Care Transitions For Older Adults Research Articles

Caregivers' burden of care during emergency department care transitions among older adults: a mixed methods cohort study.

Improving care transitions for older adults can reduce emergency department (ED) revisits, and the strain placed upon caregivers. We analyzed whether caregivers felt a change in burden following a care transition, and what may be improved to reduce it. This mixed-methods observational study nested within LEARNING WISDOM included caregivers of older patients who experienced an ED care transition. Burden was collected with the brief Zarit Burden Interview (ZBI-12), and caregivers also commented on the care transition. A qualitative coding scheme of patient care transitions was created to reflect themes important to caregivers. Comments were randomly analyzed until saturation and themes were extracted from the data. We followed both the SRQR and STROBE checklists. Comments from 581 caregivers (mean age (SD) 64.5 (12.3), 68% women) caring for patients (mean age (SD) 77.2 (7.54), 48% women) were analyzed. Caregivers overwhelmingly reported dissatisfaction and unmet service expectations, particularly with home care and domestic help. Communication and follow-up from the ED emerged as an area for improvement. Caregivers who reported an increased level of burden following a patient's care transition had significantly higher ZBI scores than caregivers who self-reported stable burden levels. Caregivers with increasing, stable, and improved levels of subjective burden all reported areas for improvement in the care transition process. Themes centering on the capacity to live at home and inadequate communication were most frequently mentioned and may represent serious challenges to caregivers. Addressing these challenges could improve both caregiver burden and ED care transitions.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments

ObjectiveImproving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions.MethodsThe LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR).ResultsComments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic.ConclusionPatients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

Too Many Walls and Not Enough Bridges: Care Transitions Models to Support Older Adults with Mental Illness and Cognitive Impairment

Challenges in transitions of care can lead to increased morbidity, mortality, and increased health care costs. In particular, older adults with mental illness (MI) or cognitive impairment (CI) are particularly vulnerable when transitioning from different health care settings and back to the community. For instance, almost half of older adults with cognitive impairment who are discharged home from the emergency department return within 30 days. Similarly, older adults with MI and CI admitted to a skilled nursing facility are less likely to be discharged and, if discharged, spend less time in the community. Importantly, these outcomes mediated by the presence of depression, agitation, and functional impairment, highlighting the need for interventions that provide symptom management and address frailty.Some interventions have been shown to improve transitions from acute care to post-acute care. The Institute for Health Improvement Age Friendly Health System Initiative incorporates the 4 M model of what matters most, mobility, medications, and mentation framework in order to bring to together evidenced based initiatives that improve safety and outcomes for older adults. These interventions embed comprehensive geriatric care throughout the care continuum: hospitals, transitions out of hospitals, and post-acute and long-term care facilities. Other interventions have utilized home visits upon discharge to minimize readmission and increase time at home. Less is known about initiatives which address the role of subspeciality care and community-based organizations (CBOs) in maintaining older adults with MI and CI in the community.Montefiore Einstein is a fully integrated academic health system including 11 hospitals including a rehabilitation hospital, 65 primary care sites, 18 mental health/ substance abuse treatments clinics, a care management organization, and a home health program. Montefiore's Center of Excellence for Alzheimer's Disease (CEAD) has successfully expanded the delivery of comprehensive, high-quality, cost-effective care for people with CI. The CEAD is staffed with board-certified neurologists, geriatricians, psychiatrists, neuropsychologists and social workers. Our focus on the early diagnosis of Alzheimer's disease and related dementias helps patients and their caregivers prepare for the future and better manage the cost of care, potentially avoiding costly, unnecessary emergency room visits and hospitalizations. It was also recently designated an IHI-designated Age Friendly system. Montefiore Home Care (MHC), established in 1947, is the nation's first hospital- based certified home health agency. 40% of homebound older adults have MI and CI but have limited access to appropriate evaluation and treatment. Accordingly in 2004, MHC developed a consultative geriatric program in collaboration with the Division of Geriatric Psychiatry to provide comprehensive social work and geriatric psychiatry assessments in the home after discharge from hospital. In addition to the collaboration with MHC, Montefiore Division of Geriatric Psychiatry has leveraged foundational funding to collaborate with CBOs to bring evidence-based mental health services to seniors over the past two decades.During this session, presenters will describe several ongoing and new Montefiore initiatives to address care transitions for older adults with MI and CI. Dr. Zwerling will describe how the CEAD is spearheading the transition for Montefiore Einstein to an Age Friendly system. Ms. Korenblatt will highlight how the MHC Geriatric Psychiatry Program social work team serves as a bridge between acute care and CBOs to minimize hospital readmissions. Finally, Dr. Ceïde will highlight a specific example of an evolving partnership with one specific CBO in order to maintain older adults with MI and CI in the community.

