Models of Care to Transition from Hospital to Home

Abstract

The American Geriatrics Society has defined transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.” A care transition represents a vulnerable time for older adults, especially those experiencing cognitive or functional impairment, low health care literacy, complex multimorbidity, or lack of caregiver support. There is an imminent need to identify seniors at risk for an adverse transitional care event who would benefit from targeted strategies to improve outcomes. Outcomes from newly developed transitional care interventions are promising. These models incorporate common themes, including a patient-centered approach, aggressive medication reconciliation, patient coaching, and a formalized process for transfer of information across care settings. New Medicare rules also support the feasibility of implementing a care transitions intervention. The future will likely see the growth of these models in addition to the use of new health information technologies as well as interventions originating from sites of care other than hospitals.