Journal
JOURNAL OF GENERAL INTERNAL MEDICINE
Volume 29, Issue 6, Pages 932-939Publisher
SPRINGER
DOI: 10.1007/s11606-013-2729-1
Keywords
care transitions; geriatrics; utilization; healthcare delivery; vulnerable populations
Funding
- Association of Specialty Professors
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With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care receivers and tailoring home care to meet patient needs, (3) building recovery plans into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy. (C) Society of General Internal Medicine 2014
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