Building Teams and Bridges to Healthy Transitions (P24)

Abstract

1.Apply principles of palliative care to transitional care and care coordination initiatives.2.Analyze barriers to and facilitators of effectivecare transitions programs in selected settings.3.Propose strategies to measure the effectiveness of palliative care-based transitions programs. By far, hospital care accounts for the greatest cost to the Medicare program. Reducing hospital readmission has become a target of payment reform as well as quality improvement. Numerous care coordination initiatives have been tested with cohorts of complexly ill older adults at high risk for hospital readmission. To date, there is no single approach that has been shown to be effective across all care delivery settings and populations. Most models have focused on coordinating transitions from hospital to home; there is considerably less evidence regarding transitions across other settings, such as skilled nursing to home. Moreover, there is growing evidence that supports an overemphasis on professionals’ roles and responsibilities paired with under appreciation of the lived experience of chronically ill older adults in communities. Increasingly, palliative care is being viewed as a viable approach to supporting safe transitions—across populations, locations, and goals for care. Using case studies from projects in progress, this session will demonstrate how palliative care can be used to structure effective care transitions approaches, engage formal and informal networks in the community, and tailor and evaluate interventions. Faculty will suggest avenues for future research, program development and policy. HPNA sponsored