Academic journal article Generations

What Does "Care Transitions" Really Mean?

Academic journal article Generations

What Does "Care Transitions" Really Mean?

Article excerpt

What are care transitions, how have they evolved, why does America's healthcare system render these transitions problematic, and what might the future hold for better, improved care?

Care transitions, or the movement of patients between one care setting or care provider and another, are fraught with opportunities for complications and breakdowns, which impact patients and their families, care providers, and ultimately the system as a whole. To be effective, care transitions must involve the healthcare system as well as long-term services and supports (LTSS), which include community-based service providers. Currently, these two systems rarely interact, as illustrated by the case study of Mrs. Harrison (page 7).

While consumers, providers, policy makers, and other stakeholders are talking more and more about care transitions, the phrase does not mean the same thing to all people. The American Geriatrics Society (Coleman and Boult, 2003) defines care transitions as:

...a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.... Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

Much of the work on transitions of care has only just begun to evolve into care initiatives that seek to address transitions issues via systematized processes. Many models have been developed and researched to provide transitional care services and are described in great depth in this issue of Generations, including the Care Transitions Intervention (Coleman et al., 2006), the Transitional Care Model (Naylor et al., 2004), Project RED (Re-Engineered Discharge) (Project RED, 2012), the Enhanced Discharge Planning Program, also known as Bridge (Altfeld et al., 2012), and Better Outcomes for Older Adults through Supported Transitions, or Project BOOST (Williams and Coleman, 2009).

To understand the value and impact of these programs, it is important to examine how we got to this point in the care transition discussion; the present state of our healthcare system that makes transitions problematic; and what the future might hold, should care transitions improvements become commonplace.

The Healthcare System and the Evolution of Care Transitions

Traditionally, the U.S. healthcare system has been focused on acute care needs, which have been served with acute care tools. It was created to address time-limited and specific illnesses or injuries as they occur in episodes, driven by restrictions dictated by Medicare, Medicaid, and private insurance policies (Wagner et al., 2001). This medical system may have been adequate in past decades, when a diagnosis such as diabetes or congestive heart failure was a death sentence, but its structure fails to address the increasingly complex and long-term needs of people with chronic conditions. Four in every five older adults have at least one chronic condition; many will live with that condition for years (Centers for Disease Control and Prevention, 2003). While these individuals may experience acute illnesses throughout their lifetime, these episodes will be complicated by the presence of a chronic condition that must also be attended to by both the medical and long-term services and support systems.

Meanwhile, a robust network of LTSS providers exists that is capable of providing continuous, coordinated service. The need for, access to, and delivery of LTSS is related to, but distinct from, healthcare services. …

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