Improving the care of older adults with complex medical needs will fall short unless public policymakers focus not only on preventing hospital readmission rates but also on better coordination of community-based "care transitions," according to a team of experts led by a Johns Hopkins geriatrician. Lessons learned from managing such transitions for older patients/residents, they say, may offer a framework for overall improvement.
Nationwide, some 22 percent of older adults experience so-called care transitions annually, moving from and among hospitals, rehabilitation facilities, nursing homes, long-term care, assisted living and their homes. Using a review of research and clinical experience, the researchers published several recommendations for health policymakers and caregivers in a report online in the Journal of General Internal Medicine:
- Community-based care "receivers" must be engaged earlier in the transition process.
- A palliative care approach that sets realistic care goals must be adopted with patients and their families.
- The focus should be not only on preventing hospitalization but also on making out-of-hospital transitions easier.
- Recovery and emergency contingency plans need to be broader than referring someone back to a primary care physician and instead include other components of an individual's healthcare system and support.
"In this framework, emphasis is placed on the importance of looking at community, system and regional factors that play into care transitions," says report co-author Alicia I. Arbaje, MD, MPH, director of transitional care research for Johns Hopkins Bayview Medical Center and assistant professor of medicine at the Johns Hopkins University School of Medicine.
Many of the group's recommendations focus on communication among providers. For example:
- Hospital staff should not only make follow-up phone calls to check on discharged patients; they also should send written care instructions.
- Family members and caregivers should be a part of the education process that occurs during discharge.
- Small chores, such as alerting a skilled home healthcare providers well in advance of someone's discharge, can make coordinating care and recovery plans more effective.
"Our suggested framework is designed to help providers think ahead instead of reacting during a patient's crisis," Arbaje says. "The conceptual framework....can be a valuable tool for healthcare systems and policymakers to guide care coordination efforts as part of healthcare reform."