Continuing care for older patients during the transitional period

Abstract

Abstract Background The world is facing increasing pressure with the continuous growth of the older population. Older patients are usually discharged with complex medical problems, high stress and vulnerability, and these factors place the elderly at risk for poor outcomes. Purpose The present review summarizes a method for providing appropriate and affordable health services by nursing professionals to meet older patient's health care needs during their transitional period which is defined as a period from discharge after hospitalization for a major disorder to recovery in a home setting. Summary Older patients with chronic diseases need seamless health care during a transitional period-a highly stressful and vulnerable period for them. Nurse professionals can conduct decent discharge planning to assist older patients with transitional problems through continuous healthcare. This review summarized the need of continuing care for older patients during the transitional period, the definition of discharge planning, the conceptual framework of discharge planning, and the professionals involved in discharge planning. It also highlights the problems of discharge planning and follow up intervention implementation in the mainland of China. Clinical implications Inadequate discharge planning and follow-up were leading factors associated with the readmission of discharged older patients. Further nursing-led discharge planning should be reinforced in China.