Care Transitions

Discharge from any care setting is a critical and vulnerable time for older adults, as our current health systems do not adequately care for patients moving between care settings, causing serious concerns for patient safety, quality of care and health outcomes.

Many older adults experience difficulties during transition for a variety of reasons. For example, patients in a hospital typically defer to their medical providers but upon discharge, many of these same patients are expected to assume a self-management role in recovery with little support or preparation. Also, health care providers and families may not realize the level of support a patient may need, especially if the patient has not returned to his or her original level of physical or cognitive health.

Unfortunately, this confusion and lack of adequate preparation can have serious consequences ranging from medication errors to an overall decline in health of an older adult that could result in hospital readmission. In fact, nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. Of those additional expenditures, an estimated $12 billion was spent on readmissions that could have been prevented.

Area Agencies on Aging have long recognized the seriousness of this issue and have been on the forefront of developing effective strategies to make smooth transitions more commonplace. A recent survey of more than half of the AAAs around the United States showed that more than 30 percent of AAAs have a care transitions program.

The most frequently used care transitions strategies AAAs employ: working directly with the older adult’s family to improve planning; providing additional services including transportation, in-home care services and case management; and providing or paying for home modification. Some AAAs have also leveraged cutting-edge, mobile technologies to significantly reduce hospital readmissions, such as a tablet care coordination platform. Taken together, these services provide a well-rounded patient-centered approach that ensures that people transition throughout the continuum of care as smoothly as possible.

To significantly improve the incidence of smooth transitions and to reduce the skyrocketing costs associated with hospital readmissions, the Community-based Care Transitions Program (CCTP) was established under Sec. 3026 of the Affordable Care Act. More than 100 sites were funded nationwide, the majority of which involved or were led by AAAs. n4a white paper on CCTP.

However, beyond the CCTP, more than half of all AAAs have formal care transitions programs.

Resources