Transitional Care

Abstract

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings.1, 2 High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and move frequently within health care settings.3–6 A growing body of evidence suggests that they are particularly vulnerable to breakdowns in care and thus have the greatest need for transitional care services.7–10 Poor “handoff” of these older adults and their family caregivers from hospital to home has been linked to adverse events,11–13 low satisfaction with care,14–16 and high rehospitalization rates.2, 17, 18 Many factors contribute to gaps in care during critical transitions.2 Poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care all contribute. Language and health literacy issues and cultural differences exacerbate the problem.2 (See “Culturally Appropriate Care,” on page 30, for more about culture’s effects on health care.) Family caregivers play a major—and perhaps the most important—role in supporting older adults during hospitalization and especially after discharge. Until recently, however, little attention was paid to family caregivers’ distinctive needs during transitions in care. Consequently, family caregivers consistently rate their level of engagement in decision making about discharge plans and the quality of their preparation for the next stage of care as poor.19 Caregiving can be rewarding, but it can also impose burdens on family caregivers.20 The stress of caregiving is likely to be exacerbated during episodes of acute illness. Nurses and social workers need to attend to the emotional needs of caregivers during transitional care to help minimize their negative experiences and to enhance their ability to support their loved ones.