Transitional Care Recommendations

Aging Today, March/April 2007 | Go to article overview

Transitional Care Recommendations


Following are key recommendations from the study From Hospital to Home: Improving Transitional Care for Older Adults by Health Research for Action at the University of California, Berkeley, School of Public Health. More detailed discussions are available at www.uch ealthaction.org/eldercare.html.

* Increase public awareness of transitional care issues for older people by educating elders and their families about the risks of hospitalization and care transitions.

* Begin discharge planning before hospitalization when possible. Review and update the plan at admission, before discharge, 72 hours after discharge, and at intervals up to six months after discharge.

* Integrate risk and needs assessment for both patients and caregivers into discharge planning, including medical, psychological, social and environmental factors.

* Improve transitional care coordination by assigning hospital staff or volunteers to follow up with patients after discharge to ensure that they are getting needed services.

* Make transitional care a priority of professional associations and health systems. Government agencies should prioritize oversight of transitional care to ensure consistency.

* Develop materials for older adults and caregivers to help them navigate the system of care during and after a hospital stay.

* Create care support centers in hospitals, where patients and caregivers can find educational programs and online resources, connect with volunteers and get referrals to community-based services.

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