Recommendations for improving care transitions for older adults with hip fracture

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Navigating Care Transitions for Older Adults in the Emergency Department When a Social Worker is Unavailable

Some Emergency Departments do not have social worker staffing to assess high- risk older adults who have been identified. This is of particular concern in during care transitions for older patients who are at risk for poor health outcomes. We describe triggers for the emergency provider to recognize older patients at high risk and bundles of appropriate services and community supports to mitigate risk.

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada

BackgroundOlder adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture.MethodsThis descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically.ResultsA total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings.ConclusionsOur findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

Reporting and analysis of Sex and Gender in Transitions of Care for Older Adults: A Methods Study

Objectives: Sex and gender based analysis may improve understanding of transitions from long term care to community or health services. Our study aims to assess how sex or gender was reported and analyzed in studies about care transitions for older adults.
 Methods: We identified longitudinal studies from a 2017 scoping review on factors affecting care transitions of older adults (participants 60 years and older) and assessed transitions from long-term care to community or health services. We used a pretested coding sheet to assess the reporting of sex or gender in 5 sections of the studies: title and abstract, introduction, methods, results, and discussion.
 Results: We included 20 longitudinal studies conducted in 3 countries (United States, Germany, and Finland ) with the study durations ranging from less than 1 year to 10 years. Almost all of the studies reported sex distribution of the sample (18/20; 90%). Sex or gender was discussed in the background and rationale by three out of 20 studies (15%). Twelve studies (60%; 12/20) planned to control for sex or gender in their statistical analysis. Association of sex with outcomes was reported by 45% (9/20) and 3 studies (15%; 3/20) provided disaggregated data on sex or gender.
 Conclusion: Almost half of the studies assessing transitions from long-term care to community or health services did not control for sex or gender in their statistical analysis. This may be a missed opportunity for understanding potential sex or gender differences in transitions in care for older adults.

What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study.

BackgroundOlder adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.ObjectiveThis protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology.MethodsThe study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs.ResultsThis project is underway and expected to be complete by Spring 2024.ConclusionsGiven the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels.Trial RegistrationClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192International Registered Report Identifier (IRRID)PRR1-10.2196/20220

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives.

Introduction:Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.Methods:The study used a qualitative design in two phases: 1) semi-structured interviews, 2) one focus group. The setting comprised one public health network and five community services in urban Australia. In Phase 1, health practitioners across settings were interviewed about their experience of transitional care. Phase 2 sought feedback about the Phase 1 findings from different practitioners. All data were thematically analysed.Findings:In Phase 1), 48 healthcare practitioners were interviewed across multiple settings. Few participants were aware of the introduction of consumer-directed care in community aged care. Four main themes were identified: ‘Rapid and safe care transition’, ‘Discussing as a team’, ‘Questioning the discharge’, and ‘Engaging patients and carers’. In Phase 2), seven participants from different settings reviewed and endorsed the findings from Phase 1.Discussion and conclusions:Findings indicate that healthcare practitioners use a range of communication and coordination processes in optimising integrated transitional care. Although participants involved their patients in transitional care planning, most participants were unaware of the recent implementation of consumer-directed care. In contexts of community-based care shaped by multidisciplinary, sub-acute and CDC models, care integration must focus on improved communication with patients and carers to ascertain their needs and to support their increased responsibility in their care transitions.

