Academic journal article Annual Review of Gerontology & Geriatrics

Physical Health Problems: Shaping Transitions of Care

Academic journal article Annual Review of Gerontology & Geriatrics

Physical Health Problems: Shaping Transitions of Care

Article excerpt


In this chapter, we use the ecology of care model to provide a broader view for an older adults transition out of the hospital after a complex illness. Hospitals are required to provide care to various age groups. This requirement is sometimes at odds with the special needs of older adults with physical problems. In the context of this chapter, a physical problem is any new onset illness in a person with preexisting functional limitations. Acute care hospitals are equipped to contain new illnesses. They are not equipped to reengage community-based caregivers (both informal and formal) who provide care once patients with acute illnesses are discharged. With an ecology of care perspective, we can create a larger view that starts and ends outside of the hospital. This view includes patients and their community-based caregivers. To illustrate the utility of this perspective, we discuss three main concepts that shape hospital discharge. The first concept is the process of entering the health care system. The second concept is the process hospitals use to define patients as both a biomedicai case and an administrative case. The third concept is the philosophy governing our payment system. All insurance sources-Medicare included-assume that adults are autonomous, independent consumers of health care. In the health care marketplace, consumers use their cognitive and financial resources to make choices. When one or more of these abilities are limited, the fit between an acutely ill person and the delivery system diminishes. Through application of the ecology of care model, we can help all stakeholders create safer transitions for persons with physical problems.


In the 1910s, the U.S. health care delivery system for persons with physical problems consisted of a physician or public health nurse coming into the home. Treatment options for severely ill older adults were limited. Diagnosis, treatment, and convalescence were ideal outcomes. Unfortunately, many died at home of conditions that we now can treat. Health care was purchased with a combination of money, goods, and services. Any member of the family living in the home participated in around-the-clock caregiving. In the home environment, the person with an illness was the focus of attention. This environment optimized contact between care giver and patient. Persons without family did not fare well.

Over the course of the century, this process radically changed. In 2011, severely ill persons with physical problems are typically required to travel to the site of health care delivery. Care is a commodity shaped by two requirements - the complexity of illness and the payment process. The first challenge for anyone with physical problems is selecting one of the many portals to enter into the health care delivery system. In addition to ones own primary care physician, retail clinics (Bohmer, 2007; Rudavsky & Mehrotra, 2010), intermediate care offices (Mehrotra, Wang, Lave, Adams, & McGlynn, 2008), and hospital emergency departments (Sullivan, Braithwaite, Dietz, & Hickey, 2010) serve as other sites of care.

An emerging business model in the health care delivery system is a retail clinic with a limited menu of services and no commitment to continuity (Scott, 2006, 2007). These retail clinics are often adjacent to a pharmacy, a grocery store, or a big box chain store such as Walmart and many have a board showing prices for minor medical treatments. Persons who can drive a car have the easiest access to these facilities. Intact cognitive function is required to participate in the consumer-directed health care delivered by these clinics. Compromised functional abilities create a barrier to care in this environment. It is not surprising that these facilities are preferred by young adults, families with small children, and middle-aged adults with no more than one or two illnesses or injuries. They are not designed to accommodate acutely ill persons with preexisting multiple medical conditions or functional limitations. …

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