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Older Adults and Care Transitions—Improving Outcomes

April 1, 2021
April 1, 2021

This blog post is based on a HealthStream article, The Transition of Care Across the Continuum: Optimizing Care for Older Adults.

After being released from the hospital, one of five Medicare beneficiaries will be readmitted within 30 days. It has been estimated that this pattern of recurrence comes at a cost of $2.6 billion annually; as many as 75% of these readmissions could possibly be avoided. Poor transitions of care are an important part of the problem.

Defining Frailty

An important first step in determining the care plan for an older patient is to assess whether the patient is frail, which can have a serious impact. According to Dr. Eleanor McConnell, director of the Centers for Excellence in Geriatric Nursing Education at Duke University, “Frailty increases the risk of falls and fractures, disability, hospitalization, complications after surgery, and even death. Determining frailty early in a hospitalization helps clinicians address the root causes of falls, disabilities, or complications, and allows them to make better plans for post-hospital care,” says McConnell. “Frailty, in combination with other risk factors, increases an older patient’s vulnerability to a difficult transition of care and re-hospitalization.”

Care Transitions and Vulnerability

In addition to frailty, says McConnell, “Older patients are more vulnerable during transitions of care because they may have poor health literacy, decreased social support, functional impairment, and or medical problems, such as coexisting chronic medical problems.”

Study participants saw a need to increase the care team’s confidence about speaking up at the time of discharge regarding concerns they may have. The module seeks to improve team knowledge and provide caregivers with the tools they need to achieve a more effective transition of care.

The National Transition of Care Coalition has defined seven intervention categories. Patient-and family-focused interventions include medication management, transition care planning, and patient and family engagement and education. Provider-focused interventions include information transfer, follow-up care, healthcare provider engagement, and shared accountability across organizations.

A Shared Framework for Caregivers

Inter-professional cooperation while caring for older adults is essential. “While care providers should rely on their experience and expertise, they should also operate within a shared framework that includes understanding the patient’s values and preferences, relying on best practices and available evidence, and setting realistic goals of care with the patient and family,” says Dr. Mitchell Heflin, associate professor of medicine at the Duke School of Medicine and senior fellow in the Center for the Study of Aging and Human Development.

“All team members should be encouraged to engage the patient by listening and questioning. It’s also important to tap into the capabilities of every team member,” says Heflin. “A few simple questions from the CNA, for example, can lead to a very important exchange, with the patient revealing important information about his or her concerns. If the CNA is empowered to speak up to the rest of the team, this will inform decision-making about the patient’s transition of care. Listening to the patient helps the team develop a care plan that addresses the patient’s goals and preferences,” Heflin explains. 

“A point person should be designated, typically one of the practitioners, to guide the interprofessional team and coordinate the transition appropriately. This point person can help formalize transition planning tools, including a transition summary, and make sure the plan is focused on the patient’s needs,” adds Heflin.

Module Now Online

HealthStream’s acute care Transitions of Care module is online now, with modules addressing other settings to follow. Each starts with a confidence survey and ends with a knowledge assessment. Upon successful completion, the participant receives an inter-professional frail elder care certificate, awarded from Duke Health.