EXPLORING OLDER ADULTS’ EXPERIENCES IN CARE TRANSITIONS

Older adults are Canada’s largest growing demographic. Later adulthood is frequently accompanied by increased comorbidities, resulting in more people living with chronic conditions for longer portions of their lives and requiring care across multiple settings. These individuals are also the most susceptible to challenges within health care systems, especially during vulnerable times such as care transitions, which can be challenging due to issues of care integration and coordination. A scoping review was conducted to explore the experiences of older adults transitioning through various levels of care. The main themes found included personal realizations, social connectedness, importance of navigating the system and recommendations for the future. During care transitions, older adults must carefully consider their personal circumstances and limitations and often accept a new baseline, thus, adapting their lives and activities to match possible limitations. Older adults indicate the need for strong social networks, accessible and available services, as well as effective communication, information, education and engagement during care transitions. Issues with care transitions can be exacerbated in smaller communities, where resources and services may be limited. As such, this scoping review is the foundation for an ongoing systematic review which aims to summarize what is known about care transitions for older adults living in small and rural communities. By better understanding the different interacting factors that might influence care transitions for older adults living in small communities, important and sustainable changes can be identified and implemented to ensure that care transitions for older adults are safe, positive and empowering.

Involvement of Acute Care Physical Therapists in Care Transitions for Older Adults Following Acute Hospitalization: A Cross-sectional National Survey.

Recent evidence has suggested physical therapist involvement in care transitions after hospitalization is associated with reduced rates of hospital readmissions. However, little is known about how physical therapists participate in care transitions for older adults, the content of care communications, and the facilitators and barriers of implementing evidence-based care transition strategies into practice. Thus, the purpose of this article is to evaluate participation in care transition activities known to influence readmission risk among older adults, and understand perceptions of and barriers to participation in these activities. We developed a survey questionnaire to quantify hospital-based physical therapist participation in care transitions and validated it using cognitive interviewing. It was introduced to a cross-sectional national sample of physical therapists who participate in the Academy of Acute Care Physical Therapy electronic discussion board using a SurveyMonkey tool. More than 90% of respondents agreed they routinely recommended a discharge location and provided recommendations for durable medical equipment for patients at the time of hospital discharge. Respondents did not routinely initiate communication with therapists in other care settings, or follow up with patients to determine whether recommendations were followed. A majority of respondents agreed their facilities would not consider many key care transition activities to count as productive time.This survey provides a novel insight into how hospital-based physical therapists participate in care transitions. Communications between rehabilitation providers across care settings are infrequent, even though those communications are recommended to help reduce readmissions. However, administrative barriers were elucidated in this study that may help explain lack of therapist involvement. Physical therapists' communications across health care setting about older adults discharging from acute care hospitalization are infrequent, but may represent a meaningful intervention target for future studies. Future research is needed to evaluate best practices for hospital-based physical therapists during care transitions.

The Role of Rehabilitation Professionals in Care Transitions for Older Adults: A Scoping Review

Aim: To identify existing theories and conceptual models that inform care transition interventions and to explore whether the role of rehabilitation professionals is explicitly stated or implied in these theories and models.Methods: We searched multiple databases and included articles published from 2000 to 2018, with distinct mention of care transitions of older adults (>65 years) from one care setting to another.Result: Two theories (Middle Range Theory and System of Care Philosophy), and six conceptual models (Coleman’s Model, 4Cs of Transitional Model, Quality Cost Model of Advanced Practice Nurses Transitional Care, Health Belief Model, Care Transition Framework, Ideal Transition in Care) were identified in 13 of the 21 articles; however, only one conceptual model in an opinion paper illustrated the role of a physiotherapist in care transition.Conclusion: Most of the models, frameworks and theories that inform care transition interventions did not explicitly consider the role of RPs.

What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS?

Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.

Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review.

ABSTRACTIntegrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.

AGS Clinician of the Year Brings International Perspective to Elder Care, Teaching

AGS Clinician of the Year Brings International Perspective to Elder Care, Teaching

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community.

Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions.

Design and Evaluation of a Prelicensure Interprofessional Course on Improving Care Transitions

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

The Adverse Reactions to Care Scale: Identifying and Measuring Triggers During Transitions in Care

Transitions in care tend to be difficult and complicated periods for older adults, families, and staff in long-term care facilities. For some older adults, care activities and care environments in facilities can lead to adverse reactions, such as resisting assistance with care or agitation and anxiety. Unfortunately, current tools do not adequately assess for triggers to such behaviors. In the current study, the 8-item Adverse Reactions to Care (ARC) scale was developed and tested with 89 older adults and their caregivers (N = 89). Exploratory factor analysis revealed the ARC scale loaded onto two distinct factors: (a) reactions to care activities and (b) reactions to care environments, with high overall reliability (alpha = 0.84). With additional testing, the ARC scale may be useful for clinicians in long-term care settings and for researchers focused on understanding care transitions for older adults.