will be dispensing medications, and explaining how the patient or family can reach back to the team with questions. A video offers a glimpse of a teach-back session.

Using the teach-back method, the provider asks Mr. Taylor to recount his understanding of his medications. Mr. Taylor does well at this, but there are a few important exceptions that require some correction and explanation. It’s a simple correction with important ramifications for his personal safety. While teach-back during the visit requires stopping and listening to the patient, it’s a very efficient way to assure safety.


Rates of delirium are as high as 50% in hospitalized older adults. In the video example, we're initially unsure about Mr. Taylor’s clarity of thinking, because we haven’t spoken with him. His age and medical problems, however, put him at high risk. Because cognitive problems are often missed, the whole team must work together to reduce the risk or manage the condition. We have a whole set of modules that introduce this team-based approach across care settings.

Whether the patient is transitioning to skilled care or home, the entire team must understand the importance of addressing sensory deficits, maintaining a sleep-wake routine, getting the patient out of bed, and encouraging normal eating and drinking.


A third of older adults in the general population are malnourished; in institutional settings or among those recovering from or suffering from acute illness, virtually all of them have problems with malnutrition. Social isolation, depression, and cognitive impairment contribute to poor nutrition, as do limited transportation, financial constraints, and difficulty preparing food.

Malnutrition is a complex phenomenon requiring assessment by the whole team and the participation of the patient and family. The module teaches adaptive practices, such as hand-over-hand or hand-under-hand feeding and other techniques to help caregivers provide for older adults.

Listen to the full Webinar here.